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Thyroid Disease And Osteoporosis

Thyroid Disease And Osteoporosis. Lisa Hays, MD Endocrinology Fellow. Outline. Signs and symptoms of hyperthyroidism Diagnostic studies for hyperthyroidism Causes and treatments of hyperthyroidism General overview of hypothyroidism Evaluation of thyroid nodules Overview of osteoporosis.

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Thyroid Disease And Osteoporosis

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  1. Thyroid DiseaseAnd Osteoporosis Lisa Hays, MD Endocrinology Fellow

  2. Outline • Signs and symptoms of hyperthyroidism • Diagnostic studies for hyperthyroidism • Causes and treatments of hyperthyroidism • General overview of hypothyroidism • Evaluation of thyroid nodules • Overview of osteoporosis

  3. Cellular effects of thyroid

  4. Anxiety/irritability Weakness Tremors Difficulty sleeping Palpitations Increased bowel movements Fatigue Weight loss Hyperkinetic movements Heat intolerance Hyperthyroidism Symptoms

  5. Case Presentation • 37 yo male presented to PCP w/ complaint of feeling poorly for past month • Also complained of weakness, difficulty sleeping, increased heart rate. 10 stools per day. • What else do we need to know before examining?

  6. Case Presentation • T 99.1, HR 92 irregular, RR 20, BP 153/75 • Physical examination • Mild proptosis • Nontender goiter with thyroid bruit present • CV: Irregularly irregular rhythm • Ext: Brisk DTR’s, mild resting tremor • What labs or studies do we need?

  7. Laboratory Studies • TSH <0.010 uIU/ml (nl 0.47-5.0) • Free T4 >6 ng/dl (nl 0.71-1.85) • Total T3 >600 ng/dl (nl 72-170) • Thyroid Stimulating Antibody 130% (nl 0-125%) • Negative Thyroid peroxidase and thyroglobulin antibodies

  8. Case Presentation • Patient was diagnosed with Graves’ Disease • Started on Methimazole 10 mg TID • Propranolol for symptom management • Anticoagulation for atrial fibrillation

  9. Thyroid Antibodies • TSH receptor antibodies • Can be stimulating or inhibitory • Thyroglobulin antibodies • Thyroid peroxidase antibodies (formerly known as microsomal)

  10. Anything else? • Radioactive Iodine Uptake • Measures the amount of iodine taken up by the thyroid in 24 hours • Normal 15-30% • Thyroid Scan • Gives an anatomic view of the thyroid • Technetium used to image

  11. High uptake Graves’ Disease Multinodular Goiter Toxic solitary Nodule TRH secreting Pituitary Tumor HCG secreting tumor Low uptake Subacute Thyroiditis Silent Thyroiditis Iodine induced Exogenous L-Thyroxine Struma ovarii Amiodarone Differential Diagnosis

  12. Graves’ Disease • Most common cause of hyperthyroidism • 60-80% of cases • Autoimmune disease • Caused by thyroid stimulating immunoglobulins • Bind to TSH receptors on thyroid • Cause hypersecrection of thyroid hormone • Cause hypertrophy & hyperplasia of thyroid follicles

  13. Pathogenesis of Graves' Disease Weetman, A. P. N Engl J Med 2000;343:1236-1248

  14. Clinical Manifestations • Symptoms and signs of hyperthyroidism • Ophthalmopathy • Present in 50% of patients • Eyelid retraction • Periorbital edema • Proptosis (exopthalmos) • Diploplia • Dermopathy (myxedema)

  15. Clinical Manifestations of Graves' Disease Weetman, A. P. N Engl J Med 2000;343:1236-1248

  16. Graves’ Disease • Associated Conditions • Type I Diabetes Mellitus • Addison’s Disease • Vitiligo • Pernicious anemia • Alopecia Areata • Myasthenia Gravis • Celiac Disease

