Hyperthyroidism

• Hyperthyroidism and thyrotoxicosis are used interchangeably,

however each refers to slightly different conditions.

Hyperthyroidism refers to over activity of the thyroid gland, with

resultant excessive secretion of thyroid hormones and accelerated
metabolism in the periphery.

• Thyrotoxicosis refers to the clinical effects of an unbound

thyroid hormone, regardless of whether or not the thyroid is the
primary source. There are a number of pathologic causes of
hyperthyroidism in children and adults.
Etiology

• Ectopic thyroid disease

• Grave’s disease
• Multi-nodular disease
• Thyroid adenoma
• Subacute thyroiditis
• Ingestion of thyroid hormone
• Pituitary disease
• Ingestion of food containing thyroid hormone
• High dietary iodine intake or very low dietary intake.
• Genetic factor.
Females

Males
• Types:

Primary thyrotoxicosis
1. Diffuse toxic goitres- graves disease

Secondary thyrotoxicosis
2. Toxic nodular goitre
3. Toxic nodule
4. Hyperthyroidism due to rare cause
DIFFUSE TOXIC GOITRE
(GRAVE’S DISEASE)
Diffue Toxic Goiter (Graves’ disease)

• Diffuse vascular goitre

• Younger women
• Eye signs
• Primary Thyrotoxicosis
• Family H/o Autoimmune Endocrine diseases
• Whole gland – Hypertrophy & Hyperplasia – abnormal
thyroid stimulating antibodies (TSHRab) binding to TSH
receptor
TOXIC NODULAR GOITRE
Toxic Nodular Goiter
• Long duration
• Middle-aged or Elderly
• Infrequently is associated with eye signs.
• Secondary thyrotoxicosis.
• Nodules inactive
• Inter-nodular thyroid tissue overactive
Toxic Nodular Goiter
• Solitary overactive nodule
• Autonomous TSH secretion is suppressed by
the high level of circulating thyroid
hormones.
• Surrounding normal thyroid tissue
suppressed and inactive.
Specific to Graves Disease
Grave’s Disease

Diffuse painless and firm enlargement of thyroid gland

Ophthalmopathy – Eye manifestations – 50% of cases
Classification of Eye Changes in Graves' Disease
• No signs or symptoms.
• Only signs, no symptoms. (Signs limited to upper lid
retraction, stare, lid lag.)
• Soft tissue involvement (symptoms and signs).
• Proptosis (measured with Hertel exophthalmometer)
• Extraocular muscle involvement.
• Corneal involvement.
• Sight loss (optic nerve involvement).
Specific to Graves Disease……..
Thyroid dermopathy consists of thickening of the skin,
particularly over the lower tibia, due to accumulation of
glycosaminoglycans (pre tibial myxedema) and is usually
bilateral.
Thyroid Acropachy is clubbing of fingers and toes in primary
thyrotoxicosis.
Investigation
• History and physical examination
• Ophthalmic examination
• ECG- atrial tachycardia
• Thyroid function test: T3 and T4
• Thyroid releasing hormone stimulation test
• Radioactive iodine uptake (RAIU)
• Thyroid scan
Principles of Treatment
Approaches
• Anti thyroid drugs, beta blockers
• Radioactive Iodine I131
• Surgery
Factors Influencing Choice of Therapy
Choice Of Therapy
• Type of thyrotoxicosis
• Age of the patient
• Co existing medical illness
• Severity of thyrotoxicosis
• Goiter size
• Presence of opthalmopathy
• Patient preference
Factors
ANTITHYROID DRUGS
Indications for anti thyroid drugs:

• Patients with high likelihood of remission

• Elderly or others with comorbidities increasing surgical risk or
with limited life expectancy
• Toxicity in pregnant women
• Moderate to severe active Graves’ ophthalmopathy (GO)
• Before surgery, to make the patient euthyroid
• Soon after starting radioactive I131therapy for 6 to 12 weeks
How long to give ATD ?
• Improved symptoms in 2 weeks and euthyroid in about 6 weeks
• Check TSH and FT4 every 4 to 6 weeks
• In Graves, remission after 12-18 months
• Monitor every 3 months for the 1st year, and then annually after
ATD
• 40% recurrence in 1 yr.
• MNG and Toxic Adenoma will not get cured by ATD.
Beta blockers
Inhibit adrenergic effects
Indications
• Prompt control of symptoms;
• Treatment of choice for thyroiditis;
• First-line therapy before surgery, radioactive iodine, and
antithyroid drugs;
Contraindications
• Use with caution in older patients and in patients with
preexisting heart disease, chronic obstructive pulmonary
disease, or asthma
• Propranolol is the most commonly prescribed medication in
doses of about 20 to 40 mg four times daily
Iodides
Block the conversion of T4to T3 and inhibit hormone release
Indications
• preoperatively when other medications are ineffective or
• contraindicated; to reduce gland vascularity before surgery for
Graves’ disease
• during pregnancy when antithyroid drugs are not tolerated;
Complications
• Paradoxical increases in hormone release with prolonged use;
• common side effects of sialadenitis, conjunctivitis, or acneform
rash;
• RADIOIODINE THERAPY
Radioactive iodine
• Concentrates in the thyroid gland and destroys thyroid tissue
• High cure rates with single-dose treatment (80 percent);
• treatment of choice for Graves’ disease, Multi nodular goitre, toxic
nodules in patients older than 40 years, and in recurrent
thyrotoxicosis
• It is effective, safe, and does not require hospitalization.
• Given orally as a single dose in a capsule or liquid form.
• RADIOIODINE THERAPY………
Drawbacks
• Delayed control of symptoms;
• post treatment hypothyroidism
Contraindicated - pregnant or breastfeeding; transient
neck soreness, flushing, and decreased taste;
• radiation thyroiditis in 1 percent of patients;
• may exacerbate Graves’ ophthalmopathy; may
require pre treatment with antithyroid drugs in
older or cardiac patients
• Surgical Treatment
Surgical treatment is reserved
• patient preference
• Pregnant women who can’t tolerate ATD
• child or adolescent intolerant of ATDs
• large goiter, with or without compressive symptoms
• severe Graves’ ophthalmopathy
• presence of suspicious nodules
SURGICAL………..
GRAVES DISEASE
Near-total or total thyroidectomy is the procedure of choice
TMNG
Near- total or total thyroidectomy should be performed
TOXIC ADENOMA
an ipsilateral thyroid lobectomy, or isthmusectomy
In patients with coexisting eye disease,
total thyroidectomy
Drugs
1. Antithyriod drugs- <45yr small goitre
- carbimazole
- propylthiouracil
- oxidation and binding of Iodine to tyrosine
2. B Adrenergic blockers
-propranolol,nadolol
3. Iodides
• Advantages : no surgery
rapid control of thyrotoxicosis
• Disadvantages : treatment is prolonged
failure rate-50%
• SE : agranulocytosis / aplastic anemia
Dose :10mg 3-4 times/day
• Replacement – thyroxine 0.1 mg – 0.15 mg
Surgery
• <45 yr large goitre
• Toxic nodule
• Toxic nodular goitre
• Advantage: goitre removed
Cure rapid
Cure rate-high
• Disadvantage : recurrence - 5%
- risk of surgery
- hypothyroidism-20-45%
- hypoparathyroidism
Radio iodine
• Indications : >45 yr
recurrent thyrotoxicosis after
surgery
• Advantages : no surgery ,no drug
• Disadvantages : isotope facility
must be available