Endocrinology - 02 (3) - Thyroid Disorders (Courses in Therapeutics and Disease State Management)

Endocrinology:
Thyroid Disorders
Courses in Therapeutics and Disease State Management
Author: Autumn Stewart, PharmD, BCACP, CTTS; Associate Professor of Pharmacy Practice; Duquesne University School of Pharmacy
http://accesspharmacy.mhmedical.com/LearningModuleGroup.aspx?id=8
Copyright © 2017 McGraw-Hill Education. All rights reserved
Epidemiology and Classification
• 12% of the U.S. population will experience thyroid disease in their
lifetime
• Thyroxine (T4) is the predominant hormone secreted by the thyroid
gland
• Thyroid activity is under the control of thyrotropin (TSH) through the
negative feedback system of the hypothalamic–pituitary–thyroid axis
• Deficiencies in T4 (hypothyroidism) or T4 in excess (thyrotoxicosis)
causes symptoms in almost all of the body’s major systems.
Laboratory Tests Used in the Diagnosis and
Treatment of Thyroid Disease (Slide 1 of 2)
• Thyroid Stimulating Hormone (TSH)
• Thyrotropin
• Produced by the anterior pituitary gland in response to TRH (thyrotropin-releasing hormone
• Stimulates secretion of T4 (thyroxine) and T3 (triiodothyronine) from the thyroid
• Regulated by negative feedback inhibition by T4 and T3
• Primary test for screening and monitoring response to thyroid replacement therapy
• Total T4
• Total Thyroxine is free + bound
• T4 is primarily bound (albumin, prealbumin, and thyroxine binding gloubulin (TBG)); remaining free fraction is active
• Affected by binding abnormalities
Link:
• Abnormal levels may indicate binding protein abnormalities Table on Thyroid Function Test Results in Differen
• Free T4 t Thyroid Conditions
• Represents active T4
• Direct measurement is more reliable than total levels
Link:
• Precursor of T3
Figure of Hypothalamic-Pituitary-Thyroid Hormon
• Measure of thyroid function e Axis
Laboratory Tests Used in the Diagnosis and
Treatment of Thyroid Disease (Slide 2 of 2)
• Triiodothyronine (T3) Link:
Table on Thyroid Function Test Results in Differen
• Produced from peripheral de-iodination of T4 hyroid Conditions
• Useful in monitoring thyrotoxicosis
• Thyroid Stimulating Hormone Receptor Antibody (TRaB) Link:
Figure of Hypothalamic-Pituitary-Thyroid Hormo
• Autoantibodies to TSH receptor on thyroid gland Axis
• Mimics TSH and stimulates TSH receptor (confirms Graves Disease)
• Thyroperoxidase Antibody (TPOAb)
• Antibodies against thyroid peroxidase in thyrocytes
• Presence identifies autoimmune disorders
• Predicts conversion of subclinical hypothyroidism to overt hypothyroidism
• Thyroglobulin Antibody (TgAb)
• Used as an adjunct to TPOAb to diagnose Hashimoto’s Thyroiditis
• Used in monitoring thyroglobulin levels in thyroid cancer
Thyroid Disorders
Hypothyroidism Thyrotoxicosis
• Symptoms • Symptoms
• Dry skin • Anxiety
• Cold intolerance • Hyperreflexia
• Weight gain • Palpitations
• Constipation
• Emotional lability
• Depression/loss of ambition
•
• Heat intolerance
Fatigue/loss of energy
• Muscle cramps/stiffness • Weight loss with increased
• Infertility/Heavy menses
appetite
• Hyperlipidemia • Amenorrhea/Menstrual disorders
Hypothyroidism
• Primary hypothyroidism
• Hashimoto’s disease
• Iatrogenic hypothyroidism
• Iodine deficiency
• Enzyme defects
• Thyroid hypoplasia
• Goitrogens
• Secondary hypothyroidism
• Pituitary disease
• Hypothalamic disease
Hypothyroidism: Autoimmune Thyroiditis
(Hashimoto’s Disease) (Slide 1 of 2)
SJ is a 44 year old female with no significant past medical history. During a
wellness visit with her primary care physician, she asks if there are any
vitamins or supplements she can take for her skin, nails, and hair. She notes
that her skin has become unusually dry and her hair is coarse and brittle.
She endorses a lack of energy lately but had attributed this to the “extra
pounds” she has put on over the last year. She denies any changes in her
