Course: Clinical Pharmacy II

Class: Pharm.D Final Year

Instructor
Dr. Muhammad Fawad Rasool

Associate Professor & Chairman

Department of Pharmacy Practice,

Bahauddin Zakariya University, Multan
PRESENTERS

Areej iqbal(71-E-17)

Nida Rasheed(67-E-17)

Aqsa khizar(100-E-17)

Samia sheikh(88-E-17)

Zarmina gull khan(54-E-17)

© Muhammad Fawad Rasool

 Hyperthyroidism(Overactive Thyroid)

Hyperthyroidism/ Hyperthyreosis
 Hyperscretion of thyroid hormones from thyroid gland/extra thyroidal
tissue

 Accelerates body metabolism

 Cause un-intentional weight loss
 A rapid or irregular heartbeat


© Muhammad Fawad Rasool

 Types of Hyperthyroidism

Primary Hyperthyroidism
 Occurs due to pathology of the thyroid gland such as
 Adenoma of thyroid
 Multinodular goiter
 Graves disease ,
 Iodine excess (job-basedow phenomenon)

© Muhammad Fawad Rasool

 Types of Hyperthyroidism
Secondary Hyperthyroidism

 Occurs due to pathology outside thyroid gland such as

 (i.e., tumor of pituitary gland)
 Excess administration of thyroid hormones
 Tumor of ectopic thyroid tissue
 Abnormal neuronal discharges in hypothalamus

© Muhammad Fawad Rasool

 Epidemiology
In Europe Hyperthyroidism and thyrotoxicosis affect 1 in 2000 people
annually
In US , Colorado Thyroid Health Survey assessed thyroid function in 25862
subjects
Hyperthyroid
13%
Hypothyroid
27%
Euthyroid
60%

Distribution of Thyroid Disorders calculated in Health Survey in

Colorado
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 Etiology

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 Risk factors
These include:

 Family history
 High iodine intake
 Smoking
 Trauma to the thyroid gland
 Toxic multinodular goiter
 Childbirth

8 © Muhammad Fawad Rasool

 Anatomy of thyroid gland

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 Thyroid hormones

 Thyroid gland produce three biologically active hormones

 Thyroxine (T4) & Triiodothyrronine(T3) and calcitonin
 T3 is more active physiologically active
 T4 is regarded as prohormone
 Role in fetal growth and development , particularly the central nervous system
 Regulate energy metabolism , virtually affect function of all body organs

© Muhammad Fawad Rasool

 Synthesis of thyroid hormones

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 Release and Regulation of Thyroid Hormones
Hypothalamic-Pituitary-Thyroid Axis

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 Pathophysiology

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 Clinical Presentation
Symptoms Signs

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Con’td……

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 Diagnosis

1) Physical Examination

 Slight tremors in fingers when they are extended

 Eye changes
 Warm and moist skin
 Thyroid neck test

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1. Physical examination

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 2. Blood tests
 T4 and TSH level are measured in blood
 High levels of thyroxine and low or nonexistent amounts of TSH indicate an
overactive thyroid
 False results with biotin supplement

© Muhammad Fawad Rasool

 Differential diagnosis
if blood test indicate hyperthyroidism
Following tests determine why thyroid is overactive
1.Radioiodine uptake test
2.Thyroid scan
3.Thyroid ultrasound

© Muhammad Fawad Rasool

 1-Radioactive Uptake Test
Obtain radioactive iodine uptake and scan of the thyroid gland

Low uptake High uptake

Thyroiditis
Homogenous radioactive Nodular radioactive iodine
iodine distribution distribution

Graves disease Toxic multinodular Toxic adenoma

adenoma

Graves disease
© Muhammad Fawad Rasool
 Treatment

Goals of therapy

Relieve sign and symptoms

Reduce thyroid hormone production

Achieve biochemical euthyroidism

Prevent long-term adverse sequelae

© Muhammad Fawad Rasool

 Beta-Blockers

 Many Manifestations of hyperthyroidism are mediated by beta-adrenergic

system .

 Beta-blockers relieve palpitation , anxiety , tremors and heat intolerance

 Don't reduce the synthesis of thyroid hormones.
 Propranolol and nadalol(non-selective) are preferred .
 Propranolol dose is 20 to 40mg four times daily.

