Hyperthyroidism resident survival guide: Difference between revisions

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{{WikiDoc CMG}}; {{AE}} {{Pervaiz Laghari}}
 
{{CMG}}; {{AE}} {{MSH}}


==Overview==
==Overview==


Hyperthyroidism and thyroid storm are disease states that result from thyroid hormone-induced hypermetabolism. The excess thyroid hormone is released from the thyroid gland as a result of excess thyroid hormone production, or by processes that disrupt the follicular structure of the gland with subsequent release of stored hormone <ref name="pmid2680469">{{cite journal| author=Roth RN, McAuliffe MJ| title=Hyperthyroidism and thyroid storm. | journal=Emerg Med Clin North Am | year= 1989 | volume= 7 | issue= 4 | pages= 873-83 | pmid=2680469 | doi= | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=2680469  }} </ref>.
[[Hyperthyroidism]] is a disease that results from [[thyroid]] [[hormone]]-induced hypermetabolism. The excess [[thyroid hormone]] is released from the [[thyroid gland]] as a result of excess [[thyroid hormone]] production, or by processes that disrupt the follicular structure of the [[gland]] with subsequent release of stored [[hormone]].
Most patients with severe hyperthyroidism present with a dramatic symptom constellation. Hyperthyroidism's typical symptoms include palpitations,heat intolerance, increased bowel movement frequency tremor, anxiety, weight loss despite
Most [[patient]]s with severe [[hyperthyroidism]] present with a dramatic symptom constellation. [[Hyperthyroidism]]'s typical symptoms include [[palpitation]]s, heat intolerance, increased [[bowel]] movement, frequent [[tremor|tremors]], [[anxiety]], [[weight loss]] despite
normal or increased appetite and shortness of breath.Goiter is commonly found on physical examination.  
normal or increased [[appetite]] and [[shortness of breath]]. [[Goiter]] is commonly found on physical examination. As a [[physician]], it is important to identify the severity of clinical signs, thyroid storm and treat them promptly. This section provides a short and straight-to-the-point overview of hyperthyroidism.


===Specific organ systems===
==Causes==
{| style="width:80%; height:100px" border="1"
===Life-Threatening Causes===
| style="width:25%" bgcolor="LightSteelBlue" ; border="1" |'''Cardiovascular'''
Life-threatening causes include conditions which may result in death or permanent disability within 24 hours if left untreated.<ref name="pmid26926973">{{cite journal| author=Kravets I| title=Hyperthyroidism: Diagnosis and Treatment. | journal=Am Fam Physician | year= 2016 | volume= 93 | issue= 5 | pages= 363-70 | pmid=26926973 | doi= | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=26926973 }} </ref><ref name="pmid21893493">{{cite journal| author=Vanderpump MP| title=The epidemiology of thyroid disease. | journal=Br Med Bull | year= 2011 | volume= 99 | issue=  | pages= 39-51 | pmid=21893493 | doi=10.1093/bmb/ldr030 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=21893493 }} </ref><ref name="pmid12826640">{{cite journal| author=Pearce EN, Farwell AP, Braverman LE| title=Thyroiditis. | journal=N Engl J Med | year= 2003 | volume= 348 | issue= 26 | pages= 2646-55 | pmid=12826640 | doi=10.1056/NEJMra021194 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=12826640  }} </ref>
| style="width:75%" bgcolor="Beige" ; border="1" |Heart rate is increased,Systolic hypertension ,pulse pressure is widened,  congestive heart failure, Atrial fibrillation
|-
| bgcolor="LightSteelBlue" | ''' Neuropsychiatric '''
| bgcolor="Beige" |Anxiety, tremor, restlessness, irritability,insomnia,psychosis, agitation,depression, seizures  
|-
|- bgcolor="LightSteelBlue"
| '''Respiratory'''
| bgcolor="Beige" | [[Dyspnea, tracheal obstruction, exacerbate underlying asthma,Pulmonary arterial systolic pressure is increased ]]
|-
|- bgcolor="LightSteelBlue"
| '''Gastrointestinal'''
| bgcolor="Beige" |Weight loss,hyperphagia,hyperdefecation and malabsorption
|-
|- bgcolor="LightSteelBlue"
| '''Skin '''
| bgcolor="Beige" |Sweating,Onycholysis,Hyperpigmentation,Thinning of the hair
|-
|- bgcolor="LightSteelBlue"
| '''Eyes '''
| bgcolor="Beige" |Stare and lid lag, ophthalmopathy.
|-
|-
|- bgcolor="LightSteelBlue"
| '''Genitourinary'''
| bgcolor="Beige" |Urinary frequency and nocturia
|- bgcolor="LightSteelBlue"
| '''Hematologic'''
| bgcolor="Beige" |Normochromic, normocytic anemia
|- bgcolor="LightSteelBlue"
| '''Neck'''
| bgcolor="Beige" |Thymic enlargement
|- bgcolor="LightSteelBlue"
| '''Bone'''
| bgcolor="Beige" | Osteoporosis and an increased fracture risk
|}


