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Thyroid disorders in everyday care

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Thyroid disorders in everyday care Chris Vreeland, RN, MSN, NP-c Georgia Mountain Endocrinology, PC * * * * * * * * * * * * * * * Thyroiditis Post-partum thyroiditis ... – PowerPoint PPT presentation

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Title: Thyroid disorders in everyday care


1
Thyroid disorders in everyday care
  • Chris Vreeland, RN, MSN, NP-c
  • Georgia Mountain Endocrinology, PC

2
Introduction
  • One in ten Americans have a thyroid disorder
  • Bodys response to thyroid disorders is fatigue -
    most common reason to seek healthcare.
  • Women particularly affected by thyroid imbalance
  • Weight
  • Fertility
  • Pregnancy
  • Menopause
  • Osteoporosis

3
Thyroid Hormone Action
  • Activates nuclear receptors which regulate
    expression of thyroid hormone-responsive genes
  • Fetus neonate differentiation of target
    tissues
  • Childhood differentiation/proliferation
  • Adolescent role in action of sex steroids

4
Thyroid Hormone Action
  • Gene expression (continued)
  • All ages
  • Regulates energy production
  • Regulates functional /structural proteins
  • Regulates action of other hormones -
    glucocorticoids, mineralocorticoids, growth
    factors, biologic amines (catecholamines)

5
Negative Feedback Loop
  • Thyroid hormone inhibits pituitary secretion of
    TSH
  • Hypothalamus plays crucial role
  • TSH very sensitive indication index of action
  • TSH thyroid hormones maintained in a certain
    relationship
  • Modified by TBG (thyroxine-binding globulin)

6
Negative Feedback Loop
  • Hyperthyroidism
  • Elevated serum thyroid level
  • Decreased TSH
  • Hypothyroidism
  • Decreased serum thyroid levels
  • Increased TSH

7
Serum Levels of Thyroid Hormones
  • T3 regulates peripheral action of hormone
  • T3 T4 both released from gland
  • Peripheral conversion of T4 to T3 occurs in liver
    and target tissues
  • In presence of liver damage, T3 conversion may be
    low despite good levels of T4

8
TBG Metabolism
  • T4 transported to tissue by TBG
  • High serum TBG (liver damage, pregnancy, OCPs,
    HRT) lowers serum concentrations of free T4 which
    decreases amount of substrate (T4) that can be
    converted to T3
  • Indirect measure of TBG abnormality is T3 uptake

9
Causes of Thyroid Disorders
  • Hyperthyroidism
  • Graves disease
  • Autoimmune
  • TSH receptor antibodies
  • Thyroiditis
  • Sub-acute
  • Post-partum
  • Pituitary tumor - TSH producing

10
Causes of Thyroid Disorders
  • Hypothyroidism (High TSH, low T3, T4)
  • Hashimoto thyroiditis
  • Autoimmune
  • TPO and thyroglobulin antibodies
  • RAI radioactive iodine ablation
  • Surgery
  • Antithyroid drugs
  • Goitrogens lithium, amiodarone

11
Normal Hormone Levels
  • TSH 0.4-5.5 MIU/L
  • Total T3 60-181 NG/DL
  • Total T4 4.5-12.5 MCG/DL
  • T3 Uptake 22-35

12
Hypothyroidism
  • Symptoms
  • Fatigue
  • Weight gain
  • Cold feeling
  • Dry hair, nails, skin
  • Hair loss
  • Heavier or longer menses
  • Constipation
  • Peripheral edema
  • Periorbital edema
  • Bradycardia
  • Hypotension
  • Infertility

13
Hypothyroidism
  • Treatment
  • Hormone replacement (L-T4)
  • Absorbed from small intestine
  • 6-day half-life
  • Daily dosing 0.025-.300 mgs
  • Branded preparations preferred to generic
  • Synthroid
  • Levoxyl
  • Tirosint

14
Hypothyroidism
  • Treatment
  • Initial dose
  • 1.7 mcg per kg
  • Pregnant may need 1.8 mcg per kg
  • Elderly usually start at lower doses, esp.
    with angina or CAD
  • Monitoring
  • 6-8 weeks after any dose change
  • Annually once stable
  • Each trimester in pregnancy

15
Hypothyroidism
  • Myxedema Coma
  • End stage of uncompensated hypothyroidism
  • Presents most often in elderly and women in
    winter months
  • Present in respiratory failure, hypotension,
    bradyarrythmia, along with serious precipitating
    illness
  • Treatment is T4 IV _at_ 1/10th dose of oral
  • ICU admit for multi-system failure

16
Hypothyroidism
  • Pearls
  • Most patients reports feeling best with TSH
    between 1-2
  • If TSH normal, but patient still not feeling
    good, think low T3 may need Cytomel (oral T3)
  • Depression very common
  • Inadequate treatment can contribute to
    infertility
  • Look for recent onset of symptom with family
    history of thyroid disease

17
Hyperthyroidism
  • Symptoms
  • Anxiety
  • Palpitations
  • Unintended weight loss
  • Decreased or absent menses
  • Oily skin
  • Fine, silky, oily-appearing hair
  • Heat intolerance
  • Exopthalmos (not all cases)
  • Tachycardia

18
Hyperthyroidism
  • Treatment
  • Anti-thyroid drugs
  • Methimazole
  • Inhibits thyroid hormone synthesis in the thyroid
    gland
  • PTU
  • Inhibits thyroid hormone synthesis in the thyroid
    gland inhibits peripheral conversion of T4 to
    T3

