16 - Farmako Graves

8/16/2019 16 - Farmako Graves

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Pharmacotherapy Hyperthyroidism

dr. R. Setiadji, M.Sc


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Clinical manifestation

Symptoms due to Hyper metabolism: Heat intolerance,

excessive perspiration, warm moist smooth skin, fatigue,

weight loss

Goiter: Enlargement or nodules

!phthalmopathy: " sense of irritation in eyes, excessive

tearing, exophthalmos, blurred vision, easy tiring of the

eyes, double vision


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Nervous system: Nervousness, emotional lability,

irritability, fine tremor of hands.

Cardiovascular: al!itation, tachycardia, atrial

fibrillation, "idened !ulse !ressure.#astrointestinal: $ncreased a!!etite,

%y!erdefecation, diarrhea

%ematolo&ic system: Moderate neutro!enia, mild

anemia. 'thers: Muscle atro!hy, oli&omenorrhear.

Clinical manifestation


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()*

Male to female +:4-

Chief clinical findin&s

Graves diseaseGraves disease

Symptoms due to Hypermetabolism

Goiter

!phthalmopathy


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"bnormal immune: #$"b Heredity

%nfection: &olecular mimicry

Cytokine

Superantigen Spirit irritation

Etiology and 'athophysiology


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(ifferential diagnosis

!ther causes of thyrotoxicosis

"nxiety neurosis or mania

Some states of hypermetabolism without thyrotoxicosis:

severe anemia, leukemia, etc Cardiac disease: atrial fibrillation, angina

'heochromocytoma

!ther causes of ophthalmoplegia )myasthenia gravis* and

exophthalmos )orbital tumor*


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+aboratory (iagnosis

Serum #, #-, .#, .#-

Sensitive #SH assay

Serum #$"b

#est of #$H irritation

$adioactive iodine uptake:

/ormal: h 01203, 2-h 241-03, peak at 2-h

#hyroid scan: 55%, 66m#c


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Si&ns and sym!toms of hy!erthyroid

0S% level

1o" 0S%%i&h 0S% rare

Measure 04

%i&h

Secondaryhy!erthyroidism

$ma&e !ituitary &land


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+ow #SH

Measure 5ree 04 1evel

Normal %i&h

Measure 5ree 03 1evel

Normal %i&h

ubclinical

!erthyroidism

esolvin&

!erthyroidism

edication

re&nancy

e" thyroid illness

03 0o6icosis

'rimary hyperthyroidism

0hyroid u!ta7e

1o" %i&h

Measure thyro&lobulin

decreased $ncreased

86o&enous 0hyroiditis$odide e6!osure

86rtra&landular

!roduction

9$ffuse Nodular

hormone

#raves

disease

Multi!le

areas

'ne hot; are

0o6ic multinodular

&oiter

0o6ic

adeno


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0he &oal of thera!y is to correct hy!ermetabaolic

state "ith fe"est side effects and lo"est incidence of

hy!othyroidism.

Treatment


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Treatment Hyperthyroidism

• 0hyrostatics – 0<

– Carbima=ole

–

Methima=ole• >etabloc7ers

– 1!ro!anolol sym!tom hy!erthyroidism

– 9!ro!ranolol bloc7 04?03

• enenan&

• Sur&ery


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PTU

• refered for !re&nant !atients, Methima=ole is associated"ith rare &enetic abnormalities

9ose + m& t.i.d

Maintenance +2 m&?day #oal: @ee! 5ree 04 at u!!er level of normal

com


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PTU

Complications• A&ranulocytosis u! to .)*• %i&h "ith 0<• Can occur suddenly• Mostly reversible "ith su!!ortive 06

• Routine B>C monitorin& controversial• Some !eo!le monitor B>C every t"o "ee7s for first month

then monthly• Advised to sto! dru& if they develo! sudden fever or sore

throat

grou


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Methimazole

9ru& of choice for non!re&nant !atients because of:• 1o" cost• 1on& half life

• 1o"er incidence of side effects• Can be &iven in conjunction "ith betabloc7er • >etabloc7ers can be ta!ered off after 4( "ee7s

of thera!y

(ose 5014 mg7day


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• Monthly 5ree 04 or 03 until euthyroid

• Maintenance dose )+ m&?day

• 0S% levels may remain undetectable for months after euthyroid

and not to be used to monitor the thera!y

Methimazole


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Methimazole

• At one year if !atient is clinically and biochemicallyeuthyroid and 0S antibodies are not detectable, thera!ycan be discontinued

• Monitor every three months for first year then annually

• Rela!ses are more common in the first year but can occuryears later

• $f rela!se occurs, iodide or sur&ery althou&h antithyroiddru&s can be restarted


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Beta Blockers

• rom!t relief of adrener&ic sym!toms• ro!ranolol "idely used• Any beta bloc7er can be used, but nonselectives

have more direct effect on hy!ermetabolism•

Start "ith +2 m& -h• $ncrease !ro&ressively until sym!toms are

controlled• Most cases (32 m& d is sufficient

$7


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Resep1

• R? 0< tab +2 m&?hr !re&nant• R? Methima=ol tab )+ m&?hr

• R? !ro!anolol tab (m& 4dd +2 bl

• R?>en=odia=e!ine 2) m& 7!


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• Remission rate: -* "hen thera!y continued for t"o years

• Rela!se in )* of cases.

• Rela!se more common in

smo7ers elevated 0S antibodies at end of thera!y

Prognosis

finish


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Iodides

$odide bloc7s !eri!heral conversion of 04 to 03 and inhibitshormone release. 0hese are used as adjunct thera!y

• >efore emer&ency nonthyroid sur&ery

• >eta bloc7ers cannot curtail sym!toms

•9ecrease vascularity before sur&ery for #raveDs disease


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Iodides

$odides are not used for routine treatment because of!arado6ical increase of hormone release "ith !rolon&eduse

Commonly used:

• Radio&ra!h contrast a&ents

$o!anoic acid

$!odate sodium

• otassium iodide

9ose + &ram? +2 "ee7s


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Radioactive Iodine

• 0reatment of choice for #raveDs disease and to6ic nodular&oiter • $ne6!ensive• %i&hly effective• 8asy to administer

• Safe• 9ose de!ends on estimated "ei&ht of &land• %i&her dose increases success rate but hi&her chance of

hy!othyroidism• Some studies have sho"n increase of hy!othyroidism

irres!ective of dose


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Radioactive Iodine

• %i&her dose is favored in older !atient• Cardiac disease

• 'ther &rou! needs !rom!t control

• 0o6ic nodular &oiter or to6ic adenoma


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Radioactive Iodine

Side effects• )* of #raveDs o!hthalmolo&y can develo! or "orsen by

use of radioactive iodine

•


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Radioactive Iodine

• eta bloc7ers used to control sym!toms before radioactive

iodine and can be combined throu&hout 06• $odine containin& meds need to be sto!!ed several "ee7s

before thera!y


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Radioactive Iodine

a!ety• Most radioactive iodine is eliminated in the urine, saliva and

feces in 4( "ee7s.

• %ave double flushin& of toilet and freuent hand "ashin&for several "ee7s

• No close contact "ith children and !re&nant !atients for 4(2 hours

• Additional 06 may be needed after three months if indicated


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"rgery

•Radioactive iodine has re!laced sur&ery for 06 ofhy!erthyroidism

• Subtotal thyroidectomy is most common

• 0his limits incidence of hy!othyroidism to 2)*

•

0otal thyroidectomy in lar&e &oiter or severe disease

Documents

16 - Farmako Graves