Prevalence of thyroid disorders - cmcgc.com · Case Study: 54 y/o woman with hypothyroidism (Hashimoto’s) for 21 years--on stable ... (Toxic Diffuse Goiter) The most common cause

1

Who should have a thyroid eval?What do those labs mean?What causes hypothyroidism?Should I treat subclinical cases?How do I give ADTs and RTH?…What’s for lunch?

Christine Kessler RN, MN, CNS, ANP-BC, BC-ADMWashington D.C./Bethesda, MD/Fort Belvoir, VA

Managing Hyper- & Hypothyroid Disorders in Clinical Practice

Objectives:At the conclusion of this session, the participant will be

able to:1. Relate underlying physiology of thyroid hormone

production to diagnostic and assessment findings.

2. More accurately interpret thyroid-related laboratory findings and discern factors that may adversely affect accuracy of findings.

3. Analyze selected case studies for the diagnosis and treatment of various abnormal thyroidal conditions.

4. Discuss the cardiovascular impact of hyper-and hypothyroidism.

Questions• When should you screen for thyroid

dysfunction?

• Is TSH the best laboratory screening for thyroid disorders?

• What are other pertinent diagnostic data and how do they relate to thyroid pathology?

• What are the most common forms of hyper- & hypothyroidism?

• Should subclincal cases be treated?

• Can armour thyroid or T3 be used as replacement therapy

2

Case 1A 75 yo woman c/o “slowing down” & feeling a “little

forgetful.” She has constipation. BP 156/88; HR 62 regular; Physical exam normal for age:

LAB: TSH 9.0 (0.5-4.5 mU/L) FT4 1.1 (0.8-1.8 ng/dL), normal chemistry. Lipids not done

Which of the following actions would be most appropriate?A. Initiate treatment of levothyroxine 25 mcg/day &

recheck TSH in 6 weeks.B. Check lipid profile and start her on treatment if her LDL

is high.C. Check FT3, if low initiate therapy with levothyroxine.D. Check anti-TPO, and repeat TSH & FT4 in 2 – 6 weeks.

Case 2A 60 yo male with history htn, dm type 2, and

hyperlipidemia.MEDS: lisinopril, HCTZ, glipizide XL, and simvastatin. VS: 98.5, HR 98 (reg), resp rate 18, BP 118/78Phys exam is unremarkable. LABS: TSH 0.18 (0.45 – 5.0 mU/L), FT4 1.6 (0.8 – 1.8

ng/dL), FT3 3.5 (1.5-7.0 pmol/L). Chem panel/lipids normal. EKG is also normal

Which of the following statements would be appropriate?A. He has subclinical hypothyroidism with increased risk of develop

osteosporosis & atrial fibrillation so start treatment.B. Check anti-TPO. If it’s positive he will likely develop Graves’

disease in the future.C. He should have thyroid ultrasound, and start ATD.D. He should have a repeat TSH and FT4 in 3 – 6 weeks along with

anti-TPO.

Prevalence of thyroid disorders

• 10 million diagnosed—13 million undiagnosed

• 360,000 new cases each year• 1:8 women will have thyroid problems in

her lifetime (5x>men)• By 60 yrs 20% woman have a thyroid

problem• 40% pts taking thyroid meds have

abnormal TSH!!

3

Canaris GJ, et al. Arch Intern Med. 2000;160:523-534.

Prevalence of Thyroid Disease by Age

Elevated TSH, %(Age in Years)

18 25 35 45 55 65 75

Male 3 4.5 3.5 5 6 10.5 16

Female 4 5 6.5 9 13.5 15 21

•The incidence of thyroid disease increases with age

Are You at Risk?

• Hx of endocrine problem, autoimmune disease

• Fibromyalgia• Female• 60 y/o• Had baby recently or menopausal• Smoker or exposed to radiation• Lithium, amiodarone, excessive flouride

or soy products

When should we screen for thyroid dysfunction?

4

Screening for Thyroid Dysfunction Recommendations for Asymptomatic Adults

OrganizationAmerican Thyroid Association

American Association ofClinical Endocrinologists

American College ofPhysicians

Screening RecommendationWomen and men >35 years of age should be screened every 5 years

Older patients, especially women, should be screened—no mention of age

Screening only in asymptomatic patients older than 60.