  17. Graves Treatment • Antithyroid drugs (Thionamides) • Proplythiouracil (PTU) 300-400 mg daily • Methimazole 30-40 mg daily • Decrease synthesis of hormone, PTU also decreases conversion of T4 to T3 • Permanent remission in 40-50% of treated patients • Risk of agranulocytosis • PTU used in pregnancy • Beta-Blockers for symptoms

  18. Graves Treatment • Thyroidectomy • Rapid cure but requires thyroid replacement • Radioactive Iodine • Iodine (131I) is given • Effect is typically seen in 3-6 months • Hypothyroidism often develops

  19. Multinodular Goiter • Less common than Graves and effects older individuals • Discrete nodules become autonomous and hyperfunction • Treatment with thyroidectomy (often poor surgical candidates) or iodine, thionamides

  20. Subacute Thyroiditis • Etiology is typically viral • Known as De Quervain’s thyroiditis or granulomatous thyroiditis • Thyroid is often enlarged, tender, painful • Very low radioactive iodine uptake • Self-resolving within weeks to months • Treatment with NSAIDS, steroids, Beta-blockers

  21. Silent Thyroiditis • Also called painless or lymphocytic thyroiditis • Not painful like subacute • Transient • Low iodine uptake

  22. Hypothyroidism • Weakness • Fatigue • Lethargy, sleepiness • Slowness of speech and thought • “Puffy” appearance • Dry skin, coarse hair • Cold intolerance • Constipation

  23. Physical Findings • Puffy features • Dry skin • Nonpitting edema • Hypothermia • Bradycardia • Slow return of deep tendon reflexes • Loss of lateral portion of eyebrows

  24. Causes of Hypothyroidism • Primary Hypothyroidism • Iodine deficiency • Iatrogenic-surgery, radioablation • Autoimmune thyroid destruction • Drugs interfering with hormone synthesis • Infiltrative disease • hemochromotosis, sarcoidosis, neoplastic disease • Congenital thyroid agensis or defects in hormone synthesis

  25. Hashimotos Thyroiditis • Most common type of thyroid disease • Autoimmune damage • Lymphocytic infiltrate, fibrosis, decreased thyroid hormone production • Autoantibodies (thyroglobulin and peroxidase) • Can also be associated with polyglandular autoimmune disease • Adrenal insufficiency, ovarian failure, vitiligo, diabetes

  26. Thyroid Replacement • Synthetic levothyroxine (T4) • Converted to T3 in the body • Studies vary on utility of using T3 • Typical replacement dose is 1.6 micrograms/kg (100-150 mcg typical) • Start with reduced dose in elderly and patients with history of heart disease

  27. Myxedema Coma • Severe untreated hypothyroidism • Hypothermia, hypoglycemia, shock, hypoventilation, ileus • 50% mortality • Treat with IV levothyroxine, steroids

  28. Thyroid Nodule • 21 yo male w/ no past medical history presents to his PCP complaining of gradually enlarging “knot” in his neck • What questions do you have? • Examination reveals a firm 3 cm nodule in right lobe of thyroid • What is the next step?

  29. Thyroid Nodules • Lifetime risk of palpable nodule 5-10% • 50% of the population has a nodule on autopsy or ultrasound • Only 1 in 20 is malignant

  30. Malignancy Papillary Follicular Medullary Anaplastic Metastasis Benign follicular adenoma Cyst Colloid Nodule Differential Diagnosis

  31. Algorithm for the Cost-Effective Evaluation and Treatment of a Clinically Detectable Solitary Thyroid Nodule Hegedus, L. N Engl J Med 2004;351:1764-1771

  32. Clinical Findings Suggesting the Diagnosis of Thyroid Carcinoma in a Euthyroid Patient with a Solitary Nodule, According to the Degree of Suspicion Hegedus, L. N Engl J Med 2004;351:1764-1771

  33. Evaluation of Nodule • Measure TSH • If Hyperthyroid (low TSH), do uptake and scan • Treat with surgery or I-131 ablation • If normal thyroid function, next step is fine needle aspiration (FNA) • Check Calcitonin level if family history of MEN2 or medullary carcinoma exists.

