thyroid diseases hypothyroidism mild hypothyroidism ...€¦ · thyroid diseases...
TRANSCRIPT
ThyroidThyroid diseasesdiseases HypothyroidismHypothyroidism
MildMild HypothyroidismHypothyroidism ThyroiditisThyroiditis
Dr hab. Jacek Daroszewski Department of Endocrinology, Diabetes and Isotope Treatment
PrevalencePrevalence of of thyroidthyroid diseasesdiseases (USA)(USA)
1. Canaris GJ, et al. Arch Intern Med. 2000;160:526-534. 2. National Center for Health Statistics. Fast stats A-Z. Available at: http://www.cdc.gov/nchs/ fastats/default.htm.
Accessed February 16, 2006. 3. U.S. Census Bureau Web site. 1997 Population Profile of the United States, p23-194. Available at: http:// www.census.gov/prod/3/98pubs/p23-
194.pdf. Accessed February 16, 2006. 4. AACE Thyroid Task Force. Guidelines. Endocr Pract. 2002;8:458-469.
33.0
Asthma 17.6
Diabetes 10.0
POCD 9.6
Thyroid diseases Hypothyroidism Nodules 21.3
CVSa 15.0
0 5 10 15 20
Patients (million)1,2,3,4
25 35 30
J.Daroszewski
Arthritis
Hypothyroidism & Hypothyroidism & ThyrotoxicosisThyrotoxicosis –– DefinitionsDefinitions areare basedbased on TSH on TSH concentrationconcentration
TSHTSH
FTFT44
Euthyroidism
Overt
Hypothyroidism
Mild Overt
Thyrotoxicosis
Mild
Progression from mild hypo- to overt ca. 4%/year
Causes of hypothyroidism (1)Causes of hypothyroidism (1) ((without without goitgoiteerr) )
Congenital failureCongenital failure ––agenesiaagenesia, , hypoplasiahypoplasia
ThyroidectomyThyroidectomy
131131--II therapytherapy
External irradiation External irradiation
((xx--rayray for lymphoma, breast cafor lymphoma, breast ca.) .)
Causes of hypothyroidism (Causes of hypothyroidism (22)) sometimessometimes with with goitgoiteerr
ChronicChronic autoimmuneautoimmune thyroiditisthyroiditis
(Hashimoto)(Hashimoto)
Congenital defects in TH synthesisCongenital defects in TH synthesis
((familialfamilial, , rarerare))
IIodineodine deficiencydeficiency
I I containigcontainig drugs: lithium, drugs: lithium, amiodaronamiodaronee, , iodine, contrast agents iodine, contrast agents
IFIF--alphaalpha, , ILIL--22
Causes of hypothyroidismCauses of hypothyroidism (3)(3) secondarysecondary (central)(central)
Hypopituitarism Hypopituitarism
Congenital malformation of Congenital malformation of hypothalamhypothalamuuss
Inflammation or neoplasm of Inflammation or neoplasm of hypothalmhypothalmuuss
Tumor, Tumor, postpost--surgerysurgery, , postpost--xx--rayray
REGULACJA WYDZIELANIA HORMONÓW TARCZYCY Hypothalamus
Pituitary
Thyroid
ThyroidThyroid hormonehormone transport and actiontransport and action
T3 T3
TR
TRE
TRANS
PORTER
T3
resp. gen
mRNA protein
effect
biol. T3
T3 T4 fT4
Deiodinase t. I
T4
Propranolol
GCS
Thyroid Binding Globulin
Prealbumin
Albumins
Affected by:
Pregnancy
Starvation
Concomitant diseases
(-)
Thyroid hormone actionThyroid hormone action
brain
nervous system
muscles (myocaridum)
gastrointestinal tract
kidney
skin
bones
endocrine system
T3
HypothyroidismHypothyroidism symptomssymptoms and and signssigns
Fatigue
Increased sensitivity to cold
Constipation
Dry skin
Unexplained weight gain
Puffy face
Hoarseness
Muscle weakness
Elevated blood cholesterol level
Muscle aches, tenderness and
stiffness
Pain, stiffness or swelling in
joints
Heavier than normal or
irregular menstrual periods
Thinning hair
Slowed heart rate
Depression
Impaired memory
Hypothyroidism and DepressionHypothyroidism and Depression Have Many Common FeaturesHave Many Common Features
Depression Hypothyroidism
• Sleep decrease
• Suicidal ideation
• Weight loss
• Appetite increase/
decrease
Nemeroff CB, J Clin Psychiatry. 1989;50(suppl):13-20.