Ladenson PW, et al. Arch Intern Med. 2000;160:1573-1575.Cooper DS. N Engl J Med. 2001;345:260-265

Baskin HJ.AACE Thyroid Guidelines, Endocr Pract. 2002;8(No. 6) revised 2002.

Screening for Thyroid Dysfunction Recommendations for Asymptomatic Adults

OrganizationRoyal College of Physicians of London, and the U.S. Preventive Services Task Force (USPSTF)

BUT:…there are ATA pregnancy guidelines:

Screening RecommendationDo not recommend any routine screening for thyroid disease in adults

Check thyroid prior to pregnancy (if at risk) and .during first trimester

Screening for Thyroid Disease: Agency for Healthcare Research and QualityU.S. Department of Health and Human Services. 2004.

.

Joint Statement of AACE, ATA andEndocrine Society:

Lack of definitive evidence for a benefit does not equate to evidence for lack of benefit. Potential benefits of early detection and treatment of subclinical thyroid dysfunction outweigh the potential side effects that could result from early detection and therapy….Therefore, we favor screening for subclinical thyroiddysfunction in adults, including pregnant women andthose contemplating pregnancy.

Thyroid, January, 2005

5

Pregnancy: What ThryoidScreening?

• Ideally, check TSH preconception/ first trimester:

• 0.4-2.5 mU/L: do not need to recheck during preg

• 2.5-5.0 mU/L: recheck TSH during 1st trimester– Check thyroid antibodies—IF THEY ARE

POSITIVE—TREAT SUBCLINICAL HYPOTHYROIDISM

What Do Thyroid Hormones Do?

The great SYNERGIZERIncreases fetal development (synergy with GH)

Increases MVO2, CO, HR

Increased B-adrenergic Beta receptor in heart

Stimulates gut motility and protein catabolism

Major impact on menses and fertility

Lipid Effects of T3

• Stimulates lipolysis and release of free fatty acids and glycerol

• Induces expression of lipogenic enzymes

• Effects cholesterol metabolism• Stimulates metabolism of cholesterol to bile

acids• Facilitates rapid removal of LDL from plasma

6

T4

T3

Hypothalamic-Pituitary-Thyroid Axis

Physiology

Pituitary

Thyroid Gland

Hypothalamus TRH

T4 T3

Liver

T4 T3

Heart

Liver

Bone

CNS

TR

Target Tissues

–

–

TSH

Adapted from Merck Manual of Medical Information. ed. R Berkow. 704:1997.

Production of T4 and T3

• T4 is the primary hormone of the thyroid gland, nearly 9-10x more T4 than T3

• T3 released in very small amounts from thyroid (but is MOST physiologic)

– About 80% of circulating T3 comes from deiodination of T4 in peripheral tissues

– About 20% comes from direct thyroid secretion

Carriers for Circulating Thyroid Hormones

• More than 99% of circulating T4 is bound to plasma carrier proteins---less T3– Thyroxine-binding globulin (TBG), binds

about 75%– thyroxine-binding prealbumin , albumin,

HDL binds the rest– Carrier proteins can be affected by

physiologic changes, drugs, and disease

7

What Can Go Wrong?

Hypothyroidism

Hyperthyroidism

Thyroid nodules/cancer

The problem can be

Intrinsic: thyroid

Extrinsic: H-P disorders

Or dietary/ medication/ acute illness problems

What are the MOST important labs to know?

• TSH

• FT4

• FT3• Thyroid

antibodies

TSH—The Gold Standard

• Assess HPA axis—feedback system

• Less errant than FT4

• Most sensitive for subclinical thyroid disease (98%) & specific (92%)

• Not as useful in central diseases

8

Thyroid Testing

• TSH (0.5-4.5 uU/ml) BUT 0.3-3.0 more appropriate

– Best test for screening for thyroid dysfunction!

– Log/linear response w/ FT4• A 2-fold change in FT4 produces a 100-fold

change in TSH

– Not specific for a particular thyroid disease.• Don’t use TSH alone for diagnosis!