© Muhammad Fawad Rasool

 Contraindications to Beta Blockers

 Beta-blockers should not be used in patients with

 Decompensated heart failure
 Asthma
 Alternatives
Beta-1 specific blockers(metoprolol and atenolol) in relative contraindicated

Clonidine , verapamil , diltiazem in absolute contraindication

© Muhammad Fawad Rasool

 Methods to remove thyroid hormones synthesis

 Four ways to reduce excess production of thyroid hormones

Anti-thyroid
Iodides
drugs

Radioactive
surgery
iodine

© Muhammad Fawad Rasool

 1-Iodides
 Large doses inhibit synthesis and release of thyroid hormones
 Serum t4 levels reduce within 24hours and effect last for 2-3 weeks
 Potassium iodide administered either as saturated solution or as lugol
solution

 Saturated solution of of pottasium iodide(SSKI) contains 38mg iodine/drop

 Lugol solution contains 6.3mg iodine/drop
 Starting dose of SSKI is 5drops every 6-8hours

© Muhammad Fawad Rasool

 Contraindications and Side Effects

 Should not be given before radioactive iodine treatment

 Causes inhibition of radoactivity
 Toxic effect include iodism
 Characterized by
 Palpitations , depression , weight loss , eruptions gynecomastia

© Muhammad Fawad Rasool

 2- Anti-thyroid drugs

 Propylthiouracil( PTU) & methimazole(MMI)

 Block iodination of tyrosine in tyroglobulin
 Inhibit conversion of T3 to T4
 Starting dose of MMI is 10-20mg/day
 Starting dose of PTU is 50-150mg thrice daily
 Therapy must be tapered after 12-24 months

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 Contraindications and Side Effects

 Contraindicated in patients
 With hypersensitivity
 Pregnancy
 Side effects include
 Agranulocytosis
 Arthralgia
 GIT upset

© Muhammad Fawad Rasool

 3-Radiocative Iodine

 I produces thyroid ablation without surgery

131

 Destroy all functioning thyroid tissue

 High cure rates (80%)
 MMI therapy before i131 to prevent 131I induced thyroid storm
 Dose of 131i based on patient estimated thyroid gland weight
 Typical dose is 10-15mCi(370-555MBql)

© Muhammad Fawad Rasool

 Contraindications and Side Effects

 Contraindicated in
 Pregnancy
 Breast caner
 Graves ophthalmology
 Side effects includes
 Thyroiditis
 Long term carcinogenic effects reported in clinical trials
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 4-Surgery/Thyroidectomy

Two different surgical techniques are

 Total thyroidectomy(TT)
 Subtotal thyroidectomy(STT)
 STT is indicated in hyperthyroidism
 Patient must be euthyroidism before surgery
 Iodine preoperatively to reduce gland vascularity

© Muhammad Fawad Rasool

 Monitoring after surgery

 Intactness of parathyroid gland

 Serum calcium levels
 Hypothyroidism
 Hypoparathyroidism
 Postoperative 1250-2500mg/day of calcium and
 0.5mcg/day calcitriol is given over 1-2weeks.

© Muhammad Fawad Rasool

 Special conditions and populations

Thyrotoxicosis and pregnancy

 Pregnancy worsen or precipitate thyrotoxicosis
 Untreated maternal thyrotoxicosis results in
 Increased miscarriage
 Premature delivery
 Eclampsia
 Low birth-weight infants
 PTU is treatment of choice
 MMI has greater teratogenic effects

© Muhammad Fawad Rasool

 Special conditions and populations

Pediatric hyperthyroidism
Beta blockers for reducing heart rate
 MMI is preferred anti-thyroid drug in children
 Dose is 0.2 to 0.5mf/kg/day.
 Dose tapering to 50% after euthyroid state achieved
 If remissions doesn't occur with anti-thyroid therapy
 Surgery and radioactive iodine offered
© Muhammad Fawad Rasool
 Special conditions and populations

Thyroid Storm
 Precipitated in previously hyperthyroid patient by
 Infection, trauma, surgery, radioactive iodine treatment
 Withdrawal from anti-thyroid drugs
 Characterized by
 High fever , tachycardia , dehydration , delirium , coma , and
 GIT disturbances
 Treated with IV esmolol , IV/oral iodine, MMI(60-80mh/day)
© Muhammad Fawad Rasool
 References

“Pharmacotherapy Principles & Practice, 6e | Pharmacotherapy Principles &

Practice | McGraw Hill Medical.” https://ppp.mhmedical.com/book.aspx?
bookid=3114 (accessed May 12, 2022).
 J. T. DiPiro, R. L. Talbert, G. C. Yee, B. G. Wells, and L. M. Posey,
Pharmacotherapy A Pathophysiologic Approach 9/E, 9th edition. New York:
McGraw-Hill Education / Medical, 2014.

© Muhammad Fawad Rasool

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