Management of

Grave’s diseases
REPORTER: HIDVARD CAMINERO
ER level intervention

 Admit patient
 Consent to care
 IVF: PNSS 1L x KVO
 Diet: NPO except meals
 Monitor VS q4, I/O qshift
 Moderate to high back rest
 Problem #1: Grave’s diseases in impending storm, thyrotoxic heart diseases in
Afib in RVR, FCII
ER level intervention

 Diagnostics:
Chest xray PA
12L ECG
TSH, F3, F4
PT INR
CBC w/ PC w/ BT
BUN, Crea, Na, K, Ca, Mg
NT-proBNP
ER level intervention

 Treatment:
Methimazole 20mg tab TID
Hydrocortisone 100mg IV q8h
Propanolol 100mg tab TID
Digoxin 0.25mg IV q24
Omeprazole 40mg IV q24
Furosemide 30mg IV q12h
Management

 HYPERTHYROIDISM OF GRAVE’S DISEASES:

1. Reducing the thyroid hormone synthesis
2. Reducing the amount of thyroid tissue
3. Surgery (Thyroidectomy)
Main antithyroid drugs

 Thionamides:
1. Propylthiouracil (Hepatotoxic)  Liver function test
2. Carbimazole
3. Methimazole

MOA: all inhibit the function of TPO and reduce oxidation and organification of
iodide.

Of unknown reason they can also reduce thyroid antibody levels

Antithyroid drugs

 Variations in antithyroid regimen:

1.) 10-20mg of carbimazole or methimazole every 8-12 hours. Once-daily after
reaching euthyroid state.

2.) 100-200mg of Propylthiouracil every 6-8 hours. Throughout the course.

Doses are gradually reduced as the thyrotoxicosis improves

Antithyroid drugs

 Thyroid function tests and clinical manifestations are reviewed

4–6 weeks after starting treatment, and the dose is titrated based
on unbound T4 levels.
Antithyroid drugs

 Titration regimen:
2.5-10mg of carbimazole or methimazole
50-100mg of propylthiouracil
Antithyroid drugs

 Remission rates
30-60% in some populations and are achieved in 12-18 months
And higher in those with TRab levels that are undetectable
Antithyroid drugs

 Side effects:
Rash  antihistamine
Urticaria
Fever
Arthralgia

Major side effects (rare): (Drug should be stopped and not restarted)
Hepatitis (propylthiouracil)
Cholestasis (methimazole and carbimazole)
Vasculitis
Agranulocytosis (sore throat, fever, mouth ulcers)  urgent CBC
Beta1 receptor blocker

 20-40mg propranolol every 6 hours

 Anticoagulation with Warfarin

-considered in all patients with Afib
Radioiodine

 Progressive destruction of thyroid cells

Carbimazole and methimazole should be stopped 2-3days before the use of

radioiodine. And restarted 3-7 days after.

Propylthiouracil is stopped for a longer period before the use of radioiodine

Total or near total thyroidectomy

 Patients who relapse after antithyroid therapy and when the patient prefer this
treatment.

 Recommendations: younger patient with very large goiter

Complications:
Bleeding
Laryngeal edema
Hypoparathyroidism
Recurrent laryngeal nerve damage
Thyrotoxic crisis or thyroid storm

 exacerbation of hyperthyroidism, accompanied by

fever, delirium, seizures, coma, vomiting, diarrhea, and jaundice.

 Large doses of Propylthiouracil (DOC)

500–1000 mg loading dose and 250 mg every 4 h
orally, nasogastric tube, or per rectum
Ophthalmopathy

 Periorbital edema  control thyroid hormone, upright sleeping position and

diuretics.

 Corneal exposure  Taping the eyelids

Severe ophthalmopathy

 Pulse therapy with IV methylprednisolone

500 mg of methylprednisolone once weekly for 6 weeks
then 250 mg once weekly for 6 weeks

Orbital decompression -removing bone from any wall of the orbit, allowing
displacement of fat and swollen extraocular muscles.
Thyroid dermopathy

 high-potency glucocorticoid ointment under an occlusive dressing