– Also useful in• Assessing thyroid Rx in primary hypothyroidism

• Monitoring TSH-suppressive tx in thyroid Ca

TSH Accuracy Affected By:• Age-increased

• Pregnancy: 1st trimester increased; then decreased

• Critical illness

• Drugs: – Dopamine, steroids—decreased

– Amiodarone, heroin—increased

TSH Findings

• Hypothyroidism (primary) increased

• Hypothyroidism (secondary) decreased

• Hyperthyroidism (primary) decreased

• Hyperthyroidism (secondary) increased

•TSH is less reliable during first 2-3 months of thyroid replacement therapy

9

TSH Targets in Pregnacy

• The new recommendations for TSH levels during pregnancy are the following:

• First trimester: less than 2.5 with a range of 0.1-2.5

• Second trimester: 0.2-3.0

• Third trimester: 0.3-3.0.

Stagnaro-Green A, Abalovich M, Alexander E, et al. Guidelines of the American Thyroid Association for the diagnosis and management of thyroid disease during pregnancy and postpartum. Thyroid. 2011;21:1081-1125

10-20% women have reduced TSH with HCG peak

Thyroid Testing• FT4 (0.7-1.9 ng/dl)

– Testing methods: various(check if abnormal TSH)

– Indications:• In conjunction w/ TSH for DX hyperthyroidism or

hypothyroidism.• Monitoring ATD in central hypothyroidism • Assessing response to 131-RAI• Monitoring ATD tx in pregnancy

• FT3 (230-619 pg/dl)– Abnormal TSH + normal FT4, then check for T3

Thyrotoxicosis

10

FT4 Findings

• Inverse relationship with TSH• More reliable in unstable thyroid

status• More affected by other variables• Genetic FT4 set-point likely

• Hyperthyroidism: increased!• Hypothyroidism: decreased!• Subclinical varied

Typical Thyroid Hormone Levels in Thyroid Disease

TSH T4 T3

Hypothyroidism High Low Low

Hyperthyroidism Low High High

TSH

HIGH

LOW

FT4 Clinical StatusLOW Primary Hypothyroidism, Thyroiditis (stage 3)

NORMAL Subclinical Hypothyroidism

HIGH Pituitary (secondary) Hyperthyroidism

HIGH Thyrotoxicosis, Thyroiditis (stage 1)

NORMAL Subclinical Hyperthyroidism, Autonomous nodules

LOW Pituitary (secondary) Hypothyroidism

Overview of Thyroid Function Tests

11

Therapy Monitoring

• Clinical and laboratory monitoring enable– Evaluation of the clinical response– Assessment of patient compliance– Assessment of drug interactions, if applicable– Adjustment of dosage, as needed

• Clinical and laboratory evaluations should be performed – At 6- to 8-week intervals while titrating– Annually once a euthyroid state is established

Antithyroid Antibodies

• Thyroid peroxisome -- Anti-TPO– 95% sensitive for Hashimotos– Less sensitive for Graves– False positive too

• TSH receptor stimulator (TSI)—found in 85% Graves disease

• Thyroglobulin: Monitor RX with RAI or Rx for thyroid CA

Ancillary Testing

• Radioactive uptake (RAIU)- scans

• Ultrasound

12

Thyroid Ultrasound

Thyroid nodules

Case Study:

54 y/o woman with hypothyroidism (Hashimoto’s) for 21 years--on stable Synthroid dose of 150 mcg/day. Her TSH has dropped abruptly.

Recently dx’d with HTN, HLD, and T2DM. On metformin XR 1500 mg daily, lisinopril 20 mg, lipitor 20 mg.

What does her fall in TSH mean and what may have caused it?