19
Hyperthyroidism
  • Dosing
  • Tapazole 10 mg BID or TID
  • PTU only 50 mg tablets available
  • Usual starting dose 2 tabs TID may double
    dose if necessary
  • Both very effective at lowering thyroid hormone
    levels
  • TSH will stay suppressed several month

20
Hyperthyroidism
  • Dosing
  • Monitor every 4-6 weeks
  • When TSH rises, may need to add T4 (thyroid
    hormone)
  • Want to leave on ATDs long enough to allow TSH
    receptor antibodies to decrease induce
    remission usually 12-18 months
  • Plan to withdraw med at 12-18 months to evaluate
    remission status

21
Hyperthyroidism
  • Side effects of anti-thyroid drugs
  • Leucocytopenia
  • Agranulocytosis-most serious
  • Pernicious anemia
  • Thrombocytopenia
  • Hepatic dysfunction
  • Allergy (discoid rashes)
  • Evaluate with CMP, CBC, thyroid hormone levels
    every 4-6 months

22
Hyperthyroidism
  • Radioactive Iodine Ablation
  • Administration of I131 iodine by mouth
  • Used after TFTs normal or if unable to control
    hyperthyroidism with drugs
  • Usually destroys gland over 3-6 months

23
Hyperthyroidism
  • Radioactive Iodine Ablation
  • Induces permanent hypothyroidism
  • May cause post-treatment thyroid storm (rare)
  • May cause aggravation of Graves eye disease
  • Pregnancy should be prevented within 6 months
    after treatment

24
Hyperthyroidism
  • Surgery
  • When disease state or gland size cant be
    controlled with drugs
  • When gland causing obstructive signs
  • Difficulty breathing either supine or upright
  • -Evaluated by PA LAT CXR
  • Difficulty swallowing food
  • -Evaluated by barium swallow

25
Hyperthyroidism
  • Thyroid Storm
  • Most often with Graves disease
  • Levels same as with Graves
  • Cardinal signs
  • Temperature 102 to 1050
  • Profuse sweating
  • Marked tachycardia (120-140 pulse rate or higher)
  • Atrial fibrillation
  • Usually induced by concurrent infection or
    surgery on hyperactive gland

26
Hyperthyroidism
  • Thyroid storm
  • Treatment
  • PTU orally or by NG tube
  • Tapazole not favored because it does not inhibit
    peripheral conversion of T4 to T3
  • Beta blockade, PO or IV
  • Supportive therapy for fever, dehydration
  • Perhaps iodine solution or corticosteroids

27
Hyperthyroidism
  • Graves Eye Disease
  • Caused by antibody effect on orbital tissue
  • Symptoms include
  • Edema
  • Inflammation
  • Hypertrophy of extra ocular muscles orbital fat
  • Exopthalmos upper lower lid retraction,
    strabismus, herniated orbital fat

28
Hyperthyroidism
  • Graves Eye Disease
  • Should be stabilized for 6 months prior to any
    other treatment modality
  • Exception is optic neuropathy caused by
    strangulation of optic nerve
  • Extent of protrusion measured by increase in
    distance between lateral orbital rim and anterior
    aspect of eye

29
Thyroid Nodules
  • May be a single nodule or larger of multiple
    nodules
  • 95 benign
  • More common in women
  • More likely malignant in men
  • Increase in size while on T4 therapy worrisome
    for malignancy

30
Thyroid Nodules
  • Note size, consistency and mobility on physical
    exam
  • Evaluate for tracheal deviation or esophageal
    obstruction
  • Usually TSH suppressed, T3 and T4 levels normal
  • Antibodies may be present, but more likely they
    are not not
  • Ultrasound best way to diagnose

31
Thyroid Nodules
  • Treatment
  • Multinodular gland without dominant nodule T4
    to shrink if TSH not suppressed
  • Single nodule 1 cm or greater fine needle
    aspiration biopsy
  • Enlarging nodule despite good dose of T4 or
    indeterminate or malignant result from FNA
    indicates need for surgery

32
Thyroiditis
  • Most common cause chronic autoimmune
    thyroiditis or post-partum thyroiditis
  • Next is sub acute thyroiditis
  • More rare acute suppurative thyroiditis

33
Thyroiditis
  • Post-partum thyroiditis
  • May occur anytime in the first year, but most
    common in first 3 months
  • Usually have hyperthyroid symptoms first,
    followed by hypothyroid findings
  • Gland usually enlarged
  • Will not have other markers for inflammation
    fever, tenderness, high sed rate

34
Thyroiditis
  • Post-partum thyroiditis
  • Usually spontaneously resolve
  • May need temporary medication support for
    symptoms
  • Beta blockers for tachycardia
  • Tranquilizers for anxiety
  • T4 for hypothyroidism
  • Can progress to permanent hypothyroidism

35
Thyroiditis
  • Sub acute
  • Usually follows viral illness
  • Gland is swollen, tender
  • Sed rate elevated gt50mm/hour
  • May have fever, even fairly mild
  • Leucocytosis
  • Follows usual pattern of transient
    hyperthyroidism, then hypothyroidism, then
    euthyroid

36
Thyroiditis
  • Sub acute
  • Treatment
  • Symptomatic
  • NSAIDS for pain, fever
  • Prednisone for severe pain unrelieved by above
  • Beta blockers for hyper phase
  • Thyroid replacement for hypo phase
  • Resolve spontaneously

37
  • Questions?

38
  • Thank you!
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