Professional Documents
Culture Documents
Diabetes, Endocrinology and Nutrition Center, Affinity Medical Group, Neenah, Wisconsin
Member, Diabetes Advisory Group, Wisconsin Diabetes Prevention and Control Program
Member, Inpatient Diabetes Management Committee, St. Elizabeth’s Hospital, Appleton, WI
Chairman, Diabetes Steering Committee, AMG/NHP, Appleton, WI
• Hypothyroidism
• Hyperthyroidism
Typical Thyroid Hormone Levels
in Thyroid Disease
TSH T4 T3
Hypothyroidism High Low Low
Subclinical Hypothyroidism
TSH >4.7 IU/mL, Free T4 Normal
Euthyroid
TSH 0.5-4.7 IU/mL, Free T4 Normal
Hyperthyroidism
TSH <0.5 IU/mL, Free T3/T4 Normal or Elevated
0 5 10
TSH, IU/mL
Braverman LE, et al. Werner & Ingbar’s The Thyroid. A Fundamental and Clinical Text. 8th ed. 2000.
Canaris GJ, et al. Arch Intern Med. 2000;160:526-534.
Vanderpump MP, et al. Clin Endocrinol (Oxf). 1995;43:55-68.
Prevalence of Abnormal Thyroid
Function
The Colorado Thyroid Disease Prevalence study
• Used thyroid stimulating hormone (TSH) levels as a
measure of thyroid function
• Prevalence of elevated TSH levels (hypothyroidism)
was 9.5% and the prevalence of decreased TSH
levels (hyperthyroidism) was 2.2%
• Lipid levels increased as thyroid function declined
• 40% of patients taking thyroid medications had
abnormal TSH levels
Females
Participants With
14
12 similar between
10 males and
8 females
6
4
• At ≥40 years of
2 age, a higher
0 percentage of
13- 20- 30- 40- 50- 60- 70- >80 female patients
19 29 39 49 59 69 79 have elevated
Age, y TSH levels
Deepening of Voice
Depression
Persistent Dry or Sore Throat
Inability to Concentrate
Thinning Hair/Hair Loss Difficulty Swallowing
Heavy Period
Weight Gain Infertility
Cold Intolerance
Elevated Cholesterol Constipation
Muscle Weakness/
Family History of Thyroid Disease or
Cramps
Diabetes
Hypothyroidism and Depression
Have Many Common Features
Depression Hypothyroidism
• Constipation
• Appetite decrease • Bradycardia
• Decreased concentration • Cardiac and lipid
• Sleep decrease • Decreased libido abnormalities
• Suicidal ideation • Delusions • Cold intolerance
• Weight loss • Depressed mood • Delayed reflexes
• Appetite increase/ • Diminished interest • Goiter
decrease • Sleep increase • Hair and skin
• Weight increase changes
• Fatigue
Bravernan LE, Utiger RE, eds. Werner & Ingbar's The Thyroid.
8th ed. Philadelphia, Pa: Lippincott Williams & Wilkins; 2000.
Persani L, et al. J Clin Endocrinol Metab. 2000; 85:3631-3635.
Primary Hypothyroidism:
Underlying Causes
• Congenital hypothyroidism
– Agenesis of thyroid
– Defective thyroid hormone biosynthesis due to enzymatic defect
• Thyroid tissue destruction as a result of
–Chronic autoimmune (Hashimoto) thyroiditis
–Radiation (usually radioactive iodine treatment for thyrotoxicosis)
–Thyroidectomy
–Other infiltrative diseases of thyroid (eg, hemochromatosis)
• Drugs with antithyroid actions (eg, lithium, iodine, iodine-
containing drugs, radiographic contrast agents, interferon alpha)
TSH
Normal
Range
T3
T4
Years
• Hyperlipidemia
• Depression
• Gynecological conditions
• Aging
300
250 Hypothyroid
Lipid Levels, mg/dL
100 Subclinical
Hyperthyroid
50 Hyperthyroid
0
Total-C* LDL-C* HDL-C* Triglycerides
50
0
Women With Euthyroid Women Euthyroid
Subclinical Women With Women
Hypothyroidi Subclinical Without
sm Hypothyroid Antibodies to
ism and Thyroid
Antibodies Peroxidase
to Thyroid
Peroxidase
Hak AE, et al. Ann Intern Med. 2000;132:270-278.
Subclinical Hypothyroidism Increases
Risk of Myocardial Infarction (cont.)
-5
-10
(mg/dL), %
-15
-20
-25
-30
-35
-40
150
LDL-C (mg/dL)
10
TC (mg/dL)
240
8
6 145
4
2
0 230 140
LT4 Placebo LT4 Placebo LT4 Placebo
Before After
AACE MEDICAL GUIDELINES FOR CLINICAL PRACTICE FOR THE EVALUATION AND TREATMENT OF HYPERTHYROIDISM AND
HYPOTHYROIDISM. ENDOCRINE PRACTICE Vol 8 No. 6 2002
JAMA 2004; 291:228-238
Treatment of Hypothyroidism
Hypothyroidism Treatment Goal
Euthyroidism
6-8 Weeks
Singer PA, et al. JAMA. 1995;273:808-812. Demers LM, Spencer CA, eds.
Demers LM, Spencer CA, eds. The National Academy of Clinical Biochemistry Web
site. Available at: http://www.nacb.org/lmpg/thyroid_lmpg.stm. Accessed July 1, 2003.
Caution in Patients With Underlying
Cardiac Disease
• Using LT4 in those with ischemic heart disease increases
the risk of MI, aggravation of angina, or cardiac
arrhythmias
• For patients <50 years of age with underlying cardiac
disease, initiate LT4 at 25-50 g/d with gradual dose
increments at 6- to 8-week intervals
• For elderly patients with cardiac disease, start LT 4 at
12.5-25 g/d, with gradual dose increments at 4- to 6-
week intervals
• The LT4 dose is generally adjusted in 12.5-25 g
increments
0
Before Ingestion After Ingestion
Changes Tachycardia
Family History of
First-Trimester Miscarriage/
Thyroid Disease
Excessive Vomiting in Pregnancy
or Diabetes
Initial Evaluation of a Patient with
Hyperthyroidism
Braverman LE, Utiger RD, eds. The Thyroid: A Fundamental and Clinical Text. 8th ed.
Philadelphia, Pa: Lippincott, Williams & Wilkins; 2000;1001.
Potential Consequences of
Subclinical Hyperthyroidism
• Beta blockers
• Corticosteroid therapy
• Bile acid sequestrants
• Iodide
Which Treatment to choose?
Depends on:
• Patient preference
• Severity of hyperthyroidism
• Evidence of complications of
hyperthyroidism
• Pregnancy
• The cause of hyperthyroidism
Unusual Thyroid Studies
TSH but FT4 also
Get FT3
• T3 toxicosis is not uncommon in Grave’s
disease- an elevated or high normal FT3
would be suggestive, as would a positive TSI
and diffuse goiter
• Sometimes seen in acute/chronic illness
• Central hypothyroidism is very rare in the
absence of risk factors or suspicious history
but would be suggested if FT3 also low
FT4, but Normal TSH and FT3
• Thyroiditis
• Iodine induced thyrotoxicosis
• Factitious Hyperthyroidism
• Central Hypothyroidism