==Causes==
*[[Thyroid storm ]]
===Life Threatening Causes===
Life-threatening causes include conditions which may result in death or permanent disability within 24 hours if left untreated.
* [[Thyroid storm ]]


===Common Causes===
===Common Causes===
* [[Graves disease]]<ref name="pmid26926973">{{cite journal| author=Kravets I| title=Hyperthyroidism: Diagnosis and Treatment. | journal=Am Fam Physician | year= 2016 | volume= 93 | issue= 5 | pages= 363-70 | pmid=26926973 | doi= | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=26926973  }} </ref><ref name="pmid21893493">{{cite journal| author=Vanderpump MP| title=The epidemiology of thyroid disease. | journal=Br Med Bull | year= 2011 | volume= 99 | issue=  | pages= 39-51 | pmid=21893493 | doi=10.1093/bmb/ldr030 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=21893493  }} </ref>
 
* Painless or transient (silent) thyroiditis<ref name="pmid12826640">{{cite journal| author=Pearce EN, Farwell AP, Braverman LE| title=Thyroiditis. | journal=N Engl J Med | year= 2003 | volume= 348 | issue= 26 | pages= 2646-55 | pmid=12826640 | doi=10.1056/NEJMra021194 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=12826640  }} </ref>
*[[Graves disease]]
* Toxic [[adenoma]] (Plummer disease)
*Painless or transient (silent) [[thyroiditis]]
* Toxic  multinodular [[goiter]]
*[[Toxic adenoma]] (Plummer disease)
* Postpartum thyroiditis
*[[Toxic  multinodular goiter]]
* [[Hyeremesis gravidarum]]
*[[Postpartum thyroiditis]]
* Subacute granulomatous (de Quervain) thyroiditis
*[[Hyeremesis gravidarum]]
* Drug-induced thyroiditis
*[[De Quervain's thyroiditis|Subacute granulomatous (de Quervain) thyroiditis]]
*Drug-induced [[thyroiditis]]


==Diagnosis==
==Diagnosis==
Shown below is an algorithm summarizing the diagnosis of [[hyprthyroidism]] according to the American Thyroid Association guidelines<ref name="pmid29035639">{{cite journal| author=| title=Correction to: Thyroid 2016;26:1343-1421. DOI: 10.1089/thy.2016.0229. | journal=Thyroid | year= 2017 | volume= 27 | issue= 11 | pages= 1462 | pmid=29035639 | doi=10.1089/thy.2016.0229.correx | pmc=5672663 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=29035639  }} </ref>.
Shown below is an algorithm summarizing the diagnosis of [[hyperthyroidism]] according to the American Thyroid Association guidelines.<ref name="pmid29035639">{{cite journal| author=| title=Correction to: Thyroid 2016;26:1343-1421. DOI: 10.1089/thy.2016.0229. | journal=Thyroid | year= 2017 | volume= 27 | issue= 11 | pages= 1462 | pmid=29035639 | doi=10.1089/thy.2016.0229.correx | pmc=5672663 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=29035639  }} </ref>
Serum TSH measurement has the highest sensitivity and specificity of any single blood test used in the evaluation of suspected thyrotoxicosis and should be used as an ini-tial screening test . However, when thyrotoxicosis is strongly suspected, diagnostic accuracy improves when aserum TSH, free T4, and total T3 are assessed at the initial evaluation. Serum TSH levels are considerably more sensitive than direct thyroid hormone measurements for assessing thyroid hormone excess. In overt hyperthyroidism, serum free T4,T3,or both are elevated, and serum TSH is subnormal (usually<0.01mU/L ina third-generation assay). In mild hyperthyroidism, serum T4 and free T4 can be normal, only serum T3 may be elevated, and serum TSH will be low or undetectable. The diagnosis of a thyrotoxic crisis is made entirely on the clinical findings. Most importantly, there is no difference in thyroid hormone levels between patients with "uncomplicated" thyrotoxicosis and those undergoing a thyroid storm.<ref name="pmid18302101">{{cite journal| author=Karger S, Führer D| title=[Thyroid storm--thyrotoxic crisis: an update]. | journal=Dtsch Med Wochenschr | year= 2008 | volume= 133 | issue= 10 | pages= 479-84 | pmid=18302101 | doi=10.1055/s-2008-1046737 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=18302101  }} </ref>
 