13

Hyperthyroidism• Hyperthyroidism refers to excess synthesis

and secretion of thyroid hormones by the thyroid gland, which results in accelerated metabolism in peripheral tissues

•Incidence ranges from

–1.9% to 2.7% in women

–0.16% to 0.23% in men

Bahn Chair RS, Burch HB, Cooper DS, et al. Hyperthyroidism and other causes of thyrotoxicosis: management guidelines of the American Thyroid Association and American Association of Clinical Endocrinologists. Thyroid. 2011;21:593–646

HyperthyroidismUnderlying Causes

– Toxic diffuse goiter (Graves disease)

– Toxic uninodular or multinodular goiter

– Toxic adenoma

– Painful subacute thyroiditis

– Silent thyroiditis

– Iodine and iodine-containing drugs and radiographic contrast agents

– Trophoblastic disease, including hydatidiform mole

– Exogenous thyroid hormone ingestion

Nervousness/Tremor

Mental Disturbances/ Irritability

Difficulty Sleeping

Bulging Eyes/Unblinking Stare/ Vision Changes

Enlarged Thyroid (Goiter)

Menstrual Irregularities/Light Period

Frequent Bowel Movements

Warm, Moist Palms

First-Trimester Miscarriage/Excessive Vomiting in Pregnancy

Hoarseness/Deepening of Voice

Persistent Dry or Sore Throat

Difficulty Swallowing

Palpitations/Tachycardia

Impaired Fertility

Weight Loss or Gain

Heat IntoleranceIncreased Sweating

Family History ofThyroid Disease

or Diabetes

Signs and Symptoms of Hyperthyroidism

Sudden Paralysis

14

FT4 Levels & Atrial Fibrilation

Selmer C, Olesen JB, Hansen ML, et al. The spectrum of thyroid disease and risk of new onset atrial fibrillation: A large population cohort study. BMJ 2012; DOI:10.1136/bmj.e7895. Available at: http://www.bmj.com

Graves Disease(Toxic Diffuse Goiter)

The most common cause of hyperthyroidism– Accounts for 60% to 90% of cases– Affects females >males– Graves disease is an

autoimmune disorder

Presents with goiter,exophthalmia, dermopathy

Labs: TSI, anti-TPO

Thyroid Acropachy

Thyroid acropachy. This is most marked in the index fingers and thumbs.

15

Onycholysis

Graves’ Dermopathy

Thyroid Dermopathy

– Thickening and redness of the dermis

• Due to lymphocytic infiltration

– Distribution

• Pretibial > 90%

• May include feet

Pink and skin coloured papules, plaques on the shin

Hyperthyroid Eye Disease• Hyperthyroidism (any cause)

– Lid lag, lid retraction and stare

• True Graves’ Ophthalmopathy– Proptosis– Diplopia– Inflammatory changes

• Conjunctival injection• Periorbital edema

16

Exophthalmus

Cranial nerve palsy

DiagnosisAssessment data:

Cardiovascular

Neuromuscular

Dermatological

Thyroid palpation Lab Data

TSH ;FT4 ; FT3

TSI, thyroid scan, US

TreatmentADTs almost always work

Methimazole is first choiceEXCEPT in first trimester, thyroid storm, or if Methimazole intolerance

Dose: 10-20 mg/day PO; after euthyroidism is achieved, reduce by 50% & administer for 12-18 months

PTU: drug of choice in uncommon situations of life-threatening severe thyrotoxicosis. May be preferable during & before the first trimester.

Dose: 300-450 mg/day PO divided q8hr initially (may require up to 600-900 mg/day)

Maintenance: 100-150 mg/day divided q8hr

17

Further Treatment

• Prolonged ATD use in toxic nodular goiter

• Radioactive Iodine

• Potassium iodide (Lugol's solution) is primarily administered for 10 days before thyroidectomy or during thyrotoxic crisis

• Non-selective beta blockers

• Surgery for MNG (RAI if needed), CA

Treatment Pointers

• Antithyroid drugs block thyroid hormone synthesis—usually short term Rx, dose individualized

• Treatment of subclinical hyperthyroidism– Yes, maybe, and no

– Consider pts at risk of atrial fibrillation/ osteoporosis

Thyroid Storm

• Exaggeration of hyperthyroid signs

• Tachycardia pronounced• Heart failure • Patient in a meltdown!!!

18

Case Study:

63 y/o woman, with hx of HLD and HTN,

Presents TSH of 0.12 mlU/ml (0.45-4.5) & FT4 of 1.0 ng/dl (4.5-11).

