Endang Isbandiati Soediono

Dr, dr, MS, SpFK

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• Large iodide load
excessive hormone production

Wolff-Chaikoff block
. Normal : escape from the block 7-14Ds
. Not overcome by TSH

• Decrease iodide transport, or iodide leak

block escape

Hashimoto’s thyroiditis hypothyroidism

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 ABNORMAL DYSFUNCTION
• CLEARANCE
CHOLESTEROL, CAROTENE, TRANSAMINASES
(SGPT, SGOT), CPK, LDH

• HYPERTHYROIDISM
. INCREASE
• HYPOTHYROIDISM
. DECREASE
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 DRUG-INDUCED
• Interferon – α
• Lithium : immune modulating; blocking
hormone release
• Amiodarone
• Iodine – induced thyrotoxicosis (Jod-
Bassedow)
Abnormal thyroid gland

. Lost protective Wolff-Chaikoff block

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 HYPERTHYROIDISM
• Pregnancy
. Thioamides : w. precaution
. RAI and iodides : absolutely CI
. PTU : preferred tx. faster OOA
thyroid storm
severe hyperthyroidism
initial dose < 300 mg/day(ddd),
maintenance do. 50-100mg/day throughout
pregnancy
. Methimazole : congenital skin defect
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• MMI
. Single daily dose
. More potent
. Less expensive
. Better tolerated
. Lo.Do. : less toxic
. HL : 4-6Hs ; DOA : 24-36Hs

• PTU
. HL : 1-2Hs

• DOA and frequency of dosing depend on the

intrathyroidal HL, not on the short plasma HL
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• Severe toxemia or thyroid storm :
. PTU : may need 1200 mg/day in divided dose
. Tapering thioamide dose :
. symptom reduce
. T4 level normal

reduced gradually, one-third each Mo.

until daily maintenance 5-15 mg MMI or
50-150 mg/day PTU
• If PTU the initial drug, because nonadherence,
need a change to MMI
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THIOAMIDE :CIE
• PTU
• Pruritic maculopapular skin rash
. Report symptoms of skin reactions :
antihistamine for pruritus, if rash persists
alternative thioamide
• Hepatitis : elevation of transaminases
. PTU shouldbe stopped immediately
. Alcoholism : avoid alcohol
• Hypoprothrombinemia , serologic abnormality,
lupus: withdrawal the drug, or (+) steroid
• Agranulocytosis:immediately report the onset of
symptom: corticosteroid
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• Potassium perchlorate
. Iodide competitive inhibitor
. Short-term tx. Amiodarone-induced hyperthyroidism
. Antithyroid effect can be overcome by iodine adm.

• Iodides
. Inhibit organification (Wolff-Chaikoff effect)
. < hormone release
. < gland vascularity
. < size

Should not be used before RAI therapy block effective RAI

retention by the gland
. Chronic iodide: avoid throughout pregnancy fetal
goiter anf asphyxiation
. Vaginal povidone, topical iodine high serum iodine
concentration : avoid
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• Adrenergic Blocker
. Ameliorate hyperthyroid sy. : palpitation, anxiety, tremor,
heat intolerance
. Propranolol (d-isomer), nadolol : block T4 to T3 conversion
. CI : asthma, COPD, sinus bradycardia, pts.w. MOA-I, TCA,
pts.w. spontaneous hypoglycemia
. Clonidine,
. Diltiazem

. PK in toxemia :
VD > ; first-pass effect; HBF > ; altered hepatic function

. propranolol clearance > : higher dose

. atenolol, nadolol : renally excretion , OD
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• Radio Active Iodine
. Maximum effect : 3-4 Mo.
. β - blocker: can be given any time
. If (+) Iodide : 3-7Ds. After RAI !!!
. Pts. w. cardiac disease and elderly :
pretreatment w. thioamide prior (1 Mo.; withdraw
1W. before and after) to RAItx.
after RAI tx. (10-14Ds.)
. Prophylactic : corticosteroid ( pts.w.mild eye sy.)

• Iodinated Contrast Media (ipodate)

. nontoxic : tx.(+) thioamide in acute thyrotoxicosis
. Not for chronic tx.
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Thyroid Storm
• Life-threatening medical emergency :
. Decompensated thyrotoxicosis, high fever,
tachycardia, tachypnea, dehydration, delirium,
coma, n, v, d
• Precipitating factors
• Tx. :
. PTU Hi.Do.
. Iodides ( 1 hour after PTU)
. Beta-blocker short acting
. Corticosteroid (antipyretic, stabilizing BP)
. Antipyretic agents : do no use NSAIDs
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 HYPOTHYROIDISM
• PREGNANCY
. Tx. Levothyroxine TSH < 1 unit/mL and
maintain normal free T4
. PB >; < free ho. concentration; modification of
peripheral metabolism; increase T4 metabolism

. Thyroid ho. demand :

increase dose 36 mcg/day ( 8 Ws.)
decrease (6-8 Ws.))after delivery
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 Metabolism and Clinical Efficacy of Drug
• Digitalis
VD
increased sensitivity (lower dose)
• Insulin degradation : delayed lower dose
• Clotting factor catabolism delays :
(tx. levothyroxine) euthyroid watch :
pts. w. warfarin excessive anticoagulation
• Respiratory depressants ( barbiturate,
phenothiazines, opioid analgesic ) : increase
sensitivity CO2 retention
precipitate myxedema coma Avoid
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Insulin

FFA
TG
• Insulin (-) :

FFA β - hydroxybutyric acid ,

acetoacetic acid, acetone

ketoacidosis

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• Biguanides
. Antihyperglycemic
. Reduce risk for developing diabetes at high risk pts. (IGT
and IFG)
• Lowers FPG :
. Hepatic gluconeogenesis <
. Insulin-stimulated glucose uptake >
• Total cholesterol <, TG <, HDL >
• Weight loss
• GI sy. : take w. food and slowly titrating dose; subside
w. time
• Drug Interactions :
. Alcohol, cimetidine, iodinated materials
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• Nonsulfonylurea Secretagogues
. DI : (+) gemfibrozil risk of hypoglycemia
. Avoid: (+) gemfibrozil and itraconazole
inhibit repaglinide metabolism

• Sulfonylurea
. DIs :
. PB displacement warfarin, salicylates,
phenylbutazone, sulfonamides
. Alters hepatic metabolism
chloramphenicol, MOA-I, cimetidine, rifampin
. Alter renal excretion allopurinol,
probenecid
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• Hypertension in DM
. Increase risk of microvascular complication
. Initial tx. : . ACE-I or . ARB
. Second-line tx. : diuretic
. CCB
. β - blocker

• CHD
. β - blocker (protection from recurrent CHD)

. LDL < 100 mg/dl HMG-CoA reductase I;

cholesterol absorption inhibitor; niacin or fenofibrate
. HDL men > 40, women > 50 mg/dL
nicotinic acid, fibric acid derv.
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• TG < 150 mg/dL glycemic
control; fibric acid derv. ; Hi.Do. Statin (+ high
LDL)
• (+) vit D improve statin tolerance,
reduce statin-ascociated myalgias

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