HYPERTHYROIDISM

AND
HYPOTHYROIDISM
Presented by: Frances Ashleigh Reign M. Solongon
THYROID GLAND
 HYPERTHYROIDISM
The term "hyperthyroidism" defines a syndrome associated
with excess thyroid hormone production. It is a common
misconception that the terms thyrotoxicosis and
hyperthyroidism are synonyms of one another. The term
"thyrotoxicosis" refers to a state of excess thyroid hormone
exposure to tissues.
 EPIDEMIOLOGY
The prevalence of hyperthyroidism is different
according to the ethnic group, while in Europe,
the frequency is affected by dietary intake of
Iodine, and some cases are due to autoimmune
disease. Subclinical hyperthyroidism occurs more
in women older than 65 than in men, while over
hyperthyroidism rates are 0.4 per 1000 women
and 0.1 per 1000 men and vary with age.
 PATHOPHYSIOLOGY
The pathophysiology of hyperthyroidism depends on the particular
variant of hyperthyroidism.

Toxic multinodular goiter presents with palpable thyroid nodules. It is

the leading cause of hyperthyroidism, particularly in older populations.
Toxic multinodular goiter leads to the production of excess thyroid
hormone from autonomous ectopic tissue, thus leading to clinical
thyrotoxicosis.

In hyperthyroidism, serum T3 usually increases more than does T4,

probably because of increased secretion of T3 as well as conversion of
T4 to T3 in peripheral tissues.
 ETIOLOGY
Ectopic thyroid tissue
Grave's disease
Multinodular goiter
Thyroid adenoma
Subacute thyroiditis
Ingestion of thyroid hormone
Pituitary disease (Anterior gland)
Ingestion of food containing thyroid hormone
Too much iodine
 SYMPTOMS
Weight loss despite an Sweating or trouble
increased appetite tolerating heat

Rapid or irregular Frequent bowel

heartbeat movements

Nervousness, irritability, An enlargement in the

trouble sleeping, fatigue neck, called a goiter

Shaky hands, muscle

weakness
DIAGNOSIS COMPLICATIONS
Complete medical Thyroid storm
history, followed by Loss of consciousness
physical examination, Shortness of breath
including blood pressure Very fast or highly
and heartbeat checks. irregular heartbeat
Complete blood count Atrial fibrillation
(CBC) Osteoporosis or thin
Thyroid scan and weakened bones
Thyroid uptake test Eye problems
 TREATMENTS
ADVERSE EFFECTS

CONTRAINDICATIONS CAUTIONS
(%)

Thionamides Rash/arthropathy (5%) Previous severe allergy Pregnancy- PTU

Carbimazole Agranulocytosis (0.3%) Cross reactivity in 10% preferred. Do not use
Propylthiouracil Hepatitis (rare)
block/replace regimens

Ensure euthyroid first

Hypothyroidism
Radioiodine Pregnancy Ophthalmopathy may
requiring lifelong T4
deteriorate

Hospital stay
Ensure euthyroid first
Neck scar
Surgery
Ophthalmopathy may
Surgical/anaesthetic
deteriorate
risk 10-75% require T4
 HYPOTHYROIDISM
Hypothyroidism can lead to a variety of end-organ effects with a
wide range of disease severity, from entirely asymptomatic
individuals to patients in coma with multisystem failure. In the
adult, manifestations of hypothyroidism are varied and
nonspecific. In the child, thyroid hormone deficiency may
manifest as growth or intellectual retardation.
 EPIDEMIOLOGY
Large-scale neonatal screening programs in North America,
Europe, Japan, and Australia are now in place. The frequency of
congenital hypothyroidism in North America and Europe is 1
per 3,500 to 4,000 live births.

In the Third National Health and Nutrition Examination Survey,

levels of serum TSH and total thyroxine (T4) were measured in a
representative sample of adolescents and adults (age 12 or
older).
 PATHOPHYSIOLOGY
The most common cause of hypothyroidism is the inability of the
thyroid gland to produce a sufficient amount of thyroid hormone.

Production of thyroid depends upon the TSH, iodine intake and protein
intake

Enlargement of thyroid glands results goitre form increased secretion

of pituitary gland

TSH stimulates the thyroid to secrete more level of T4

 ETIOLOGY
The most prevalent etiology of primary hypothyroidism is an iodine deficiency
in iodine-deficient geographic areas worldwide.