{{familytree/start |summary=PE diagnosis Algorithm.}}
{{familytree/start |summary=PE diagnosis Algorithm.}}
{{familytree | | | | | | | | A01 |A01= <div style="float: left; text-align: left; height: 28em; width: 19em; padding:1em;"> Clinical assessment of signs & symptoms for hyperthyroidism:
{{familytree | | | | | | | | A01 |A01= <div style="float: left; text-align: left; height: 30em; width: 19em; padding:1em;"> Clinical assessment of signs & symptoms for [[hyperthyroidism]]:
* Tachycardia
* [[Tachycardia]]
* Palpitations
* [[Palpitation]]s
* Anxiety, insomnia
* [[Anxiety]], [[insomnia]]
* Fine tremors in outstretched hands
* Fine [[tremor]]s in outstretched [[hand]]s
* Heat intolerance
* Heat intolerance
* Diaphoresis
* [[Diaphoresis]]
* Weight loss
* [[Weight loss]]
* irregular pulse (in atrial fibrillation)  
* Irregular [[pulse]] (in [[atrial fibrillation]])  
* dyspnea
* [[Dyspnea]]
* orthopnea
* [[Orthopnea]]
* brisk deep tendon reflexes
* Brisk deep tendon [[reflex]]es
* proximal muscle weakness
* [[Proximal muscle weakness]]
* pretibial myxedema (Graves’ disease)
* Pretibial [[myxedema]] ([[Graves’ disease]])
* lid lag, lid retraction, decrease lacrimation (thyroid eye disease)}}   
* Lid lag, lid retraction, decrease [[lacrimation]] (thyroid eye disease)}}   
{{familytree | | | | | | | | | ! | | | }}
{{familytree | | | | | | | |!| | | }}
{{familytree | | | | | | | | B01 |B01= Measure serum Thyroid stimulating hormone levels }}
{{familytree | | | | | | | | B01 |B01= Measure serum [[Thyroid-stimulating hormone]] levels }}
{{familytree | | | |,|-|-|-|-|^|-|-|-|-|.| }}
{{familytree | | | |,|-|-|-|^|-|-|-|-|.| }}
{{familytree | | | C01 | | | | | | | | C02 |C01= Low TSH |C02= High TSH }}
{{familytree | | | C01 | | | | | | | |C02|C01= Low [[Thyroid-stimulating hormone|TSH]] (usually <0.01mU/L) |C02= High [[Thyroid-stimulating hormone|TSH]] }}
{{familytree | |,|-|^|-|-|-|.| | | | | |!| | | | | }}
{{familytree | |,|-|^|-|-|-|.| | | | | |!| | | | }}
{{familytree |D01| | | | |D02| | | | | D03 | | | |D01= Mild hyperthyroidism: Serum T4 and T3 values in normal range or only T3 levels are elevated. |D02= Overt hyperthyroidism: Both serum T3 and T4 levels elevated}}
{{familytree |D01| | | |D02| | | | |D03| | |D01= Mild [[hyperthyroidism]]: Serum [[Thyroid hormone|T4 and T3]] values in normal range or only [[thyroid hormone|T3]] levels are elevated. |D02= Overt [[hyperthyroidism]]: Both serum [[Thyroid hormone|T3 and T4]] levels elevated |D03= Elevated serum [[Thyroid hormone|T4 and T3]] levels}}
{{familytree | | | | | | |!| | | | | | | | | }}
{{familytree | | | | | | |!| | | | | | |!| | }}