diet and her only medication is an over-the-counter laxative she takes a few
times a week as needed.
• What screening tests can be done to screen for thyroid disease as a cause
of her symptoms?
Hypothyroidism: Autoimmune Thyroiditis
(Hashimoto’s Disease) (Slide 2 of 2)
• Screening Evidence supports screening in patients with:
• TSH (TSH with reflex free T4) Autoimmune disease Pernicious anemia
1st degree relative with Radiation to the thyroid
• Diagnosis autoimmune thyroid gland
• T4 (low-normal) disease
A history of thyroid Psychiatric disorders
• Elevated Thyroperoxidase and surgery or abnormal
Thyroglobulin antibodies thyroid exam
• Subclinical hypothyroidism Taking amiodarone or Disorders associated with
• TSH 5-10mIU/ml lithium thyroid disease
• Overt hypothyroidism Reference: Endocr Pract. 2012; 18:6
• TSH >10mIU/ml
Link:
Table covering Thyroid Function Test Results in Differ
ent Thyroid Conditions
Hypothyroidism: Management
• Subclinical hypothyroidism
• Positive antibodies
• Cardiac disease
• Symptomatic
• Levothyroxine 25-75 mcg/day
• Overt hypothyroidism
• Full replacement dose is approximately 1.6mcg/kg of ideal body weight (typically 125mcg/day)
• Lower starting doses
• Elderly: 50 mcg
• Coronary heart disease: 12.5-25mcg
• Dosage adjustments
• Based on TSH 6 weeks after initiation, dose adjustments, or change in manufacturer
• Target is TSH in normal range
• Adjustments made in increments of 12.5-25 mcg
• Slower in elderly or underlying cardiac disease
• Stable patients every 12 months
Link: Table covering Thyroid Preparations Used in the Treatment of Hypothyroidism
Concept Review
• SJ returns 1 week later for follow-up on lab work.
• TSH: 9.3 mIU/ml
• TPO Antibodies are elevated
• She is diagnosed with subclinical hypothyroidism and is started on
levothyroxine 25mcg QAM.
Hypothyroidism: Patient Education
(Slide 1 of 2)
• Administration
• 30-60 minutes on empty stomach first thing in the morning
• Adverse Effects
• Thyrotoxicosis
• Heart failure
• Angina pectoris
• Myocardial infarction
• Osteoporosis
• Hypersensitivity rare with synthetic T4
Hypothyroidism: Patient Education
(Slide 2 of 2)
Selected Interactions Affecting • Charcoal
Absorption • Orlistat
• Bile acid sequestrants • Ciprofloxacin
• Sucralfate • H2 receptor antagonists
• Multivitamins • Proton pump inhibitors
• Antacids • Grapefruit juice
• Ferrous sulfate • Espresso coffee
• Phosphate binders • High fiber diet
• Calcium salts • Soy
• Chromium picolinate
Thyrotoxicosis (Slide 1 of 5)
Link: Table on Differential Diagnosis of Thyrotoxicosis
Link: Photos illustrating features of Graves’ Disease
• Graves’ Disease
• Thyrotoxicosis
• Exophthalmos
• Lid lag
• Pretibial myxedema
• Thyroid acropachy
• Screening
• TSH (TSH with reflex free T4)
• T4/T3
• Radioactive iodine uptake (RAIU) test
• Thyroid Stimulating Hormone Receptor Antibody
• Diagnosis
• TSH (undetectable-low)
• T4/T3 high
• Increased RAIU
• Positive antibodies
Link:
Table covering Thyroid Function Test Results in Different Thyroid Conditions
Management
• Beta-blockers
Link:
Table covering Treatments for Hyperthyroidism Caused by Graves’ Dise
ase
• Thioureas
• Methimazole (MMI) 15-60mg daily in 3 divided doses
• Propylthiouracil (PTU) 300-600 mg daily in 3 divided doses
• Methimazole is the drug of choice
• Exception: 1st trimester of pregnancy
• Doses tapered monthly
• Monitoring
• Hepatotoxicity
• Rash
• Leukopenia/Agranulocytosis
• Arthralgias
• Patient education
• Hepatotoxicity
• Report jaundice, dark urine, pale stools
• Agranulocytosis
• Report malaise, fever, oropharyngeal infection
• Continue 12-24 months to induce remission
• Potential need for lifelong treatment with T4

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Link: Table covering Thyroid Preparations Used in the Treatment of Hypothyroidism

Link: Photos illustrating features of Graves’ Disease

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