She is asymptomatic.

What is her diagnosis and how (or will) you treat her?

Hypothyroidism

• Hypothyroidism is a disorder with multiplecauses in which the thyroid fails to secrete an adequate amount of thyroid hormone

– The most common thyroid disorder

– Usually caused by primary thyroid gland failure

– Also may result from diminished stimulation of the thyroid gland by TSH (secondary)

Incidence of Hypothyroidism

• Woman 5-10x > men• 6-9% woman; 21% by 75 yrs

(16% in men)• 1:4000 neonates

19

Primary Hypothyroidism: Underlying Causes

• Congenital hypothyroidism– Agenesis of thyroid– Defective thyroid hormone synthesis

• Thyroid tissue destruction as a result of– Chronic autoimmune (Hashimoto) thyroiditis– Radiation (like radioactive iodine treatment for thyrotoxicosis)– Thyroidectomy– Other infiltrative diseases of thyroid (eg, hemochromatosis)

• Drugs with antithyroid actions (eg, lithium, iodine, iodine-containing drugs, radiographic contrast agents, interferon alpha)

Subclinical Hypothyroidism

• Subclinical hypothyroidism affects 2-3% of women in pregnancy.

Common Features of Hypothyroidism

Hypothermia

Hypoventilation

Bradycardia

20

Tiredness

Forgetfulness/Slower Thinking

Moodiness/ Irritability

Depression

Inability to Concentrate

Thinning Hair/Hair Loss

Loss of Body Hair

Dry, Patchy Skin

Weight Gain

Cold Intolerance

Elevated Cholesterol

Family History of Thyroid Disease or Diabetes

Muscle Weakness/Cramps

Constipation

Infertility

Menstrual Irregularities/Heavy Period

Slower Heartbeat

Difficulty Swallowing

Persistent Dry or Sore Throat

Hoarseness/Deepening of Voice

Enlarged Thyroid (Goiter)

Puffy Eyes

Clinical Features of Hypothyroidism

Diagnosis Algorithm for Hypothyroidism

TSH0.4 to 4.0 IU/mL

PatientEuthyroid

TSH<0.4 IU/mL

Patient Hyperthyroid?Hyperthyroidism

Diagnosis

TSH>4.0 IU/mL

Go to Next Step

SuspectHypothyroid? Test TSH

Primary Hypothyroidism Diagnosis Algorithm

FT4 High

ConsultEndocrinologist

for PossibleTSH-Secreting

Pituitary Tumor orThyroid Hormone

Resistance

TSH >4.0 IU/mL Test FT4

*Free T4 estimate

FT4

Low

PatientHypothyroid

HypothyroidismManagement

FT4

Normal

HypothyroidismManagement

PatientSubclinicalHypothyroid

Demers LM, Spencer CA, eds. The National Academy of Clinical Biochemistry Web site. Available at: http://www.nacb.org/lmpg/thyroid_lmpg.stm. Accessed July 1, 2003.

Ayala AR, et al. Cleve Clin J Med. 2002;69:313-320.

Ayala AR, et al. The Endocrinologist. 1997;7:44-50.

Endocr Pract. 2002;8:457-469.

21

Diagnostic Studies of Hypothyroidism

• High TSH, low FT4 +/or FT3

• Elevated Anti-TPO or anti-TG in Hashimotos thyroiditis

• Abnormal thyroid scan

• Lipids, electrolytes, EKG, LFTs

Cholesterol Levels Elevate With Increasing TSH Levels


209216

223 226229

238 239

270 267

200

210

220

230

240

250

260

270

280

Mea

n To

tal C

hole

ster

ol

Leve

l, m

g/dL

<0.3 0.3-5.1

>5.1-10

>10-15

>15-20

>20-40

>40-60

>60-80

>80

TSH, IU/mL

Abnormal

Euthyroid

Definition of Mild Thyroid Failure

• Elevated TSH level (>4.0 IU/mL)

• Normal total or free serum T4

and T3 levels

• Few or no signs or symptoms of hypothyroidism

McDermott MT, et al. J Clin Endocrinol Metab. 2001;86:4585-4590.

