Management Of Benign

Thyroid Disorders

Dr. Ganesh H.K.

Cosultant Endocrinologist,
A J Hospital & Research Center,
Mangalore.
 Agenda

Physiology

Hypothyroidism

Hyperthyroidism
Physiology
Thyroid Hormone Synthesis
 Thyroid Function Tests
Which one should be selected ?

Single Most Useful Test

of Thyroid Function

TSH
Are All Functional Derangements
Identified Correctly ?

Primary Hypothyroidism

Thyrotoxicosis “YES”

Euthyroid State

Central hypothyroidism: Can be missed

 Should It Be “Total” or “Free”
Hormone Assessment?

• Binding protein related abnormalities

• Endogenous antibodies

Free Hormones

Pregnancy, OCP use, Liver/Kidney failure

 To Summarize…

• Under steady state

- TSH is a single most useful
screening diagnostic test

• TSH, T4: Identify all functional

derangements
Hypothyroidism
 29 year old lady
 Severe tingling and numbness of both upper
limbs, especially hands
T3: 72 ng/dl [60-180]
 Nerve conduction study: T4:
Carpal Tunnel
6.5 µg/dl [5.5-12]
Syndrome TSH: 45.3 µIU/ml [0.3-
5.5]
 On enquiry,
Constipation, wt gain, menorrhagia, hair loss
 Adv: Release surgery
 At Risk Population
 Past history of autoimmune thyroid disease
 Positive anti-TPO antibodies
 Past history of RAI therapy
 Family history of autoimmune thyroid
disease
 Iodine deficiency area
 Drug exposure
 Clinical Spectrum
Symptoms
 Weakness  Loss of hair
 Dry, coarse skin/hair  Dyspnea
 Lethargy  Hoarseness of voice
 Weight gain  Anorexia
 Slow speech  Deafness
 Sensation of cold  Memory impairment
 Thick tongue  Constipation
 Edema  Neck swelling
 Signs

 Bradycardia  Non pitting oedema

 Dry skin  Slow

speech/movements
 Puffiness of face
 Delayed relaxation of
 Goitre DTR
Unusual Manifestations

 Depression
 Infertility
 Precocious puberty
 Pericardial effusion
 Carpal tunnel syndrome
 Pituitary adenoma
 Subclinical Hypothyroidism
 Normal T3(FT3) and T4(FT4) with increased TSH

 Progression to frank hypothyroidism high in AMA

positive patients.

 In patients without goitre, positive AMA, or other

risk factors observe, repeat TSH
 When To Treat…?

1. Dyslipidemia 7. Neuropsychiatric
2. Goiter manifestations
3. +ve anti-TPO 8. Carpal tunnel syndrome
4. Pregnancy 9. Unexplained hyponatremia
5. Infertility 10. Short stature
6. TSH > 10 11. Pubertal problems

( Source: 2004 Consensus Study Conducted by the Indian Thyroid Society’ )

 Treatment
 L-thyroxine: preparation of choice
 Dose 100 mcg/m2
 Long (6 days) half life, once daily dose
 Bio availability can change with change in
product and lot
 T3 not indicated for chronic management of
primary hypothyroidism
 Crude thyroid extract (Ebexid)/Amino acids
– not recommended
Determinants Of Thyroxine Requirements
 Age of patient
 Duration and severity of hypothyroid state
 Underlying cardiac disease if any
 Concomitant drug therapy
 Healthy young patients: Start full dose
 Long standing disease, elderly, IHD
 Small dose 25mcg/day
 Increase by 25 mcg once in 4 weeks
 Drug Interactions
 Phenobarbitone, Phenytoin, Rifampin
accelerate metabolism of LT4
 Sucralfate, aluminium hydroxide, ferrous
gluconate/sulfate decrease absorbtion of LT4
 Soyabean decrease absorbtion of LT4

 Requirements of OAD/ insulin increase in a

diabetic after LT4 treatment
 Monitoring

 Steady state T4: achieved at 6 weeks

 Monitor TSH 8-12 weeks after start of
treatment
 Once TSH is stable, monitor it every
yearly
 Failure to respond very rare; ?
Compliance
Can Hypothyroidism Be Transient..?
 Post partum thyroiditis
 De Quervain’s thyroditis
 Drugs
Amiodarone, lithium
 Autoimmune thyroditis (<5%)
 Treat Patients for 6 months
 Withdraw treatment, repeat TSH 6-8 weeks after
withdrawing LT4
Thyrotoxicosis
Should we differentiate between
hyperthyroidism and thyrotoxicosis?
 28 year old lady
 Weight loss, palpitations,
tremors and sweating:
one month

 O/E:
Tachycardia
No goiter/ neck tenderness
 Thyrotoxicosis
 T3: 320 ng/dl (60-180)
 T4: 17.6 μg/dl (5.5-12)
 TSH: < 0.01 μIU/ml (0.3-5)

Shall we start Carbimazole…?

