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HYPOTHYROIDISM. TATTTSH 5.6-9.9 T4 Normal rangeWhat now?. COMPENSATED HYPOTHYROIDISM. TSH >5 persistently: check thyroid antibodies, if ve inevitable Hypothyroidism (Wickham study: Vanderpump et al). Treat if symptomatic, if >10 TreatIf
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1. ENDOCRINE DISORDERS:THYROID DYSFUNCTION
2. HYPOTHYROIDISM TATT
TSH 5.6-9.9 T4 Normal range
What now?
3. COMPENSATED HYPOTHYROIDISM TSH >5 persistently: check thyroid antibodies, if +ve inevitable Hypothyroidism (Wickham study: Vanderpump et al). Treat if symptomatic, if >10 Treat
If –ve monitor TFT 3-6 monthly
TSH > 10 Hypothyroidism likely,
if TSH rising then treat if symptomatic
Remember thyroxine treatment is life long
Consider 3 month trial in borderline cases
4. THYROTOXICOSIS Cases
5. CASE 1 30 year old lady presents with weight loss, palpitations and insomnia
TSH <0.03
T3 25
What to do?
Bloods
Treatment
6. Case 1 FBC ? Neutropaenia
Thyroid Antibodies
Clinical Assessment (smooth goitre versus MNG) Not scan !
Thyroid eye disease=Graves’ disease
Treatment
7. Case 1Treatment Symptoms = Beta Blockers
Carbimazole 30-40mg. (Remember side effects: Sore throats, mouth ulcers and rashes)
4-8 weeks to return to normal
Block and replace or titrate
No difference in outcomes
8. Case 1Treatment BLOCK and REPLACE:
40mg Carbimazole, add 50-100microg of T4
Repeat TFT 8 weeks, adjust Thyroxine only.
6 month stable treatment 50% chance of remission
Otherwise 18 months of treatment
9. Case 1Treatment TITRATE:
Reducing dose every 6 weeks
Check TFT including T3. Adjust for T3
TSH is always delayed. Aim to be on 5mg by 12months of treatment
10. AUTOIMMUNE THYROTOXICOSIS Factors predicting a remission on Thionamides:
Female gender
Age > 40 years
Small goitre
Mild hyperthyroidism
T3 thyrotoxicosis
High Thyroid Peroxidase (TPO) Antibody titre
Negative TSH-Receptor Antibody?
Normal TSH during remission
11. AUTOIMMUNE THYROTOXICOSIS: A genetic abnormality resulting in the lack of a specific clone of Suppressor T cells
?
allowing its targeted T Helper cells to multiply
?
allowing ? cells to produce TSH-Receptor antibodies (TSH-R Ab)
14. Thyroid Eye Disease (TED)
periorbital oedema, gritty, diplopia.
Proptosis reduces nerve compression
LOSS of COLOUR VISION = Urgent
15. CASE 2 55 year female presents with new onset AF
T3 15
TSH <0.03
Thyroid Antibodies negative
Treatment options:
Radioactive Iodine, Surgery, or Pills
16. Case 2Radioactive Iodine ‘Curative’ or ‘Ablative’
Constant dose or Calculated dose
Pre-treatment with Ionamide
Concomittant treatment with glucocorticoids (especially if TED)
Smoking
Restrictions: Pregnancy and children
10% Recurrence, 65% hypothyroidism (1st year)
17. Surgery Large Goitre
Failure of other options
Local complications (nerves, bleeding, parathyroids)
Total thyroidectomy = T4
18. CASE 3 30 year old lady presents with weight loss, palpitations and insomnia
TSH <0.03
T3 12
What to do?
19. CASE 3 30 year old lady presents with weight loss, palpitations and insomnia
TSH <0.03
T3 12
What to do?
4 month old baby
20. Post Partum Thyroiditis Thyrotoxic symptoms associated with post partum hormone changes
Become hypothyroid, if antibodies positive more likely to be permanent
Treat symptoms Beta Blockers for toxic symptoms
If hypothyroid -ve antibodies try to avoid thyroxine, or try withdrawal later
21. CASE 4 30 year old lady presents with weight loss, palpitations and insomnia
TSH <0.03
T3 12
What to do?
Painful gland
22. Viral Thyroiditis Toxic symptoms
-ve antibodies
Raised inflammatory markers
Isotope uptake scan may be of use
Treat with Beta blockers
May need high dose Steroids if severe (30 mg/day)
May develop long term hypothyroidism (watch and wait)
23. THYROTOXICOSIS: Causes Graves’ Disease
Solitary Nodule
Multi-nodular Goitre
Viral Thyroiditis
Post-partum thyroiditis
Drug/Iodine
24. Drug Induced Thyroid Dysfunction Amiodarone: check TFT before and 6 monthly
Classic picture T4 upper end of normal range, T3 low (TSH suppressed)
Hypothyroidism treat if antibody +ve and TSH >10.
Thyroxicosis type 1 or Type 2: refer check antibodies and plasma viscosity
25. Thyroid Cancer On T4
Aim of treatment to suppress TSH
Do not allow TSH to be recordable, aim for T3 to be top end of normal range or mildly above
T3 treatment for radioactive iodine