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endocrine disorders: thyroid dysfunction

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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endocrine disorders: thyroid dysfunction

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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

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