{{familytree | | | | | | E01 | | | | | | | |E01= Perform thorough physical examination of thyroid gland and look for signs for thyroid eye disease. Thyroid gland diffusely enlarged with symmetrical hypertrophy and new onset of ocular symptoms}}
{{familytree | | | | | |E01| | | | | |E02| |E01= Perform thorough [[physical examination]] of [[thyroid gland]] and look for signs for [[thyroid]] [[eye]] [[disease]]. [[Thyroid gland]] diffusely enlarged with symmetrical [[hypertrophy]] and new onset of ocular [[symptom]]s |E02= Repeat [[Thyroid-stimulating hormone|TSH]] levels in serial dilution }}
{{familytree | | | | |,|-|^|-|-|.| | | | | }}
{{familytree | | |,|-|-|^|-|.| | | |,|-|^|-|-|.| }}
{{familytree | | | F01 | | | | F02 | | | |F01= Yes. Graves' disease |F02= No }}
{{familytree | | |F01| |F02| | |F03| | |F04| |F01= Yes. [[Graves' disease]] |F02= No |F03= Positive |F04= Negative }}
{{familytree | | | | | | | | | ! | | | | }}
{{familytree | | | | | | |!| | | | |!| | | | |!| | }}
{{familytree | | | | | | | | | G01 | | | |G01= Measure serum assays of TRAb and radioactive iodine uptake thyroid scan }}
{{familytree | | | | | |G01| | | |G02| | |G03| |G01= Measure serum assays of TRAb and radioactive [[iodine]] uptake [[thyroid]] scan |G02= High [[Thyroid-stimulating hormone|TSH]] levels due to hetrophilic [[antibodies]] |G03= Look out for [[pituitary]] lesion }}
{{familytree | | | | | | | | | | | | | }}
{{familytree | | | | | | |!| | | | |!| | | | |!| | }}
{{familytree | | | | | | |!| | | |H01| | | |H02| |H01= Measurement of serum levels of human anti-mouse [[antibodies]] |H02=<div style="float: left; text-align: left; height: 8em; width: 19em; padding:1em;">
* Perform MRI [[Brain]]
* High ratio of the [[serum]] level of alpha subunit of the [[pituitary]] glycoprotein [[hormone]] }}
{{familytree | |,|-|-|-|-|+|-|-|-|-|-|.| | }}
{{familytree |I01| | | |I02| | | |I03| |I01= Diffuse increase in [[iodine]] uptake |I02= Localized increase in [[iodine]] uptake |I03= Subnormal or absent uptake of [[iodine]] }}
{{familytree | |!| | | | |!| | |,|-|-|-|+|-|-|-|.| | }}
{{familytree |J01| | |J02| |J03| |J04| |J05| |J01= [[Graves' disease]] |J02= [[Toxic nodular goiter]] |J03= [[Subacute thyroiditis]]/ [[Postpartum thyroiditis]] |J04= Factitious ingestion of [[thyroid hormone]]s |J05= Excess intake of [[iodine]] recently }}
{{familytree | | | | | | | | | | |!| | |!| | | |!| | }}
{{familytree | | | | | | | | | |H01| |H02| |H03| |H01= High levels of [[thyroglobulin]] in serum |H02= Low [[thyroglobulin]] levels |H03= Measure spot [[urine]] iodine or 24 hour [[urine]] [[iodine]] level }}
{{familytree/end}}
 
