Hyperthyroidism resident survival guide: Difference between revisions

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__NOTOC__
__NOTOC__
{{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 |D03= Elevated serum T4 and T 3 levels}}
{{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| | | | | |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 symptoms |E02= Repeat TSH levels in serial dilution }}
{{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| | |F03| | |F04| |F01= Yes. Graves' disease |F02= No |F03= Positive |F04= Negative }}
{{familytree | | |F01| |F02| | |F03| | |F04| |F01= Yes. [[Graves' disease]] |F02= No |F03= Positive |F04= Negative }}
{{familytree | | | | | | |!| | | | |!| | | | |!| | }}
{{familytree | | | | | | |!| | | | |!| | | | |!| | }}
{{familytree | | | | | |G01| | | |G02| | |G03| |G01= Measure serum assays of TRAb and radioactive iodine uptake thyroid scan |G02= High TSH levels due to hetrophilic antibodies |G03= Look out for pituitary lesion }}
{{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: 28em; width: 19em; padding:1em;">
{{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
* Perform MRI [[Brain]]
* High ratio of the serum level of alpha subunit of the pituitary glycoprotein hormone }}
* High ratio of the [[serum]] level of alpha subunit of the [[pituitary]] glycoprotein [[hormone]] }}
{{familytree | |,|-|-|-|-|+|-|-|-|-|-|.| | }}
{{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 |I01| | | |I02| | | |I03| |I01= Diffuse increase in [[iodine]] uptake |I02= Localized increase in [[iodine]] uptake |I03= Subnormal or absent uptake of [[iodine]] }}
{{familytree | |!| | | | |!| | |,|-|-|-|+|-|-|-|.| | }}
{{familytree | |!| | | | |!| | |,|-|-|-|+|-|-|-|.| | }}
{{familytree |J01| | |J02| |J03| |J04| |J05| |J01= Graves' disease |J02= Toxic nodular goiter |J03= Subacute thyroiditis/ Postpartum thyroiditis |J04= Factitious ingestion of thyroid hormones |J05= Excess intake of iodine recently }}
{{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 | | | | | | | | | | |!| | |!| | | |!| | }}
{{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 | | | | | | | | | |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}}


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==Treatment==
==Treatment==
Shown below is an algorithm summarizing the treatment of [[Graves' disease]] according to the American Thyroid Association guidelines.
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>
{{familytree/start |summary=PE diagnosis Algorithm.}}
{{familytree/start |summary=PE diagnosis Algorithm.}}
{{familytree | | | | | | | | A01 |A01= Overt Graves' disease }}  
{{familytree | | | | | | | | A01 |A01= Overt [[Graves' disease]] }}  
{{familytree | | | | |,|-|-|-|+|-|-|-|-|.| | | }}
{{familytree | | | | |,|-|-|-|+|-|-|-|-|.| | | }}
{{familytree | | | |B01| | |B02| | |B03| | |B01= Antithyroid medications |B02= Radioactive iodine ablation |B03= Surgery }}
{{familytree | | | |B01| | |B02| | |B03| | |B01= [[Methimazole|Antithyroid medications]] |B02= Radioactive [[iodine]] ablation |B03= [[Surgery]] }}
{{familytree | | | |!| | | | |!| | | | | |!| }}
{{familytree | | | |!| | | | |!| | | | | |!| }}
{{familytree | | | C01 | | |C02| | | | |C03| |C01= <div style="float: left; text-align: left; height: 24em; width: 19em; padding:1em;">
{{familytree | | | C01 | | |C02| | | | |C03| |C01= <div style="float: left; text-align: left; height: 22em; width: 19em; padding:1em;">
* Methimazole (MMI) is a drug of choice because of its lower side effects profile.  
* [[Methimazole]] (MMI) is a drug of choice because of its lower side effects profile.  
* It should be continued for a minimum duration of 12 to 18 months.  
* It should be continued for a minimum duration of 12 to 18 months.  
* Regular monitoring with TSH and TRAb should be done. |C02= <div style="float: left; text-align: left; height: 24em; width: 19em; padding:1em;">
* Regular monitoring with [[Thyroid-stimulating hormone|TSH]] and TRAb should be done.
* Administered in patients with persistent thyrotoxicosis after anti-thyroid medications or patients who cannot tolerate anti-thyroid medications.
* Ideal in [[patient]]s with:
* Risk of worsening of existing thyroid eye disease. |C03= <div style="float: left; text-align: left; height: 24em; width: 19em; padding:1em;">Total or near-total thyroidectomy is recommended. The advantages are:  
** Mild [[disease]]
* High cure rate
** Small [[goiter]]
* Zero recurrence rate with total thyroidectomy. }}
** [[Pregnancy|Pregnant]] females
{{familytree | |,|-|^|.| | | | | | | | |!| }}
** Elderly [[patient]]s with [[cardiopulmonary]] [[comorbities]] |C02= <div style="float: left; text-align: left; height: 22em; width: 19em; padding:1em;">
{{familytree | D01 | | D02 | | | | | | D03 |D01= |D02= |D03= }}
* Administered in [[patient]]s with:
{{familytree | |!| | | | | | | | | |,|-|^|.| }}
** persistent [[thyrotoxicosis]] after [[methimazole|anti-thyroid medications]]
{{familytree | E01 | | | | | | | E02 | | | E03 |E01= |E02= |E03= }}
** [[patient]]s who cannot tolerate [[methimazole|anti-thyroid medications]].
{{familytree | | | | | | | | | | |!| | | | |!| }}
** [[patient]]s with previous [[neck]] [[surgery]] or [[neck]] [[irradiation]].
{{familytree | | | | | | | | | | F01 | | | F02 |F01= |F02= }}
* 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}}
{{familytree/end}}


{| class="wikitable"
{{familytree/end}}
===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
==Dos==
|-
| An iodinated radiocontrast agent
| 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
|-


|}
*[[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>


==Do's==
==Don'ts==
 
* 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
*[[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" />
==Don'ts==
*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>
* 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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