• Bradycardia
• Cardiac and lipid
abnormalities
• Cold intolerance
• Delayed reflexes
• Goiter
• Hair and skin
changes
• Constipation
• Appetite decrease
• Decreased concentration
• Decreased libido
• Delusions
• Depressed mood
• Diminished interest
• Sleep increase
• Weight increase
• Fatigue
Diagnosis of hypothyroidism on Diagnosis of hypothyroidism on tthe basishe basis oof clinical symptoms is difficultf clinical symptoms is difficult
982 estimations of TSH with suspicion of 982 estimations of TSH with suspicion of hypothyroidism hypothyroidism -- GP)GP)
TSH in 42 subjects (4.3%)TSH in 42 subjects (4.3%)
SchectmanSchectman, 1989, 1989
Risk Factors for DevelopingRisk Factors for Developing Thyroid FailureThyroid Failure (1)(1)
Medical history of Surgical or 131I treatment
Neck irradiation
Postpartum thyroiditis
Certain autoimmune disorders: type 1 diabetes, RA, Addison
Treatment with lithium, immune-response modulators (eg, interferon alfa), amiodarone,
x-ray contrast agents
Most patients have no obvious risk factorsMost patients have no obvious risk factors
Cooper DS. N Engl J Med. 2001;345:260-264.
HypercholestrolemiaHypercholestrolemia
AtaxiaAtaxia syndromssyndroms
KlinefelterKlinefelter--, Down, Down--, Turner, Turner--, , syndromessyndromes
Risk Factors for Developing Thyroid FailureRisk Factors for Developing Thyroid Failure (2)(2)
DiagnosDiagnosttiicc Algorithm for Algorithm for HypothyroidismHypothyroidism
TSH
0.4 to 4.0 IU/mL
Patient
Euthyroid
TSH
<0.4 IU/mL
Patient Hyperthyroid?
Consult Hyperthyroidism
Diagnosis
Algorithms
TSH
>4.0 IU/mL
Measure FT4
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.
Suspect
Hypothyroid? Test TSH
Hypothyroidism Treatment GoalHypothyroidism Treatment Goal EuthyroidismEuthyroidism
The goal of hypothyroidism therapy is The goal of hypothyroidism therapy is to replace thyroxine to mimic normal, to replace thyroxine to mimic normal, physiologic levels and alleviate signs, physiologic levels and alleviate signs, symptoms, and biochemical symptoms, and biochemical abnormalitiesabnormalities
Braverman LE, et al. Werner & Ingbar’s The Thyroid. A
Fundamental and Clinical Text. 8th ed. 2000.
Hypothyroidism Hypothyroidism -- TreatmentTreatment Levothyroxine sodium is the treatment of choice for the
routine management of hypothyroidism Adults: about 1.7 g/kg of body weight/d (50-200 g/d) Elderly <1.0 g/kg of body weight/d
Shoul be taken at least 30 min. before breakfast
Clinical and biochemical evaluations at 6- to 8-week
intervals until the serum TSH concentration is normalized (lower half part of the range)
Given the narrow and precise treatment range for levothyroxine therapy, it is preferable to maintain the patient on the same brand throughout treatment
Singer PA, et al. JAMA. 1995;273:808-812.
Endocr Pract. 2002;8:457-469.
Primary Hypothyroidism Treatment AlgorithmPrimary Hypothyroidism Treatment Algorithm
TSH >4 IU/mL TSH <0.5 IU/mL
Initial Levothyroxine Dose
Increase
Levothyroxine
Dose by
12.5 to 25 g/d
Repeat TSH Test
6-8 Weeks
TSH 0.5- 2.0 IU/mL
Symptoms Resolved
Measure TSH at 6 Months,
Then Annually or
When Symptomatic
Continue Dose Decrease
Levothyroxine
Dose by
12.5 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.
Mild Thyroid FailureMild Thyroid Failure ((subclinicalsubclinical))
Progression of Thyroid Disease Progression of Thyroid Disease
Ayala AR, et al. Endocrinologist. 1997;7:44-50.
Years
Normal Range
TSH
Overt Hypothyroidism
Mild Thyroid Failure Euthyroid
T3
T4
Definition of Mild Thyroid FailureDefinition of Mild Thyroid Failure
An isolated elevated TSH level in the An isolated elevated TSH level in the setting of normal Tsetting of normal T33 and Tand T44 levels levels
Symptoms may be present or absentSymptoms may be present or absent
Cooper DS. N Engl J Med. 2001;345:260-265.
Mild Thyroid FailureMild Thyroid Failure PrevalencePrevalence
Worldwide prevalence between 1% and 10%Worldwide prevalence between 1% and 10%
Highest rates are in women older than 60 Highest rates are in women older than 60 years of ageyears of age
Over the age of 74, 16% of men and 21% of Over the age of 74, 16% of men and 21% of women have the disorderwomen have the disorder
Cooper DS. N Engl J Med. 2001;345:260-264.