{{familytree/end}}
{{familytree/end}}


==Treatment==
==Treatment==
Thyroid storm may lead to irreversible cardiovascular collapse and death if proper treatment is not initiated in the Emergency Department.<ref name="pmid2680469">{{cite journal| author=Roth RN, McAuliffe MJ| title=Hyperthyroidism and thyroid storm. | journal=Emerg Med Clin North Am | year= 1989 | volume= 7 | issue= 4 | pages= 873-83 | pmid=2680469 | doi= | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=2680469  }} </ref>
Shown below is an algorithm summarizing the treatment of [[Graves' disease]] according to the American Thyroid Association guidelines.<ref name="RossBurch2016">{{cite journal|last1=Ross|first1=Douglas S.|last2=Burch|first2=Henry B.|last3=Cooper|first3=David S.|last4=Greenlee|first4=M. Carol|last5=Laurberg|first5=Peter|last6=Maia|first6=Ana Luiza|last7=Rivkees|first7=Scott A.|last8=Samuels|first8=Mary|last9=Sosa|first9=Julie Ann|last10=Stan|first10=Marius N.|last11=Walter|first11=Martin A.|title=2016 American Thyroid Association Guidelines for Diagnosis and Management of Hyperthyroidism and Other Causes of Thyrotoxicosis|journal=Thyroid|volume=26|issue=10|year=2016|pages=1343–1421|issn=1050-7256|doi=10.1089/thy.2016.0229}}</ref><ref name="NwatsockTaieb2012">{{cite journal|last1=Nwatsock|first1=JF|last2=Taieb|first2=D|last3=Tessonnier|first3=L|last4=Mancini|first4=J|last5=Dong-A-Zok|first5=F|last6=Mundler|first6=O|title=Radioiodine Thyroid Ablation in Graves′ Hyperthyroidism: Merits and Pitfalls|journal=World Journal of Nuclear Medicine|volume=11|issue=1|year=2012|pages=7|issn=1450-1147|doi=10.4103/1450-1147.98731}}</ref>
For patients with clinical features of  thyroid storm,we start immediate treatment with a beta blocker And then either 200 mg of propylthiouracil (PTU) every four
{{familytree/start |summary=PE diagnosis Algorithm.}}
hours or methimazole (orally 20 mg every four to six hours). PTU is preferred over methimazole due to the effect
{{familytree | | | | | | | | A01 |A01= Overt [[Graves' disease]] }}
of PTU to decrease the conversion from T4 to T3. Iodine administration should be postponed for at least one hour after administration of thionamide
{{familytree | | | | |,|-|-|-|+|-|-|-|-|.| | | }}
to prevent the iodine from being used as a substrate for new hormone synthesis.
{{familytree | | | |B01| | |B02| | |B03| | |B01= [[Methimazole|Antithyroid medications]] |B02= Radioactive [[iodine]] ablation |B03= [[Surgery]] }}
We also administer glucocorticoids (hydrocortisone, 100 mg intravenously every
{{familytree | | | |!| | | | |!| | | | | |!| }}
eight hours) in patients with thyroid storm clinical features.Supporting therapy and the detection and treatment of any precipitating factors ( e.g.
{{familytree | | | C01 | | |C02| | | | |C03| |C01= <div style="float: left; text-align: left; height: 22em; width: 19em; padding:1em;">
infection) in addition to specific thyroid therapy can be vital to the eventual outcome.The infection needs to be detected and treated,
* [[Methimazole]] (MMI) is a drug of choice because of its lower side effects profile.  
and the aggressive correction of hyperpyrexia is required.
* It should be continued for a minimum duration of 12 to 18 months.
Acetaminophen should be used instead of aspirin, as the latter will
* Regular monitoring with [[Thyroid-stimulating hormone|TSH]] and TRAb should be done.
increase concentrations of serum-free T4 and T3 by interfering with protein binding.
* Ideal in [[patient]]s with:
** Mild [[disease]]
** Small [[goiter]]
** [[Pregnancy|Pregnant]] females
** Elderly [[patient]]s with [[cardiopulmonary]] [[comorbities]] |C02= <div style="float: left; text-align: left; height: 22em; width: 19em; padding:1em;">
* Administered in [[patient]]s with:
** persistent [[thyrotoxicosis]] after [[methimazole|anti-thyroid medications]]
** [[patient]]s who cannot tolerate [[methimazole|anti-thyroid medications]].
** [[patient]]s with previous [[neck]] [[surgery]] or [[neck]] [[irradiation]].
* There is a risk of worsening of existing [[thyroid]] [[eye]] [[disease]]. |C03= <div style="float: left; text-align: left; height: 22em; width: 19em; padding:1em;">
* Total or near-total [[thyroidectomy]] is recommended for [[patient]]s with:
** Large [[goiter]] causing compression
** Known or suspected [[thyroid]] [[malignancy]]
** Clinically moderate to severe [[Graves' disease]]
** [[Patient]]s with cold nodules on radioactive [[iodine]] uptake scan
*The advantages are:
** High cure rate
** Zero recurrence rate with total [[thyroidectomy]]. }}
{{familytree/end}}


Once clinical improvement is shown, iodine therapy may
{{familytree/end}}
be discontinued and glucocorticoids may be tapered and discontinued.Beta blockers can be stopped but only after
the tests on thyroid function have returned to normal.To maintain the euthyroidism, the
dosage of thionamides should be titrated. PTU should be changed to methimazole due to the
improved safety profile of methimazole and higher compliance rates. Patients who fail medical therapy should be treated with therapeutic plasma exchange or thyroidectomy. The mortality of thyroid storm is currently reported at 10%.<ref name="pmid23920160">{{cite journal| author=Chiha M, Samarasinghe S, Kabaker AS| title=Thyroid storm: an updated review. | journal=J Intensive Care Med | year= 2015 | volume= 30 | issue= 3 | pages= 131-40 | pmid=23920160 | doi=10.1177/0885066613498053 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=23920160  }} </ref> 