? Treatment
 Treatment
 Started on Carbimazole 30 mg/day
 Returns after 1 month with florid
hypothyroidism
Facial puffiness
Reason…?
Weight gain of 8 kg
Edema feet
Silent thyroiditis
TSH: 75 μIU/ml
 Thyrotoxicosis

Biochemical and physiologic manifestations of

excessive quantities of the thyroid hormones.
 Causes

 Not associated with hyperthyroidism

Subacute thyroiditis
Anti thyroid
Silent drugs: not indicated
thyroiditis
Postpartum thyroiditis
Symptomatic treatment
Thyrotoxicosis factitia
EctopicPeriodic
thyroid tissue (struma ovarii,
observation
functioning metastatic thyroid cancer).
 How To Avoid…?

Whenever there is doubt….

No goiter/small goiter
Short duration of symptoms
No features of Graves’

Technitium scan thyroid

RAIU scan
Reduced Uptake
 Causes
 Associated with hyperthyroidism
Graves’ disease
Toxic MNG
Toxic adenoma
Iodine excess (Jod- Basedow phenomenon)
e.g. Amiodarone induced.
Gestational thyrotoxicosis
Trophoblastic tumors
TSH secreting adenomas
Thyroid hormone resistance.
Diffuse Increased Uptake
 50 year old lady
 Symptoms of toxicosis
since 4-5 months
 Significant weight loss

 Diffuse goiter
 Staring look
 Moderate, inactive
ophthalmopathy
 T3: 650 ng/dl (60-180)
 T4: 24.6 μg/dl (5.5-12)
 TSH: 0.001 μIU/ml (0.3-5)

 Diagnosis: Graves’ disease

with moderate, inactive
ophthalmopathy.
 Management..
 Anti thyroid drugs
Titrating doses of Carbimazole/
methimazole/ PTU
Minimum duration: 1 year

 No treatment for ophthalmopathy

 Why Medical Management…?
 Only form of therapy correcting the basic
pathology

 Chances of complete cure without

hypothyroidism: Much higher than surgery/
radioiodine therapy

 Only treatment when T4 levels are very high

 Drugs

 Thionamides
Carbimazole
Methimazole
Propylthiouracil
 Iodides
 Lithium
Graves’ Disease

TSH-receptor antibody
TSH-receptor

Thyroid hormone overproduction

Excessive Thyroid Hormone

Synthesis
Antithyroid drugs

TSH-receptor antibody
TSH-receptor

Thyroid hormone overproduction

Block Thyroid Hormone Synthesis

 Thionamides
 Inhibit the oxidation and organic binding of iodide:
intrathyroidal iodine deficiency.
 No influence on preformed horrmone release
 Large doses of PTU: impair the conversion of T4 to
T3
 Directly influence the immune response, decline in
antigen presentation, decrease the immune infiltration
and reduces the autoantibody levels
 Thionamides
 Half-life
Carbimazole: 6 hours
Propylthiouracil: 1.5 hours.
 Both drugs are accumulated by the thyroid
gland.
 A single dose of carbimazole may exert an
antithyroid effect for longer than 24 hours.
 Both Carbimazole and PTU cross the placenta;
PTU to a lesser extent.
 Adverse Effects
 Common (1 to 5%)
Rash
Urticaria
Fever
Arthralgia
 Rare (<1%)
Hepatitis
SLE-like syndrome
Agranulocytosis.
Which anti thyroid drug is superior?
 Choosing The Right Drug
Carbimazole Propylthiouracil

Once a day dosing Thrice daily dosing

Cheaper Expensive
Advantage in:

Fewer reactions More serious reactions

Pregnancy

Rapid normalization of T4 Slower Toxic crisis

Less effects for further RAI Decreased efficacy

Fulminant hepatic failure
 Management Of Graves’ Disease
 Initial dose
Carbimazole: 20 to 40 mg/ day.
Propylthiouracil: 150 mg every 8 hours.
 β blockers: Relief from adrenergic symptoms
 Symptomatic improvement: within the first 2
weeks.
 Therapeutic response
Occurs after a latent period: 6-8 weeks
(after glandular hormone stores are depleted).
 Follow up
 Clinical manifestations: 3 weeks
 T3, T4 levels: 4-6 weeks
(TSH remains suppressed for many
months after starting treatment).
 Dosage: Stepped up/ down depending upon
clinical features and T3, T4 levels.
 Dose of Carbimazole gradually reduced to
maintenance dose of 2.5-5 mg (with which
TSH remains within the normal range).
 Follow up

 Once the TSH is normalized, always monitor

with TSH.
 Treatment should be continued for at least 6
months after TSH normalization.
 Total duration of treatment: 12-24 months.
 Relapse

Radioiodine therapy Thyroidectomy

 Indications For Surgery…

 Severe Graves’ ophthalmopathy

 Pregnancy (2nd trimester), if anti thyroid drugs
fail
 Very large goiters
 Graves’ disease with cold nodules
 Not willing for RAI
 Take Home Message…
 Hypothyroidism: Early diagnosis and proper
monitoring; easily treatable

 Thyrotoxicosis should be differentiated

from hyperthyroidism

 Medical management: To be tried at least for

an year in Graves’ disease
Thank You…

Dr. Ganesh H.K.