PRIMARY HYPOTHYROIDISM SECONDARY HYPOTHYROIDISM

1. Hashimoto's disease
2. Iatrogenic hypothyroidism
3. Iodine deficiency 1. Pituitary disease
4. Enzyme defects 2. Hypothalamic disease
5. Thyroid hypoplasia
6. Goitrogens
 SYMPTOMS
Dry skin Cold intolerance

Weight gain Complaints of lethargy

Constipation and
Depression
weakness

Fatigue
DIAGNOSIS COMPLICATIONS
Antithyroid peroxidase Goiter or enlarged
antibodies and anti-TG thyroid gland
antibodies are likely to Obesity
be elevated in Infertility
autoimmune thyroiditis. Heart diseases such as
Thyroid function tests slowed heart rate
(TFTs) Depression
Thyroid scan Impaired memory
Peripheral neuropathy
Myxedema coma
 TREATMENTS
DRUG/DOSAGE COMMENTS/
CONTENT RELATIVE DOSE
FORM EQUIVALENCY

Unpredictable hormonal
THYROID USP Desiccated beef or 1 grain (equivalent to 60-100 stability; inexpensive
TABLETS pork thyroid gland mcg of T4) generic brands may not
be bioequivalent.

Standardized biologically
to give T4:T3 ratio of 2.5:1
THYROGLOBULIN Partially not purified
1 grain more expensive than
TABLETS pork thyroglobuin
thyroid extract; no clinical
advantage
 TREATMENTS
DRUG/DOSAGE COMMENTS/
CONTENT RELATIVE DOSE
FORM EQUIVALENCY

Stable; predictable
potency; generics are
bioequivalent; when
switching from natural
LEVOTHYROXINE thyroid to L-thyroxine,
TABLETS/ VIAL Synthetic T4 50-60 mcg lower dose by 1/2 grain;
INJECTION variable absorption
between products; half-
life= 7 days, so daily
dosing; considered to be
drug of choice.
 TREATMENTS
DRUG/DOSAGE COMMENTS/
CONTENT RELATIVE DOSE
FORM EQUIVALENCY

Uniform absorption,
LIOTHYRONINE
Synthetic T3 15- 37.5 mcg rapid onset; half-life= 1.5
TABLETS
days, monitor TSH assays