==Dos==


*[[Beta-blocker]]s are recommended for symptomatic relief of systemic symptoms like [[tachycardia]], [[anxiety]], and [[tremor]]s. It is strongly recommended for elderly [[patient]]s with a resting [[heart rate]] greater than 90 beats per minute and coexisting cardiovascular diseases.<ref name="RossBurch2016">{{cite journal|last1=Ross|first1=Douglas S.|last2=Burch|first2=Henry B.|last3=Cooper|first3=David S.|last4=Greenlee|first4=M. Carol|last5=Laurberg|first5=Peter|last6=Maia|first6=Ana Luiza|last7=Rivkees|first7=Scott A.|last8=Samuels|first8=Mary|last9=Sosa|first9=Julie Ann|last10=Stan|first10=Marius N.|last11=Walter|first11=Martin A.|title=2016 American Thyroid Association Guidelines for Diagnosis and Management of Hyperthyroidism and Other Causes of Thyrotoxicosis|journal=Thyroid|volume=26|issue=10|year=2016|pages=1343–1421|issn=1050-7256|doi=10.1089/thy.2016.0229}}</ref>
*The total T3 to T4 plasma levels ratio can assess the etiology of [[thyrotoxicosis]] in [[patient]]s in whom the radioactive iodine uptake scan is contraindicated.  An overactive [[thyroid gland]] will release more T3 compared to T4. Hence in [[Graves’ disease]] and toxic nodular [[goiter]] total T3 to T4 ratio will be high (i.e. >20), while in sub-acute or post-partum [[thyroiditis]], the ratio of T3 to T4 will be low (i.e. <20).<ref name="pmid23935127">{{cite journal| author=Carlé A, Knudsen N, Pedersen IB, Perrild H, Ovesen L, Rasmussen LB | display-authors=etal| title=Determinants of serum T4 and T3 at the time of diagnosis in nosological types of thyrotoxicosis: a population-based study. | journal=Eur J Endocrinol | year= 2013 | volume= 169 | issue= 5 | pages= 537-45 | pmid=23935127 | doi=10.1530/EJE-13-0533 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=23935127  }} </ref> <ref name="pmid3110204">{{cite journal| author=Shigemasa C, Abe K, Taniguchi S, Mitani Y, Ueda Y, Adachi T | display-authors=etal| title=Lower serum free thyroxine (T4) levels in painless thyroiditis compared with Graves' disease despite similar serum total T4 levels. | journal=J Clin Endocrinol Metab | year= 1987 | volume= 65 | issue= 2 | pages= 359-63 | pmid=3110204 | doi=10.1210/jcem-65-2-359 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=3110204  }} </ref>
*TRAb is faster and more cost-effective compared to radioactive iodine thyroid uptake scan to diagnose [[Graves’ disease]]. It should be preferred for the diagnosis of [[Graves’ disease]].<ref name="pmid22435785">{{cite journal| author=McKee A, Peyerl F| title=TSI assay utilization: impact on costs of Graves' hyperthyroidism diagnosis. | journal=Am J Manag Care | year= 2012 | volume= 18 | issue= 1 | pages= e1-14 | pmid=22435785 | doi= | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=22435785  }} </ref>
*Near-total or total [[thyroidectomy]] is the treatment of choice for toxic multinodular [[goiter]]. Isolated lobectomy or isthmusectomy is carried out for toxic [[adenoma]]. Radioactive iodine ablation therapy have resulted in severe [[thyrotoxicosis]] with worsening of cardiac rhythms including [[supraventricular tachycardia]], [[atrial flutter]] or [[atrial fibrillation]]s in [[patient]]s with non-toxic and toxic multi-nodular [[goiter]].<ref name="pmid29035639" /><ref name="pmid10593131">{{cite journal| author=Koornstra JJ, Kerstens MN, Hoving J, Visscher KJ, Schade JH, Gort HB | display-authors=etal| title=Clinical and biochemical changes following 131I therapy for hyperthyroidism in patients not pretreated with antithyroid drugs. | journal=Neth J Med | year= 1999 | volume= 55 | issue= 5 | pages= 215-21 | pmid=10593131 | doi=10.1016/s0300-2977(99)00066-2 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=10593131  }} </ref>


{| class="wikitable"
==Don'ts==
===Drug List===
! Drug
! Initial daily dose
! Mechanisim of action
|-
|Beta blocker
| Propranolol 60 to 80 mg orally every four to six hours,
|Control the symptoms and signs
|-
| Thionamide
| PTU 200 mg every four hours or methimazole,20 mg orally every four to six hours
| Block new hormone synthesis
|-
| Iodine
| (Lugol's) solution, 10 drops (6.25 mg iodide/iodine per drop [0.05 mL]) three times daily
|Block the release of thyroid hormone
|-
|Glucocorticoids
| Hydrocortisone, 100 mg intravenously every eight hours


