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Disorders of Thyroid Function
Disorders of Thyroid Function
Disorders of Thyroid Function
Hypothyroidism
Hyperthyroidism
Typical Thyroid Hormone Levels
in Thyroid Disease
TSH T4 T3
Hypothyroidism High Low Low
Hyperthyroidism Low High High
Thyroid Disease Spectrum
Overt Hypothyroidism
TSH >4.7 IU/mL, Free T4 Low
Subclinical Hypothyroidism
TSH >4.7 IU/mL, Free T4 Normal
Euthyroid
TSH 0.5-4.7 IU/mL, Free T4 Normal
Hyperthyroidism
TSH <0.5 IU/mL, Free T3/T4 Normal or Elevated
0 5 10
TSH, IU/mL
Braverman LE, et al. Werner & Ingbars The Thyroid. A Fundamental and Clinical Text. 8th ed. 2000.
Canaris GJ, et al. Arch Intern Med. 2000;160:526-534.
Vanderpump MP, et al. Clin Endocrinol (Oxf). 1995;43:55-68.
Prevalence of Abnormal Thyroid
Function
The Colorado Thyroid Disease Prevalence study
Used thyroid stimulating hormone (TSH) levels as a
measure of thyroid function
Prevalence of elevated TSH levels (hypothyroidism)
was 9.5% and the prevalence of decreased TSH
levels (hyperthyroidism) was 2.2%
Lipid levels increased as thyroid function declined
40% of patients taking thyroid medications had
abnormal TSH levels
Females
Participants With
similar between
males and
females
At 40 years of
age, a higher
percentage of
female patients
have elevated
TSH levels
Deepening of Voice
Depression
Persistent Dry or Sore Throat
Inability to Concentrate
Thinning Hair/Hair Loss Difficulty Swallowing
Heavy Period
Weight Gain Infertility
Cold Intolerance
Elevated Cholesterol Constipation
Muscle Weakness/
Family History of Thyroid Disease or
Cramps
Diabetes
Hypothyroidism and Depression
Have Many Common Features
Depression Hypothyroidism
Constipation
Appetite decrease Bradycardia
Decreased concentration Cardiac and lipid
Sleep decrease Decreased libido abnormalities
Suicidal ideation Delusions Cold intolerance
Weight loss Depressed mood Delayed reflexes
Appetite increase/ Diminished interest Goiter
decrease Sleep increase Hair and skin
Weight increase changes
Fatigue
Bravernan LE, Utiger RE, eds. Werner & Ingbar's The Thyroid.
8th ed. Philadelphia, Pa: Lippincott Williams & Wilkins; 2000.
Persani L, et al. J Clin Endocrinol Metab. 2000; 85:3631-3635.
Primary Hypothyroidism:
Underlying Causes
Congenital hypothyroidism
Agenesis of thyroid
Defective thyroid hormone biosynthesis due to enzymatic defect
Thyroid tissue destruction as a result of
Chronic autoimmune (Hashimoto) thyroiditis
Radiation (usually radioactive iodine treatment for thyrotoxicosis)
Thyroidectomy
Other infiltrative diseases of thyroid (eg, hemochromatosis)
Drugs with antithyroid actions (eg, lithium, iodine, iodine-
containing drugs, radiographic contrast agents, interferon alpha)
Subclinical Overt
Euthyroid Hypothyroidism Hypothyroidism
TSH
Normal
Range
T3
T4
Years
Hyperlipidemia
Depression
Gynecological conditions
Aging
300
250 Hypothyroid
Lipid Levels, mg/dL
100 Subclinical
Hyperthyroid
50 Hyperthyroid
0
Total-C* LDL-C* HDL-C* Triglycerides
50
0
Women With Euthyroid Women Euthyroid
Subclinical Women With Women
Hypothyroidi Subclinical Without
sm Hypothyroid Antibodies to
ism and Thyroid
Antibodies Peroxidase
to Thyroid
Peroxidase
Hak AE, et al. Ann Intern Med. 2000;132:270-278.
Subclinical Hypothyroidism Increases
Risk of Myocardial Infarction (cont.)
-5
-10
(mg/dL), %
-15
-20
-25
-30
-35
-40
150
LDL-C (mg/dL)
10
TC (mg/dL)
240
8
6 145
4
2
0 230 140
LT4 Placebo LT4 Placebo LT4 Placebo
Before After
AACE MEDICAL GUIDELINES FOR CLINICAL PRACTICE FOR THE EVALUATION AND TREATMENT OF HYPERTHYROIDISM AND HYPOTHYROIDISM.
ENDOCRINE PRACTICE Vol 8 No. 6 2002
JAMA 2004; 291:228-238
Treatment of Hypothyroidism
Hypothyroidism Treatment Goal
Euthyroidism
6-8 Weeks
Singer PA, et al. JAMA. 1995;273:808-812. Demers LM, Spencer CA, eds.
Demers LM, Spencer CA, eds. The National Academy of Clinical Biochemistry Web site.
Available at: http://www.nacb.org/lmpg/thyroid_lmpg.stm. Accessed July 1, 2003.
Caution in Patients With Underlying
Cardiac Disease
Using LT4 in those with ischemic heart disease increases
the risk of MI, aggravation of angina, or cardiac
arrhythmias
For patients <50 years of age with underlying cardiac
disease, initiate LT4 at 25-50 g/d with gradual dose
increments at 6- to 8-week intervals
For elderly patients with cardiac disease, start LT4 at
12.5-25 g/d, with gradual dose increments at 4- to 6-
week intervals
The LT4 dose is generally adjusted in 12.5-25 g
increments
0
Before Ingestion After Ingestion
Changes Tachycardia
Family History of
First-Trimester Miscarriage/
Thyroid Disease
Excessive Vomiting in Pregnancy
or Diabetes
Initial Evaluation of a Patient with
Hyperthyroidism
Braverman LE, Utiger RD, eds. The Thyroid: A Fundamental and Clinical Text. 8th ed.
Philadelphia, Pa: Lippincott, Williams & Wilkins; 2000;1001.
Potential Consequences of
Subclinical Hyperthyroidism
Beta blockers
Corticosteroid therapy
Bile acid sequestrants
Iodide
Which Treatment to choose?
Depends on:
Patient preference
Severity of hyperthyroidism
Evidence of complications of
hyperthyroidism
Pregnancy
The cause of hyperthyroidism
Unusual Thyroid Studies
iTSH but FT4 also i
Get FT3
T3 toxicosis is not uncommon in Graves
disease- an elevated or high normal FT3
would be suggestive, as would a positive TSI
and diffuse goiter
Sometimes seen in acute/chronic illness
Central hypothyroidism is very rare in the
absence of risk factors or suspicious history
but would be suggested if FT3 also low
iFT4, but Normal TSH and FT3
Thyroiditis
Iodine induced thyrotoxicosis
Factitious Hyperthyroidism
Central Hypothyroidism