Stable; predictable;
expensive; lacks
LIOTRIX Synthetic T4:T3 in 4:1 50-60 mcg T4 and 12.5-15
therapeutic rationale
TABLETS ratio mcg T3
because T4 is converted
to T3 periphally.
 CASE STUDY
Christina Lopez is a 45-year-old woman who presents to her new PCP
complaining of feeling tired, lethargic, and “fuzzy-headed” for the last 6
months. She has seen her previous PCP several times over this period
of time, and she has been told that her symptoms are probably due to
anemia, depression, or perimenopause. Several months ago, she
developed menorrhagia that resulted in iron deficiency anemia
(hematocrit 31%, MCV 68 μm3). However despite treatment with iron
(and resultant improvement of her anemia), a hormonal contraceptive
to help regulate her menstrual cycle, and an antidepressant, her
symptoms have slowly worsened.
 CASE STUDY
She notes that 2 years ago, she attended a local health fair that provided a
variety of laboratory tests. The result of her TSH at that time was 6.2 mIU/L,
and her total cholesterol was 246 mg/dL. Her PCP felt that the TSH value was
compatible with subclinical hypothyroidism and therefore could not explain
her symptoms. She also has noticed that her skin seems more dry and itchy
and that she has difficulty keeping warm and frequently wears a sweater,
even in warm weather.
 FINDINGS
Feeling tired, lethargic, and "fuzzy-
headed" for the last 6 months
has been told that her symptoms are
probably due to anemia, depression,
perimenopause
months ago, developed menorrhagia
which resulted to iron deficiency
dry appearing skin and scalp
an increase in the number of
episodes of constipation in the past
intolerance to cold
ASSESSMENT
Physical exam- The doctor will also
examine your thyroid gland as you
swallow to see if it's enlarged, bumpy or
tender and check your pulse to see if it's
rapid or irregular.
CBC- Blood tests that measure thyroxine
and thyroid-stimulating hormone (TSH)
can confirm the diagnosis. Blood test for
levels of sugar, cholesterol and thyroid
stimulating hormones.
TSH tests- to help your health care
provider find and maintain the right
dosage of medication for you.
Thyroid function tests (TFTs)
Thyroid scan
 RESOLUTION
NON-PHARMACOLOGIC
Antioxidant-rich foods: e.g.
Blueberries, tomatoes, bell peppers,
whole grains
Foods containing selenium: e.g.
sunflower seeds, Brazil nuts
Foods containing tyrosine: e.g.
meats, dairy, and legumes
Eat healthy and nutritious diet with
necessary amounts of iodine, calcium,
and sodium. High calorie diet to
replenish energy burned by the body
Exercise regularly and drink plenty of
water
PHARMACOLOGIC
MOM (Milk of magnesia)
30mL (oral) daily PRN
Fluoxetine 20 mg po daily
Ortho Tri-Cyclen-28 1 po daily
FeSO4 300 mg po daily
Calcium carbonate 500 mg po
twice daily
Acetaminophen 325–650 mg
po PRN headache, body aches
Levothyroxine
 MONITORING
Repeat HGB test
Endoscopy
Check TSH level regularly
Avoid Iodine-rich foods: e.g. iodized salt
Avoid Cruciferous vegetables: e.g. broccoli, cabbage, spinach,
kale, and brussel sprouts
Avoid Caffeine and Alcohol
Avoid Soy
 CASE STUDY
Debbie James is a 32-year-old woman who returns to her PCP with
complaints of worsening palpitations and continuing shortness of
breath with exertion. She saw the PCP 2 weeks ago for the shortness of
breath and was diagnosed with bronchitis. Despite treatment with an
antibiotic and an inhaler, the symptoms have not resolved. The
palpitations started a few months ago and would come and go until the
past week when they began occurring more frequently, almost daily.
She denies CP. She reports a 10-kg weight loss over the past 2 months,
despite a good appetite. She feels hot all of the time and sweats a lot.
She also reports that she has been losing her hair recently and that she
is more irritable than usual.
 FINDINGS
worsening palpitations and
continuing shortness of breath with
exertion
10-kg weight loss over the past 2
months
hot flashes and sweats a lot
Hair loss and irritability
Hyperpigmented on upper back and
lower extremities; warm and moist.
Goiter and Atrial fibrillation
Fingernails and toenails are flaking.
Thumbnails have prominent ridges.
She has occasional N/V/D.
ASSESSMENT
Physical exam- The doctor will also
examine your thyroid gland as you
swallow to see if it's enlarged, bumpy or
tender and check your pulse to see if it's
rapid or irregular.
CBC- Blood tests that measure thyroxine
and thyroid-stimulating hormone (TSH)
can confirm the diagnosis. Blood test for
levels of sugar, cholesterol and thyroid
stimulating hormones.
Thyroid scan- To check for abnormalities
in the thyroid gland by visualizing the
functioning and non-functioning tissue.
Thyroid uptake test- To measure the
ability of thyroid gland to collect or take
up iodine.
 RESOLUTION
NON-PHARMACOLOGIC PHARMACOLOGIC
Surgical removal of the
Antithyroid Medications/
hypersecreting thyroid gland
Drugs
Surgery should be considered for
patients with a large thyroid gland Thiourea Drugs -
(>80 g) Propylthiouracil (PTU),
Eat healthy and nutritious diet with methimazole (MMI)
necessary amounts of iodine, Iodides
calcium, and sodium Radioactive Iodine
Exercise regularly
Adrenergic Blockers
Foods with antioxidants, Cruciferous
vegetables, Vitamin D rich Foods,
Omega-3 fatty acid containing foods,
and Calcium-rich Foods
 MONITORING
PTU and MMI reduce the synthesis of thyroid hormones and are
similar in efficacy and adverse effects, but their dosing ranges
differ by 20-fold.
Response to PTU and MMI is seen in 4 to 6 weeks with a maximal
response in 4 to 6 months; treatment usually continues for 1 to 2
years, and therapy is monitored by clinical signs and symptoms
and by measuring the serum concentrations of TSH and free
thyroxine.
Take only prescribed nutritional supplements
Avoid eating excessive amounts of iodine-rich foods.
Check thyroid regularly
Drink a lot of water
Avoid smoking, drinking alcohol, and caffeine