Braverman LE, Utiger RD, eds. The Thyroid: A Fundamental and Clinical Text. 8th ed. Philadelphia, Pa: Lippincott, Williams & Wilkins; 2000;1001.

22

Populations at Risk for Mild Thyroid Failure

• Women• Prior history of Graves disease or

postpartum thyroid dysfunction• Elderly• Other autoimmune disease• Family history of

– Thyroid disease– Pernicious anemia– Type 1 Diabetes mellitus

Caraccio N, et al. J Clin Endocrinol Metab. 2002;87:1533-1538.

Carmel R, et al. Arch Intern Med. 1982;142:1465-1469.

Perros P, et al. Diabetes Med. 1995;12:622-627.

Mild Thyroid Failure May Be Confused With Other Disorders

• Hyperlipidemia

• Depression

• Gynecological conditions

• Aging


Aldin V, et al. Am Fam Physician. 1998;57:776-780.

Nemeroff CB. J Clin Psychiatry. 1989;50(suppl):13-20.

Braverman LE, et al. Werner & Ingbar’s The Thyroid. A Fundamental and Clinical Text. 8th ed. 2000.

Mild Thyroid Failure May Increase Cardiovascular Disease Risk

• Mild thyroid failure has been evaluated as a cardiovascular risk factor– Increased (LDL-C) levels

– Reduced HDL

– Increased prevalence of aortic atherosclerosis

– Increased incidence of myocardial infarction

23

Primary Hypothyroidism Treatment Algorithm

TSH >4 IU/mL TSH <0.5 IU/mL

Initial Levothyroxine Dose

IncreaseLevothyroxine

Dose by12.5 to 25 g/d

Repeat TSH Test

6-8 Weeks

TSH 0.5- 2.0 IU/mLSymptoms Resolved

Measure TSH at 6 Months, Then Annually or

When Symptomatic

Continue Dose DecreaseLevothyroxine

Dose by12.5 to 25 g/d

Singer PA, et al. JAMA. 1995;273:808-812.

Demers LM, Spencer CA, eds. The National Academy of Clinical Biochemistry Web site. Available at:

http://www.nacb.org/lmpg/thyroid_lmpg.stm. Accessed July 1, 2003.

< 50 yrs: 25-50IU/mL

Half that in elderly

Hypothyroidism (Treatment)

Synthroid (LT4)

• 80% of PO dose is absorbed

• The main absorptive sites proximal and mid-jejunum.

• Food can ↓ LT4 absorption up to 40-50%. .

• T-1/2 LT4 is 7 days – can be given weekly in non compliant pt’s.

• Target: TSH 1.0-2.5 mU/L

Factors That May Reduce Levothyroxine Effectiveness

• Malabsorption Syndromes– Postjejunoileal bypass

surgery– Short bowel syndrome– Celiac disease

• Reduced Absorption– Colestipol hydrochloride – Sucralfate– Ferrous sulfate– Food (eg, soybean formula)– Aluminum hydroxide– Cholestyramine– Sodium polystyrene

sulfonate

• Drugs That Increase Clearance

– Rifampin– Carbamazepine– Phenytoin

• Factors That Reduced T4to T3 Clearance

– Amiodarone– Selenium deficiency

• Other Mechanisms– Lovastatin– Sertraline

Braverman LE, Utiger RD, eds. The Thyroid: A Fundamental and Clinical Text. 8th ed. 2000.

Synthroid® [package insert]. Abbott Laboratories; 2003.

24

T3 Replacement

• Yeah or nay?

