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PHMD 446: THYROID AND

ANTITHYROID DRUGS
REVIEW OF THYROID PHYSIOLOGY
The thyroid gland consists of folicular cells
• TSH binds to receptor on the follicular cell and sends a
signal to nucleus of the cell
• The signal increases expression of gene that codes for
synthesis of a protein – Thyroglobulin
• The signal also stimulates the enzyme thyroperoxidase –
TPO
• Iodine is oxidised by TPO. Oxidised iodine rapidly
iodinates tyrosine residues within thyroglobulin to form
monoiodotyrosine (MIT) and diiodotyrosine (DIT). The
process is called iodide organification.
Thyroidal peroxidase (TPO) is transiently blocked by high levels of intrathyroidal
iodine and blocked more persistently by thioamide drugs

• Two molecules of DIT combine in thyroglobulin to form L-thyroxine (T 4)

• One MIT + DIT form T3
• Thyroxine, T3, MIT, DIT are released from thyroglobulin by exocytosis and
proteolysis of thyroglobulin. The MIT and DIT are de-iodinated within the gland
and the iodine reutilised.
• The process of proteolysis is also blocked by high levels of intrathyroidal iodide.
• The ratio of T4:T3 is approx. 5:1. So most of the hormone released is thyroxine
(T4).
• Most of T3 circulating is from peripheral conversion of T4 to T3.
T4 crosses into tissues and is converted to active T3 by
the enzyme de-iodinase.
T3 acts on genes that increases expression of many
enzymes. One such enzyme is Na/K ATPase
This enzyme uses a lot of ATP. This requires metabolism
– glycolysis, lipolysis, glycogenolysis. Thus increase
metabolism generating heat/body temperature
TRANSPORT OF THYROID HORMONES
• Thyroxine and T3 in plasma reversibly bind to proein –
thyroxine binding globulin (TBG)T3).
• Many physiologic states and drugs affect T4, T3 and thyroid
transport.
• Drugs such as amiodarone, Lithium, iodinated contrast
media, B-blockers, and corticosteroids and sevre illness or
starvation inhibit conversion of T4 to T3
Common effects of Thyroid hormone:
• Heart: activates B1 – increases HR, stroke volume increasing
CO
• Bone: maintains balance between osteoblasts and osteoclast
• Nervous system: increase symthatetic drive
• GIT: increase motility and secretions
• Skin: increase cutaneous blood flow nourshing hair, skin and
nail growth. Also acts on sebaceous glands
• Reproductive system: devlopment of reproductive system,
regulate sex hormone binding globulin levels
• Muscle tissue: regenration and growth of skeletal muscles
ANTI- THYROID AGENTS

• The thioamides - methimazole, propylthiouracil

• Carbimazole which is converted to methimazole
• Methimazole is 10x more potent than
propylthiouracil
• Due to warnings about hepatitis propylthiouracil is
reserved for use in first trimester of preganancy, in
thyroid storm and in patients intolerant to
methimazole.
Distinguish between primary and
secondary hyperthyroidism

β-HCG produced by
choriocarcinoma in uterus.
They act like TSH
stimulating thyoid gland.
Since pituitary is normal,
TSH level will reduce but
T4, T3 will remain high
Produce TSH receptor anti-
bodies which stimulates the
gland to produce T4, T3
PATHOPHYSIOLOGY OF TOXIC ADENOMA AND
TOXIC MULTINODULAR

The nodules are caused by TSH receptor mutations

which are capable of stimulating TSH receptors (auto-
stimulation)
Thyroid acropathy – digital clubbing
Sudden acute exacerbation of
all symptoms of
thyrotoxicosis
NEXT LECTURE
This is an end stage of untreated hypothyroidism.
All drugs are admin. IV BECAUSE these pts absorb drugs
poorly from other routes

These pts have parge pools of empty T3 and T4 binding

sites which must be filled before there is adequate free
thyroxine to affect metabolism. A loading dose of L-
thyroxine is therefore given initially.
Hypothyroidism and pregnancy
• Hypothyroid women are often anovulatory and therefore
infertile until restoration of euthyroid state.
• This has led to widespread use of thyroid hormone for
fertility. But no evidence of usefulness in euthyroid pts
• In pregnant hypothyroid women, its essential to ensure
daily dose of thyroxine is adequate BECAUSE development
of fetal brain depends on maternal thyroxine.
Drug-induced hypothyroidism
• Can be satisfactorily managed with levothyroxine if the
offending agent cannot be stopped
• With amiodarone-induced hypothyroidism, L-thyroxine
wmay be required after stopping amiodarone BECAUSE of
its long half life