THYROID DISORDERS

Arriza Kryssan M .Soria, MD, FPCP, FPCEDM

IM-Endocrinologist
THYROID GLAND

• The thyroid gland lies across the larynx in

front of the thyroid cartilage (“Adam’s
apple”).
• Its lobes extend laterally on both sides of
the front of the neck.
• The thyroid gland secretes two hormones
that regulate protein synthesis, enzyme
activity, and stimulate mitochondrial
oxidation.
• These are thyroxine (T4) and tri-
iodothyronine (T3).
THYROID HORMONE ACTIONS

• Thyroid hormones have three

principal actions:
(1) stimulation of energy use,
(2) stimulation of the heart,
and
(3) promotion of growth and
development
THYROID FUNCTION TESTS
THYROID DISORDERS

• Hyperthyroidism

• Hypothyroidism
HYPERTHYROIDISM

• Thyrotoxicosis
• Clinical state that results from inappropriately high thyroid hormone action in tissues
generally due to high thyroid hormone levels

• Hyperthyroidism
• A form of thyrotoxicosis due to inappropriately high synthesis and secretion of thyroid
hormones by the thyroid
 Causes of Hyperthyroidism
Excessive TSH-Receptor Stimulation Destruction of Follicles with hormone release

Graves disease (TRAb)

Subacute de Quervain thyroiditis
Pregnancy-associated Transient hyperthyroidism Painless thyroiditis/ postpartum thyroiditis

Trophoblastic Disease
Acute thyroiditis
Familial gestational hyperthyroidism
Drug-induced thyroiditis
TSH-producing pituitary adenoma
Extrathyroidal Sources
Autonomous Thyroid Hormone Secretion Iatrogenic overreplacement

Multinodular toxic goiter Excessive self administered thyroid meds

Food and supplements containing excessive thyroid

Solitary toxic thyroid adenoma hormone

Congenital activating TSH receptor mutation Functional thyroid cancer metastasis

Struma ovarii
1. Williams Textbook of Endocrinology, 14 edition: Hyperthyroid disorders
th
SIGNS AND SYMPTOMS
CLINICAL MANIFESTATIONS

• Increased circulatory demands

• Increased synthesis and degradation of proteins
• Sympathetic overactivity
• Muscle wasting
• Ocular muscle involvement may mimic myasthenia gravis
• Hypokalemic periodic paralysis
• Warm, moist skin
• Dyspnea
• Increased appetite, diarrhea, increased gastric emptying and motility
• Hepatic dysfunction
• Bone demineralisation
 Antithyroid Drugs

INDICATIONS:
- Patient with likelihood of remission
- Pregnancy
- Elderly/ limited life expectancy
- High surgical risk
- Unable to follow radiation safety regulations
- Previously operated or irradiated neck
- Lack of access to a high volume thyroid surgeon
- Moderate to severe active GO
- Who need more rapid biochemical disease control

2016 ATA Guidelines for diagnosis and Management of Hyperthyroidism and other causes of Thyrotoxicosis
 Antithyroid Drugs

CONTRAINDICATIONS:

- Previous known major adverse reactions to ATD

2016 ATA Guidelines for diagnosis and Management of Hyperthyroidism and other causes of Thyrotoxicosis
 Antithyroid Drugs

• Goal:
render the patient euthyroid as quick as possible

- Control hyperthyroidism, NOT cure

- NON-adherence- usual cause of failure

- Higher rate of remission

2016 ATA Guidelines for diagnosis and Management of Hyperthyroidism and other causes of Thyrotoxicosis
 Thionamides

- Methimazole
Starting dose: 20-30mg/day
Maintenance dose: 5-10mg/day

- Propylthiouracil
Starting dose: 300-400mg/day (divided in 3-4
doses)
Maintenance dose: 50-100mg/day

Williams Textbook of Endocrinology, 14 th edition: Thyroid Physiology and Diagnostic Evaluation

 Antithyroid Drugs

Initial Methimazole daily dose

Dose FT4 Level

5-10mg/day 1-1.5x ULN

10-20mg/day 1.5-2x ULN

30-40mg/day 2-3x ULN

ULN = upper limit of normal
2016 ATA Guidelines for diagnosis and Management of Hyperthyroidism and other causes of Thyrotoxicosis
 Antithyroid Drugs

• Methimazole used in all patients

EXCEPT : during the first trimester

pregnancy
treatment for thyroid storm
minor reactions to MMI

where Propylthiouracil is preferred

2016 ATA Guidelines for diagnosis and Management of Hyperthyroidism and other causes of Thyrotoxicosis
HYPOTHYROIDISM

• Primary hypothyroidism is characterized by a decrease in T4 and an increase in TSH

levels.

• Primary hypothyroidism is caused by acute or chronic inflammation of the thyroid gland,

radioiodine therapy, excess intake of antithyroid drugs, and surgery.

• Myexedema is severe hypothyroidism characteristic by lethargy, apathy, memory

impairment, emotional changes, slow speech, deep coarse voice, edema of the eyelids
and face, thick dry skin, cold intolerance, slow pulse, constipation, weight gain, and
abnormal menses.
SIGNS AND SYMPTOMS
CLINICAL MANIFESTATIONS
DIAGNOSIS OF HYPOTHYROIDISM
THYROID REPLACEMENT DRUG

• The synthetic thyroid preparations are levothyroxine (T4),

liothyronine (T3), and liotrix (which contains a combination of T4
and T3 in a 4:1 ratio)
THYROID REPLACEMENT DRUG
THYROID REPLACEMENT DRUG
THYROID REPLACEMENT DRUG