Hyperthyroidism. Objectives. Clinical Manifestations. Slide 1. Slide 2. Slide 3. Implications for Primary Care. hyperthyroidism

Transcription

1 1 Hyperthyroidism Implications for Primary Care Laura A. Ruby, DNP, CRNP Wellspan Endocrinology 2 Objectives! Discuss the clinical manifestations of hyperthyroidism! Review the use of the diagnostic studies! Differential diagnosis of hyperthyroidism! Discuss treatment options for the various forms of hyperthyroidism! Review recommendations for specialty referral 3 Clinical Manifestations! Anxiety/emotional lability! Weakness! Tremor! Palpitations! Heat intolerance! Increased perspiration! Palpitations/tachycardia! Unexplained weight loss! Diarrhea or increased frequency of BMs

2 4 Clinical Manifestations in Older Patients! Cardiopulmonary symptoms may be more prominent! New onset atrial fibrillation! Tachycardia! Dyspnea on exertion! Edema! Apathetic thyrotoxicosis 5! Thyroid function tests! TSH, T3, T4! Free T3 & T4! Thyroid antibodies Diagnosis! TPO thyroid peroxidase antibodies! TGA thyroglobulin antibodies! TBII thyroid binding inhibitor immunoglobulin! TSI thyroid stimulating immunoglobulin 6! Radiologic Tests Diagnosis! Radioidine Uptake! 24 hr thyroid uptake & scan! Establish the cause! Suppression Scan! Thyroid ultrasound?

3 7 Diagnosis! Miscellaneous tests! Sed rate! IL6 interleukin 6! Urinary iodine levels! CMP! Calcium! Liver function tests 8 Primary Hyperthyroidism Graves Toxic multinodular goiter Toxic adenoma Sub-acute thyroiditis Painless thyroiditis Hashitoxicosis 9 Secondary Hyperthyroidism Central TSH driven! High TSH, T3, T4! TSH secreting tumor? Medications Radiation thyroiditis Hyperemesis gravidarum Trophoblastic disease

4 10 Offending medications Amiodarone Lithium Excessive levothyroxine replacement Intentional suppressive therapy 11 Differential Diagnosis Graves disease " Eye manifestations? " Positive TBII or TSI AB " RAI scan shows diffuse or homogeneous uptake " 4 & 24 hr uptake elevated Toxic goiter or adenoma " Negative antibodies>? " RAI scan shows focal or heterogeneous uptake " 4 & 24 hr uptake elevated 12 Differential Diagnosis Sub-acute thyroiditis " Classic presentation " Transient hyperthyroid phase " Acute neck tenderness " RAI typically shows decreased uptake Other acute thyroiditis " Hashitoxicosis " Post Partum thyroiditis " Drug induced Lithium, Amiodarone " Euthyroid sick syndrome

5 13 Treatment Options! Thionamides methimazole, PTU! Beta blockers! Miscellaneous meds! Radioiodine ablation! Surgery 14 Sub-clinical hyperthyroidism To treat or not to treat? 15 Thionamides Methimazole " Longer duration " Once daily dosing " Lower incidence of adverse affects Propylthiouricil PTU " Higher incidence of liver toxicity " Lower teratogenic affects preferred in pregnancy

6 16 Thionamides! Adverse affects! Rash! Liver! Agranulocytosis 17 Beta Blockers " Used for symptomatic relief to decrease the clinical symptoms such as tachycardia & tremor " Beta blockers do not address the underlying cause of hyperthyroidism 18 Other meds! Iodine! Glucocorticoids! Lithium! Cholestyramine

7 19 Radioiodine Ablation! Preferred treatment! Graves remission rate after 2 years only 30%! I131 capsules concentrate in thyroid tissues & induces localized cell damage (6 18 wks)! 50 70% chance of post RAI hypothyroidism! 25-30% euthyroid no meds! 15-20% may need second RAI dose! MAY WORSEN OPTHALMOPATHY!! 20 Discussion 21 Surgery! Not common treatment of hyperthyroidism! Rate approx. 1%! Indicated with large, obstructive goiter! Pregnant women allergic to thionamides! High suspicion of malignant nodule

8 22 Long Term Implications! Graves # periods of remission & exacerbation! Hypothyroidism! RAI risk??! Risks in uncontrolled hyperthyroidism 23 Recommendations for specialty referral