• Triiodothyronine (Cytomel) 25 mcg (fast)

• Liotrix (Thyrolar) – 1 unit 12.5 mcg T3/ 50 mcg t4– Dosing consideration

Drug →Thyroid Tablets,

USP(Armour®

Thyroid)

Liotrix Tablets, USP

(Thyrolar™a)

LiothronineTablets, USP(Cytomel®b)

Levothyroxine Tablets, USP(Unithroid® c, Levoxyl® d,

Levothroid® e, Synthroid® f)

Approx. Dose Equivalent

1/4 grain (15 mg) 1/4 25 mcg (.025 mg)


1/2 grain (30 mg) 1/2 12.5 mcg 50 mcg (.05 mg)


1 grain (60 mg) 1 25 mcg 100 mcg ( .1 mg)


1 1/2 grains (90 mg) 1 1/2 37.5 mcg 150 mcg (.15 mg)


2 grains(120 mg) 2 50 mcg 200 mcg (.2 mg)


3grains (180 mg) 3 75 mcg 300 mcg (.3 mg)

Dessicated Armour Thyroid

The basic "rule of thumb" in converting thyroid doses:

100 mcg of T4 is roughly equivalent to 25 mcg of T3, or 1 grain (60 mg) of desiccated thyroid

25

Case 1A 75 yo woman c/o “slowing down” & feeling a “little

forgetful.” She has constipation. BP 156/88; HR 62 regular; Physical exam normal for age:

LAB: TSH 9.0 (0.5-4.5 mU/L) FT4 1.1 (0.8-1.8 ng/dL), normal chemistry. Lipids not done

Which of the following actions would be most appropriate?A. Initiate treatment of levothyroxine 25 mcg/day &

recheck TSH in 6 weeks.B. Check lipid profile and start her on treatment if her LDL

is high.C. Check FT3, if low initiate therapy with levothyroxine.D. Check anti-TPO, and repeat TSH & FT4 in 2 – 6 weeks.

Case 2A 60 yo male with history htn, dm type 2, and

hyperlipidemia.MEDS: lisinopril, HCTZ, glipizide XL, and simvastatin. VS: 98.5, HR 98 (reg), resp rate 18, BP 118/78Phys exam is unremarkable. LABS: TSH 0.18 (0.45 – 5.0 mU/L), FT4 1.6 (0.8 – 1.8

ng/dL), FT3 3.5 (1.5-7.0 pmol/L). Chem panel/lipids normal. EKG is also normal

Which of the following statements would be appropriate?A. He has subclinical hypothyroidism with increased risk of develop

osteosporosis & atrial fibrillation so start treatment.B. Check anti-TPO. If it’s positive he will likely develop Graves’

disease in the future.C. He should have thyroid ultrasound, and start ATD.D. He should have a repeat TSH and FT4 in 3 – 6 weeks along with

anti-TPO.

Postpartum Thyroiditis

• Postpartum thyroiditis (PPT) reportedly affects 4-10% of women.

• PPT is an autoimmune thyroid disease that occurs during the first year after delivery.

• Will develop transient hyper- or hypothyroidism.

26

A word about goiters---seen in people with hyper-, hypo-, and euthyroid

References

• https://www.aace.com/files/hypo-hyper.pdf

• Burman KD. What Is the Clinical Importance of Subclinical Hyperthyroidism? Arch Intern Med. 2012;172(10):809-810. doi:10.1001

• .LeBeau SO, Mandel SJ. Thyroid disorders during pregnancy. Endocrinol Metab Clin North Am. Mar 2006;35(1):117-136, vii

• Rosario PW, Bessa B, Valadao MM, et al. Natural history of mild subclinical hypothyroidism: prognostic value of ultrasound. Thyroid. Jan 2009;19(1):9-12.

• The Endocrine Society. Management of thyroid dysfunction during pregnancy and postpartum: an Endocrine Society clinical practice guideline. National Guideline Clearinghouse. Available at http://guideline.gov/content.aspx?id=11283. Accessed April 24, 2009

• http://thyroidguidelines.net

• Wartofsky L. Myxedema coma. Endocrinol Metab Clin North Am. Dec 2006;35(4):687-698

• Zamfirescu I, Carlson HE. Absorption of levothyroxine when coadministered with various calcium formulations. Thyroid. May 2011;21(5):483-6.

SMILE……

I’M DONE!!

Documents

Prevalence of thyroid disorders - cmcgc.com · Case Study: 54 y/o woman with hypothyroidism (Hashimoto’s) for 21 years--on stable ... (Toxic Diffuse Goiter) The most common cause