Prevalence of Elevated Serum TSH Prevalence of Elevated Serum TSH by Decade of Age and Genderby Decade of Age and Gender
• At <40 years of
age, prevalence is
relatively low and
similar between
males and
females
• At ≥40 years of
age, a higher
percentage of
female patients
have elevated
TSH levels
Males
FemalesFemales
NHANES III Study (N=17 353)
Hollowell JG, et al. J Clin Endocrinol Metab. 2002;87:489-499.
Part
icip
ants
With
Ele
vate
d T
SH
, %
Potential benefits from treatmentPotential benefits from treatment
Prevent progression to overt Prevent progression to overt hypothyroidismhypothyroidism
Improve serum lipid profile, which may Improve serum lipid profile, which may reduce the risk of death from reduce the risk of death from cardiovascular causescardiovascular causes
Reduce symptoms, including psychiatric Reduce symptoms, including psychiatric and cognitive abnormalitiesand cognitive abnormalities
Cooper DS. N Engl J Med. 2001;345:260-264.
Rationale for Treating Rationale for Treating Mild Thyroid FailureMild Thyroid Failure
ThyroiditisThyroiditis
AcuteAcute –– suppurativesuppurative ((bacterialbacterial infectioninfection))
SubacuteSubacute painfulpainful (de (de Quervain’sQuervain’s) )
viralviral, , unknownunknown
ChronicChronic ((lymphocyticlymphocytic, , HashimotoHashimoto))
SubacuteSubacute autoimmuneautoimmune
SilentSilent
PostPost--partumpartum
ChronicChronic fibroticfibrotic ((Riedel’sRiedel’s thyroiditisthyroiditis))
Chronic Chronic ThyroiditisThyroiditis
Also known as Hashimoto’s diseaseAlso known as Hashimoto’s disease
TThe most common cause of he most common cause of spontaneousspontaneous hypothyroidismhypothyroidism
AutoantibodiesAutoantibodies::
TPO TPO antibody antibody
thyroglobulinthyroglobulin antibodyantibody
Gross and Microscopic Pathology Gross and Microscopic Pathology of Chronic of Chronic ThyroiditisThyroiditis
UltrasoundUltrasound imagingimaging of HTof HT
Presentation and CoursePresentation and Course
Painless goiter in a patient who is either Painless goiter in a patient who is either euthyroideuthyroid or hypothyroidor hypothyroid
MajorityMajority of of patientspatients withoutwithout goitergoiter
May have periods of May have periods of thyrotoxicosisthyrotoxicosis
Treat with Treat with levothyroxinelevothyroxine
No No immunosuppressionimmunosuppression
SubacuteSubacute PainfulPainful ThyroiditisThyroiditis
Also known as De Quervain's thyroiditisAlso known as De Quervain's thyroiditis
Most common cause of thyroid pain and Most common cause of thyroid pain and tendernesstenderness
Pain may radiate to ear, teeth, jawPain may radiate to ear, teeth, jaw
Acute inflammatory disease most likely due to Acute inflammatory disease most likely due to viral infectionviral infection
Transient hyperthyroidism followed by Transient hyperthyroidism followed by transient hypothyroidism; permanent transient hypothyroidism; permanent hypothyroidism or relapses are uncommonhypothyroidism or relapses are uncommon
44--phase phase coursecourse of of subacutesubacute thyroiditisthyroiditis ((painfulpainful and and autoimmunologicalautoimmunological))
FunctionFunction 131131I I uptakeuptake
1. 1. HyperHyper--
2. 2. EuEu--
3. 3. HypoHypo--
4. 4. EuEu-- NN 1 2 3 4
Treatment of Treatment of SubacuteSubacute ThyroiditisThyroiditis
Symptomatic: NSAIDS or a Symptomatic: NSAIDS or a glucocorticoidglucocorticoid ((prednisonprednison 3030--40 mg/40 mg/dayday))
BetaBeta--blockers indicated if there are signs of blockers indicated if there are signs of thyrotoxicosisthyrotoxicosis
LevothyroxineLevothyroxine may be given during may be given during hypothyroid phasehypothyroid phase
SummarySummary
Thyroid disease is a prevalent conditionThyroid disease is a prevalent condition
Effective screening requires biochemical Effective screening requires biochemical confirmation to avoid misdiagnosis confirmation to avoid misdiagnosis
Levothyroxine therapy is recommended Levothyroxine therapy is recommended for for majoritymajority of of patientspatients
Effective in different types of thyroid disordersEffective in different types of thyroid disorders
Provides benefit for many organ systemsProvides benefit for many organ systems
Reduces CAD risk factorsReduces CAD risk factors
ImprovesImproves mentalmental disordersdisorders