  34. Algorithm for the Cost-Effective Evaluation and Treatment of a Clinically Detectable Solitary Thyroid Nodule Hegedus, L. N Engl J Med 2004;351:1764-1771

  35. Fine Needle Aspiration • FNA is most effective way to distinguish between benign and malignant nodules • Inexpensive, performed as outpatient • Ultrasound guided FNA if not palpable or less than 1.5 cm in diameter • What results will I see? • Benign-75% of the time • Malignant-4% of cases • Suspicious or inadequate-22%

  36. Algorithm for the Cost-Effective Evaluation and Treatment of a Clinically Detectable Solitary Thyroid Nodule Hegedus, L. N Engl J Med 2004;351:1764-1771

  37. Management of Nodules • Malignant • Total thyroidectomy • Suspicious • Thyroidectomy • Benign • Discuss with the patient • Ultrasound surveillance • Surgery • Consider levothyroxine suppression (varying results)

  38. Case Presentation • FNA revealed papillary thyroid carcinoma • Patient underwent total thyroidectomy • Treatment with I-131 ablation after surgery

  39. Osteoporosis

  40. Case Presentation • 70 year old female asks her PCP if she should have a bone density done. • What questions should her PCP ask? • No history of fractures • Menopause was surgical at age of 55 • Mother fractured her hip at 74

  41. Osteoporosis • Definition • Microarchitectural deterioration of bone tissue leading to decreased bone mass • Bone fragility • Susceptibility to fracture • A problem of decreased peak bone mass and accelerated bone loss • Affects 10 million in the United States

  42. Hip Fractures Can Lead to Disability, Loss of Independence, and Even Death • Hip fracture is associated with increased risk of: • Disability: 50% never fully recover1,2 • Long-term nursing home care required: 25%2 • Increased mortality within 1 year due to complications: up to 24%3 • Lifetime risk of death: comparable to that of breast cancer4 1. Consensus Development Conference. Am J Med. 1993;94:646-650. 2. Riggs BL, Melton LJ III. Bone. 1995;17:505S–511S. 3. Ray NF et al. J Bone Miner Res. 1997;12(1):24–35. 4. Cummings SR et al. Arch Intern Med. 1989;149:2445–2448.

  43. Osteoporosis • Primary osteoporosis • Unrelated to chronic illness • Related to aging and decreased gonadal function • Secondary osteoporosis • Secondary to chronic illnesses that cause accelerated bone loss • Examples: Glucocorticoid use, celiac sprue, hyperthyroidism

  44. Current cigarette smoking Personal history of fracture as an adult Low body weight (<127 lbs) History of fracture infirst-degree relative Estrogen deficiency, including menopause onset <age 45 Alcoholism Caucasian race Low calcium intake (lifelong) Advanced age Impaired eyesight despiteadequate correction Female sex Recurrent falls Dementia Inadequate physical activity Poor health/frailty Poor health/frailty Risk Factors for Osteoporotic Fracture Nonmodifiable Potentially Modifiable Gold color denotes risk factors that are key factors for risk of hip fracture, independent of bone density. National Osteoporosis Foundation, Physician’s Guide to Prevention and Treatment of Osteoporosis. Belle Mead, NJ: Excerpta Medica, Inc.; 1998.

  45. Diagnosis of Osteoporosis • History and physical examination to exclude secondary osteoporosis • Laboratory studies if suspect secondary osteoporosis • Measurement of Bone Mineral Density (BMD) • Dual X-ray Absorptiometry (DEXA scan) • Provides most reproducible values of bone density • g/cm2

  46. BMD and Fracture Risk Are Inversely Related Forearm 100 Colles' Spine Vertebrae 4000 Hip Hip and Heel 90 3000 Relative BMD (%) 80 Annual Fracture Incidence 2000 70 1000 60 0 35- 85+ 30 40 50 60 70 80 90 39 Age Age Faulkner KG. J Clin Densitom. 1998;1:279–285. Cooper C. Baillières Clin Rheumatol. 1993;7:459–477.

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