| Reduce T4-to-T3 conversion, promote vasomotor stability, possibly reduce the autoimmune process in Graves' disease, and possibly treat an associated relative adrenal insufficiency
*[[Pregnancy|Pregnant]], [[lactation|lactating]] females, [[patient]]s with co-existing [[thyroid]] [[malignancy]] or those with high clinical suspicion of [[thyroid]] [[cancer]] should avoid radioactive [[iodine]] ablation therapy. Non-pregnant females should plan a [[pregnancy]] at least six months after RIA.<ref name="pmid29035639" />
|-
*[[Methimazole|Anti-thyroid medications]] are contraindicated in [[patient]]s who experience [[anaphylaxis]] or serious adverse reactions from the medications.<ref name="pmid29035639" />
| An iodinated radiocontrast agent
*Elderly [[patient]]s with co-existing severe [[cardiac]], [[pulmonary]] [[disease]]s, or decreased surgical access should avoid [[thyroid]] [[surgery]]. [[Thyroidectomy]] is also contraindicated in [[pregnancy|pregnant]] females during the first and third [[trimester]] of [[pregnancy]] as [[anesthetic]] [[drug]]s have [[teratogenic]] effects on a developed [[fetus]]. There in an increased risk of [[abortion]] in the first [[trimester]] and [[preterm delivery]] in the third [[trimester]]. The ideal time for [[thyroidectomy]] in [[pregnancy|pregnant]] females is during the second [[trimester]]. There is also an increased incidence of intraoperative adverse reactions like [[hypocalcemia]] and [[recurrent laryngeal nerve]] injury in [[pregnant]] [[patient]]s.<ref name="pmid19451480">{{cite journal| author=Kuy S, Roman SA, Desai R, Sosa JA| title=Outcomes following thyroid and parathyroid surgery in pregnant women. | journal=Arch Surg | year= 2009 | volume= 144 | issue= 5 | pages= 399-406; discussion 406 | pmid=19451480 | doi=10.1001/archsurg.2009.48 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=19451480  }} </ref><ref name="pmid6661836">{{cite journal| author=Weingold AB| title=Appendicitis in pregnancy. | journal=Clin Obstet Gynecol | year= 1983 | volume= 26 | issue= 4 | pages= 801-9 | pmid=6661836 | doi=10.1097/00003081-198312000-00005 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=6661836  }} </ref>
| 0.5 to 1 g once daily.
|inhibit the peripheral conversion of T4 to T3
|-
| Bile acid sequestrants 
| Cholestyramine,4 g orally four times daily
| Decrease enterohepatic recycling of thyroid hormones
|-
 
|}
 
==Do's==
 
* Start immediate treatment with a beta blocker
 
* Acetaminophen should be used instead of aspirin
 
* Iodine administration should be postponed for at least one hour after administration of thionamide
 
* Propranolol, PTU, and methimazole can be administered through a nasogastric tube
 
==Don'ts==
* The content in this section is in bullet points.


==References==
==References==
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Latest revision as of 19:43, 27 January 2021


Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Mydah Sajid, M.B.B.S.

Overview

Hyperthyroidism is a disease that results from thyroid hormone-induced hypermetabolism. The excess thyroid hormone is released from the thyroid gland as a result of excess thyroid hormone production, or by processes that disrupt the follicular structure of the gland with subsequent release of stored hormone. Most patients with severe hyperthyroidism present with a dramatic symptom constellation. Hyperthyroidism's typical symptoms include palpitations, heat intolerance, increased bowel movement, frequent tremors, anxiety, weight loss despite normal or increased appetite and shortness of breath. Goiter is commonly found on physical examination. As a physician, it is important to identify the severity of clinical signs, thyroid storm and treat them promptly. This section provides a short and straight-to-the-point overview of hyperthyroidism.

Causes

Life-Threatening Causes

Life-threatening causes include conditions which may result in death or permanent disability within 24 hours if left untreated.[1][2][3]

Common Causes

Diagnosis

Shown below is an algorithm summarizing the diagnosis of hyperthyroidism according to the American Thyroid Association guidelines.[4]

 
 
 
 
 
 
 
Clinical assessment of signs & symptoms for hyperthyroidism:
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Measure serum Thyroid-stimulating hormone levels
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Low TSH (usually <0.01mU/L)
 
 
 
 
 
 
 
High TSH
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Mild hyperthyroidism: Serum T4 and T3 values in normal range or only T3 levels are elevated.
 
 
 
Overt hyperthyroidism: Both serum T3 and T4 levels elevated
 
 
 
 
Elevated serum T4 and T3 levels
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Perform thorough physical examination of thyroid gland and look for signs for thyroid eye disease. Thyroid gland diffusely enlarged with symmetrical hypertrophy and new onset of ocular symptoms
 
 
 
 
 
Repeat TSH levels in serial dilution
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Yes. Graves' disease
 
No
 
 
Positive
 
 
Negative
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Measure serum assays of TRAb and radioactive iodine uptake thyroid scan
 
 
 
High TSH levels due to hetrophilic antibodies
 
 
Look out for pituitary lesion
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Measurement of serum levels of human anti-mouse antibodies
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Diffuse increase in iodine uptake
 
 
 
Localized increase in iodine uptake
 
 
 
Subnormal or absent uptake of iodine
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Graves' disease
 
