Curriculum vitae

Tips And Tricks In Managing

Thyroid Disorders
Classification of Thyroid Disorders

Form
Diffuse Nodular

Function
Hypo- Euthyroid Hyper-

Pathology
Benign Malignant
Distinguish Diffuse From
Nodular Goiter
 Over or Under Production of
Thyroid Hormones

HYPERTHYROIDISM: HYPOTHYROIDISM:

Overproduction of Low production of

Thyroid hormones thyroid hormones
 Permutation of Thyroid Disorders
Based on “FFP”
Form Function Pathology
Diffuse Hypothyroid Benign
Malignant
Euthyroid Benign
Malignant
Hyperthyroid Benign
Malignant
Nodular Hypothyroid Benign
Malignant
Euthyroid Benign
Malignant
Hyperthyroid Benign
Malignant
  Clinical Situations Where Antithyroid Drug
Is The Preferred Mode of Treatment

Pregnancy

●
Women
●
With mild disease
●
Small goiters
●
Negative or low-titer TRAb

Active Graves Ophthalmopathy (GO)

Patients with high likelihood of remission:

Ross DS, et al. THYROID. 26(10): 1343-1421, 2016

  Clinical Situations Where Surgery Is
The Preferred Mode of Treatment
Active GO

Patients with periodic paralysis

Thyroid malignancy confirmed or suspected

One of more large thyroid nodules

Coexisting primary hyperparathyroidism requiring surgery

Ross DS, et al. THYROID. 26(10): 1343-1421, 2016

  Clinical Situations Where RAI Is The
Preferred Mode of Treatment
Comorbidities with increased surgical risk and/or
limited life expectancy
Liver disease
Major adverse reactions to ATDs
Patients with previously operated or externally
irradiated necks
 Patients with periodic paralysis
 Patients with right pulmonary hypertension, or
congestive heart failure
 Lack of access to a high-volume thyroid surgeon

Ross DS, et al. THYROID. 26(10): 1343-1421, 2016

  Contraindications To RAI As
Treatment For Graves’
Hyperthyroidism

Pregnancy
Lactation
Coexisting or suspicion of thyroid cancer
Unable to comply with radiation safety
guidelines
Ross DS, et al. THYROID. 26(10): 1343-1421, 2016
The Synthesis Of Thyroid Hormones
Treatment Of Hyperthyroidism
Mechanisms Of Anti-Thyroid
Drugs
 Factors That Determine The
Levothyroxine Dose Required
Patient’s Lean body Pregnanc
weight mass y status
Etiology of
hypothyroidis
m
Degree of
TSH elevation Age
Presence of
General
cardiac
clinical context
disease
Jonklaas, J., et al. Guidelines For The Treatment Of Hypothyroidism 2014 (doi: 10.1089/thy.2014.0028)
 Initial Daily Dosage Of L-Thyroxine Is
Dependent On Age, Sex, And Body Size

Young healthy adults

●
Full replacement dosage

Elderly patients

●
20–25% less per kilogram

Females

●
Higher dose requirement

Ideal body weight

●
Lean body mass is the best predictor of daily requirements

Garber JR et al. for the AACE-ATA Taskforce on Hypothyroidism in Adults. THYROID. 22(12): 2012: 1200-1235.
 Therapy Initiation:
Full Replacement Formula

~ 1.6 g/kg of body weight/d

up to 4.0 g/kg of body weight/d

<1.0 g/kg of body weight/d

Ross DS, et al. THYROID. 26(10): 1343-1421, 2016

Singer PA, et al. JAMA. 1995;273:808-812.
Endocr Pract. 2002;8:457-469.
 Best Approach To Initiating And
Adjusting Levothyroxine Therapy

Jonklaas, J., et al. Guidelines For The Treatment Of Hypothyroidism 2014 (doi: 10.1089/thy.2014.0028)
 Conditions That Increase
Levothyroxine Dose Requirements
• Helicobacter pylori–related gastritis
• Atrophic gastritis
• Celiac disease

Jonklaas, J., et al. Guidelines For The Treatment Of Hypothyroidism 2014 (doi: 10.1089/thy.2014.0028)
 Medications That May Alter
Levothyroxine Requirement
• Estrogen and androgens
• Tyrosine kinase inhibitors
• Phenobarbital
• Phenytoin
• Carbamazepine
• Rifampin
• Sertraline

Jonklaas, J., et al. Guidelines For The Treatment Of Hypothyroidism 2014 (doi: 10.1089/thy.2014.0028)
The Axis That Controls Thyroid
Hormone Synthesis
The hypothalamo-pituitary-thyroid axis relationship
is like a seesaw with the fulcrum off-center

Euthyroid

Seesaw
0 0

FT4, FT3 Level TSH Level

 Subclinical Hypothyroidism

Seesaw
0 0

FT4, FT3 Level TSH Level

Negative feedback at Work

 Overt Primary Hypothyroidism

Seesaw
0 0

FT4, FT3 Level TSH Level

Negative feedback at Work

 Euthyroid

Seesaw
0 0

FT4, FT3 Level TSH Level

Negative feedback at Work

 Subclinical Hyperthyroidism

Seesaw
0 0

FT4, FT3 Level TSH Level

Negative feedback at Work

 Hyperthyroidism

Seesaw
0 0

FT4, FT3 Level TSH Level

Negative feedback at Work

  Guide To Initial MMI Daily
Dosing

5–10 mg if free T4  is 1–1.5 X ULN

●

10–20 mg if free T4  is 1.5–2 X ULN

●

30–40 mg if free T4  is 2–3 X ULN

●

Ross DS, et al. THYROID. 26(10): 1343-1421, 2016

 Monitoring of patients taking ATDs

Ross DS, et al. THYROID. 26(10): 1343-1421, 2016

 Treatment And Follow-up of
Thyroid Dysfunction
Treatment Monitor
Hypothyroidism
Overt Levothyroxine TSH
Hyperthyroidism
Overt ATD Ft4, T3
Surgery (TSH)
RAI
Five Tips In Managing Thyroid Disorders

Proper initial diagnosis is the key to appropriate management

Plan the most appropriate management from the beginning

Block excess hormone production at all possible sites along

synthetic pathway

Ensure that the proper treatment dose is received by the patient

Choose the most appropriate parameter to monitor response to

treatment
 Case
23-year-old student complained of frequent pounding since last
3 months, frequent sweating, weight loss about 5 kg, sleeping
not soundly, often restless, weak. Taken to hospital with was
carried, legs limp, difficult to stand / walk
 Case
23-year-old student complained of frequent pounding since last
3 months, frequent sweating, weight loss about 5 kg, sleeping
not soundly, often restless, weak. Taken to hospital with was
carried, legs limp, difficult to stand / walk

Lab: Hb / Hkt / L / Tr , Glucose, LFT wnr

fT4 4 X ULN, TT3 3 X ULN
TSH < 0.001
Na / K 139 / 2,3 mmol/l
 Case
23-year-old student complained of frequent pounding since last 3
months, frequent sweating, weight loss about 5 kg, sleeping not
soundly, often restless, weak.Taken to hospital with was carried,
legs limp, difficult to stand / walk

Lab: Hb / Hkt / L / Tr , Glucose, LFT wnr

fT4 4 X ULN, TT3 3 X ULN
TSH < 0.001
Na / K 139 / 2,3 mmol/l

Terapi: Thiamazol 10 mg 2x2

KSR 2x1

The next lab test in one month recommended

Proper knowledge leads to best
patient care!