hipertiroidisme ham.pptx
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HipertiroidismeDepartemen ilmu kesehatan THT-KL
M. Fahmy H070100185
Anatomy of thyroid gland
Hypothalamus-
Pituitary- Thyroid Axis
Fisiologi hormon tiroid
Thyrotoxicosis and HyperthyroidismDefinitions
Thyrotoxicosis◦The clinical syndrome of hypermetabolism that results when the serum concentrations of free T4, T3, or both are increased
Hyperthyroidism◦Sustained increases in thyroid hormone biosynthesis and secretion by the thyroid gland
The 2 terms are not synonymousBraverman LE, et al. Werner & Ingbar’s The Thyroid. A
Fundamental and Clinical Text. 8th ed. 2000.
Prevalence of Thyrotoxicosis
In a cross-sectional study of urban and rural adults, the prevalence of thyrotoxicosis ranged from ◦ 1.9% to 2.7% in women◦ 0.16% to 0.23% in men
Tunbridge WMG, et al. Clin Endocrinol. 1977;7:481-493.
Tabel : Penyebab tirotoksikosis 7,8,9
Hipertiroidisme Primer Tirotoksikosis tanpa
hipertiroidisme
Hipertiroidisme Sekunder
Penyakit Graves
Gondok multinodula
toksik
Adenoma toksik
Obat : yodium, lithium
Karsinoma tiroid yang
berfungsi
Struma ovary (ektopik)
Mutasi TSH-r
Hormon tiroid berlebih
(tirotoksikosis faktisia)
Tiroiditis subakut
Silent thyroiditis
Destruksi kelenjar :
amiodaron
I-131, radiasi, adenoma,
infark
TSH secreting tumor
chGH secreting tumor
Tirotoksikosis gestasi
Resistensi hormon
tiroid
Common Signs and Symptoms of Thyrotoxicosis
Symptoms Signs Nervousness Hyperactivity Fatigue Tachycardia Weakness Systolic hypertension Increased perspiration Warm, moist, or
smooth skin Heat intolerance Stare and eyelid
retraction Tremor Tremor Hyperactivity Hyperreflexia Palpitations Muscle weakness Appetite/weight changes Menstrual disturbancesBraverman LE, et al. Werner & Ingbar’s The Thyroid. A
Fundamental and Clinical Text. 8th ed. 2000.
SYSTEMIC EFFECTSRESPIRATORYDyspnea, panting,
hyperventilation respiratory muscle weakness increased tissue carbon dioxide levels +/- congestive heart failure
SYSTEMIC EFFECTSCARDIOVASCULAR
Thyrotoxic cardiomyopathy◦ Hypermetabolic state◦ Systemic hypertension◦ Direct T3 and T4 action on heart
muscle LV hypertrophy, IVS hypertrophy,
RA and aortic dilation, enhanced contractility
1. Graves’ Disease (Toxic Diffuse Goiter)
The most common cause of hyperthyroidism ◦ Accounts for 60% to 90% of cases◦ Incidence in the United States estimated at
0.02% to 0.4% of the population◦ Affects more females than males, especially in
the reproductive age rangeGraves disease is an autoimmune disorder
possibly related to a defect in immune tolerance
Graves Disease
Autoimmune disorder◦ Production of TSH receptor autoantibodies◦ Stimulate thyroid hormone overproduction
Characterized by the presence of B- and T-lymphocytes in thyroid tissue◦ TSH receptor activation◦ Thyroglobulin and thyroid peroxidase antibodies◦ Sodium/iodide cotransporter (NIS) activity
enhanced (increased RAI)◦ Autoantigens
Abbott Laboratories Diagnostics Division Web site. Available at: et al. Werner & Ingbar’s The Thyroid. A Fundamental and Clinical Text. 8th ed. 2000.
2. Toxic Multinodular Goiter
More common in places with lower iodine intake◦ Accounts for less than 5% of thyrotoxicosis
cases in iodine-sufficient areasEvolution from sporadic diffuse goiter to
toxic multinodular goiter is gradualThyrotropin receptor mutations and TSH
mutations have been found in some patients with toxic multinodular goiters
Surgery or 131I is recommended treatment
Braverman LE, et al. Werner & Ingbar’s The Thyroid. A Fundamental and Clinical Text. 8th ed. 2000.