 
Toxic nodular goiter
 
Subacute thyroiditis/ Postpartum thyroiditis
 
Factitious ingestion of thyroid hormones
 
Excess intake of iodine recently
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
High levels of thyroglobulin in serum
 
Low thyroglobulin levels
 
Measure spot urine iodine or 24 hour urine iodine level
 

Treatment

Shown below is an algorithm summarizing the treatment of Graves' disease according to the American Thyroid Association guidelines.[5][6]

 
 
 
 
 
 
 
Overt Graves' disease
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Antithyroid medications
 
 
Radioactive iodine ablation
 
 
Surgery
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
  • Administered in patients with:
  • There is a risk of worsening of existing thyroid eye disease.
    •  
     
     
     
  • Total or near-total thyroidectomy is recommended for patients with:
  • The advantages are:
    •  

    Dos

    Don'ts

    References

    1. ↑ Kravets I (2016). "Hyperthyroidism: Diagnosis and Treatment". Am Fam Physician. 93 (5): 363–70. PMID 26926973.
    2. ↑ Vanderpump MP (2011). "The epidemiology of thyroid disease". Br Med Bull. 99: 39–51. doi:10.1093/bmb/ldr030. PMID 21893493.
    3. ↑ Pearce EN, Farwell AP, Braverman LE (2003). "Thyroiditis". N Engl J Med. 348 (26): 2646–55. doi:10.1056/NEJMra021194. PMID 12826640.
    4. ↑ 4.0 4.1 4.2 4.3 "Correction to: Thyroid 2016;26:1343-1421. DOI: 10.1089/thy.2016.0229". Thyroid. 27 (11): 1462. 2017. doi:10.1089/thy.2016.0229.correx. PMC 5672663. PMID 29035639.
    5. ↑ 5.0 5.1 Ross, Douglas S.; Burch, Henry B.; Cooper, David S.; Greenlee, M. Carol; Laurberg, Peter; Maia, Ana Luiza; Rivkees, Scott A.; Samuels, Mary; Sosa, Julie Ann; Stan, Marius N.; Walter, Martin A. (2016). "2016 American Thyroid Association Guidelines for Diagnosis and Management of Hyperthyroidism and Other Causes of Thyrotoxicosis". Thyroid. 26 (10): 1343–1421. doi:10.1089/thy.2016.0229. ISSN 1050-7256.
    6. ↑ Nwatsock, JF; Taieb, D; Tessonnier, L; Mancini, J; Dong-A-Zok, F; Mundler, O (2012). "Radioiodine Thyroid Ablation in Graves′ Hyperthyroidism: Merits and Pitfalls". World Journal of Nuclear Medicine. 11 (1): 7. doi:10.4103/1450-1147.98731. ISSN 1450-1147.
    7. ↑ Carlé A, Knudsen N, Pedersen IB, Perrild H, Ovesen L, Rasmussen LB; et al. (2013). "Determinants of serum T4 and T3 at the time of diagnosis in nosological types of thyrotoxicosis: a population-based study". Eur J Endocrinol. 169 (5): 537–45. doi:10.1530/EJE-13-0533. PMID 23935127.
    8. ↑ Shigemasa C, Abe K, Taniguchi S, Mitani Y, Ueda Y, Adachi T; et al. (1987). "Lower serum free thyroxine (T4) levels in painless thyroiditis compared with Graves' disease despite similar serum total T4 levels". J Clin Endocrinol Metab. 65 (2): 359–63. doi:10.1210/jcem-65-2-359. PMID 3110204.
    9. ↑ McKee A, Peyerl F (2012). "TSI assay utilization: impact on costs of Graves' hyperthyroidism diagnosis". Am J Manag Care. 18 (1): e1–14. PMID 22435785.
    10. ↑ Koornstra JJ, Kerstens MN, Hoving J, Visscher KJ, Schade JH, Gort HB; et al. (1999). "Clinical and biochemical changes following 131I therapy for hyperthyroidism in patients not pretreated with antithyroid drugs". Neth J Med. 55 (5): 215–21. doi:10.1016/s0300-2977(99)00066-2. PMID 10593131.
    11. ↑ Kuy S, Roman SA, Desai R, Sosa JA (2009). "Outcomes following thyroid and parathyroid surgery in pregnant women". Arch Surg. 144 (5): 399–406, discussion 406. doi:10.1001/archsurg.2009.48. PMID 19451480.
    12. ↑ Weingold AB (1983). "Appendicitis in pregnancy". Clin Obstet Gynecol. 26 (4): 801–9. doi:10.1097/00003081-198312000-00005. PMID 6661836.


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