Toxic Multinodular Goiter
MNG is an enlarged thyroid gland containing multiple nodules◦ The thyroid gland becomes more nodular with
increasing age◦ In MNG, nodules typically vary in size◦ Most MNGs are asymptomatic
MNG may be toxic or nontoxic◦ Toxic MNG occurs when multiple sites of autonomous
nodule hyperfunction develop, resulting in thyrotoxicosis
◦ Toxic MNG is more common in the elderly
3. Toxic AdenomaAutonomously functioning thyroid
nodule hypersecreting T3 and T4 resulting in thyrotoxicosis (Plummer’s disease)
Almost never malignantManage with antithyroid drugs
followed by either I-131 or surgery
Laboratory Testing in Thyroid DiseaseTSH:
◦ Pituitary hormone which stimulates thyroid◦ May rise transiently in recovery from other
illnessFree T4:
◦ direct measure of thyroxine activity◦ May be transiently suppressed in severe
acute illnessFree T3: suspect hyperthyroid but normal
FT4Thyroid peroxidase/thyroperoxidase
antibody:◦ Anti-TPO◦ High levels in Hashimoto’s (95%) & Graves◦ TSH receptor stimulating Ab measures
activity in Graves-use in pregnancy
Typical Thyroid Hormone Levels in Thyroid Disease
TSH T4
T3
Hypothyroidism High Low Low
Hyperthyroidism Low High High
Subclinical Hypothyroidsm High normal normal
Subclinical Hyperthyroidsm Low normal normal
Scans/Ultrasound
Radioiodine uptake (RAIU)Thyroid ScanUltrasoundFine needle Aspiration
Treatment of Hyperthyroidism
1. Antithyroid drugs
2. Surgical resection
3. Radioactive iodine therapy
Braverman LE, et al. Werner & Ingbar’s The Thyroid. A Fundamental and Clinical Text. 8th ed. 2000.
1. Antithyroid Drug Therapy
Acute hyperthyroid symptomsGoal of therapy:
◦Inhibit peripheral conversion of T4 to T3◦Inhibit synthesis and release of T4 and
T3 from thyroid glandPropylthiouracil (PTU)Methimazole [generic] or Tapazole®
Antithyroid Drug TherapyA. PTU:
◦Inhibits peripheral conversion of T4 to T3◦Inhibits thyroid hormone synthesis and
release from thyroid glandB. Methimazole [generic]:
◦Inhibits thyroid hormone synthesis and release from thyroid gland
C. Beta-blocker therapy:◦Ameliorates tachycardia, sweating,
tremor, nervousness◦Propanolol: starting dose 20-40 mg
PO q6h◦Caution in patients with CHF or
bronchospasm
2. Subtotal ThyroidectomySurgical complications:
◦Vocal cord paralysis (1%)◦Hypothyroidism (up to 43% after 10
years)◦Hypoparathyroidism◦Recurrence of hyperthyroidism (10-
15%)
3. Radioactive Iodine 131[I] AblationTreatment of choice in patients >
21 years old with Graves’ DiseaseTreatment of choice in patients <
21 years old without remission after antithyroid drug therapy
Treatment of choice in patients with toxic multinodular goiter or toxic thyroid adenoma
Radioactive Iodine Ablation (cont’)
Single dose of 131[I] orally80% euthyroid after single dose> 50% of patients will develop
hypothyroidism◦Assay TSH every 3 months after
therapy
Radioactive Iodine Ablation (Cont’)
Levothyroxine therapy when patient becomes hypothyroid
Life-long Levothyroxine therapyRIA contraindicated in
pregnancy, lactation, iodine allergy◦Screen pre-menopausal women for
pregnancy prior to treatment
Thyroid StormA life-threatening crisis .Estimated mortality : 20-30% . the result of thyroid surgery .Caused more often by
antecedent Grave’s disease .
Precipitants of Thyroid StormSurgery .Radioiodine therapy .Iodinated contrast dyes .Thyroid hormone ingestion .Diabetic Ketoacidosis .Cerebrovascular accident .Pulmonary embolism and CHF .
Pathophysiology of Thyroid Storm1) An acute decrease in
thyroxine-binding globulin => high levels of free hormone .
2) Thyroid hormone increases the density of beta-adrenergic receptors & alters responsiveness to catecholamines at a postreceptor level .
Treatment of Thyroid StormBlock hormone synthesis with
either : a) Propylthiouracil 100-600 mg
loading PO or NG , 200-250 mg q4h for total daily dose of 1200-1500 mg ; or
b) methimazole 20 mg PO ( 10-40 mg range ) q 4h .
Treatment of Thyroid Storm ( continued )Inhibit hormone release : Iodides –Potassium iodide ( SSKI ) 5
drops PO Q6-8H , or Lugol’s solution 7-8 drops ( 1 mL PO
Q6H ) or Ipodate 1-3 g daily ( as 1 g Q8H for
24 hours , then 500 mg Q12H ) . If severe iodide allergy , lithium
carbonate 300 mg Q6H .
Treatment of Thyroid Storm ( continued )Glucocorticoids : Hydrocortisone (
300 mg IV , then 100 mg IV q8h ) ; dexamethasone ( 2 mg Q6H ) .
Adrenergic blockade : Propranolol ( 0.5-3 mg IV over 15 minutes slow IV , then 60-80 mg PO Q4H ) ; Esmolol ( 0.25-0.5 mcg/kg loading , infusion of 0.05-0.1 mcg/kg/min ) .
Adjunctive Therapy for Thyroid Storm Treat fever aggressively with
acetaminophen .IV fluid containing 10% dextrose
are recommended .Administer vitamin supplements ,
including thiamine .Treat CHF with conventional
methods .
Adjunctive Therapy for Thyroid Storm ( continued )Identify the precipitating event ,
including infection .Consider plasmapheresis ,
hemodialysis or peritoneal dialysis for removal of metabolically active hormone .
THANK YOU…
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