Hyperthyroidism

Question 1

What are the signs and symptoms of hyperthyroidism? (10)

Answer 1

1. Goiter
2. Hyperactivity
3. Disturbed sleep
4. Fatigue
5. Palpitations
6. Anxiety
7. Heat intolerance
8. Increased appetite
9. Unintentional weight loss
10. Diarrhea
    (Others)

Question 2

What are the main complications of hyperthyroidism? (6)

Answer 2

1. Graves’ orbitopathy
2. Thyroid storm (thyrotoxic crisis)
3. Pregnancy complications
4. Reduced bone mineral density
5. Heart failure
6. Atrial fibrillation

Question 3

What are the main risk factors for hyperthyroidism? (4)

Answer 3

1. Smoking
2. Family history of thyroid disease
3. Co-existant autoimmune conditions
4. Low iodine intake

Question 4

Primary hyperthyroidism refers to when the condition arises from the __________ rather than due to a ______________ disorder

Answer 4

thyroid gland

pituitary or hypothalamic

Question 5

What is the most common cause of primary hyperthyroidism?

Answer 5

Graves’ disease (autoimmune disorder mediated by antibodies that stimulate the thyroid-simulating hormone (TSH) receptors)

Question 6

What are the less common causes of primary hyperthyroidism? (2)

Answer 6

1. Toxic multinodular goiter (autonomously functions thyroid nodules that secrete excess thyroid hormone
2. Drug-induced thyrotoxicosis

Question 7

In overt hyperthyroidism, TSH levels are _______ and FT3 and/or FT4 levels are _______.

Answer 7

Below the reference range

Above the reference range

Question 8

In subclinical hyperthyroidism, TSH levels are _______ and FT3 and/or FT4 levels are _______.

Answer 8

Low

Within the reference range

Question 9

What are the aims of treatment for hyperthyroidism? (3)

Answer 9

1. Alleviate symptoms
2. Align thyroid function tests within or close to the reference range
3. Reduce the risk of long-term complications

Question 10

What are the non-drug treatment options for primary hyperthyroidism? (2)

Answer 10

1. Radioactive iodine
2. Surgery (total or partial thyroidectomy)

**whilst awaiting these treatments, antithyroid drugs should be offered to control hyperthyroidism

Question 11

True or false: thyroid storm is a medical emergency

Answer 11

True

Refer patients urgently to an endocrinologist if a pituitary or hypothalamic disorder is suspected, and refer or discuss with an endocrinologist all patients with new-onset hyperthyroidism (base urgency on clinical judgement); if malignancy is suspected, refer patients using a suspected cancer pathway

Question 12

What three aspects of hyperthyroidism management should be explained to patients?

Answer 12

1. Some patients feel well even when their thyroid function tests are outside the reference range
2. Even when they have no symptoms, treatment may be advised to reduce the risk of long-term complications
3. Symptoms may lag behind treatment changes for several weeks to months

Question 13

_________ should be considered alongside supportive treatment (eg beta-blockers) for patients with hyperthyroidism, awaiting specialist assessment and further treatment

Answer 13

Antithyroid drugs

Carbimazole is first line
PTU may be offered to patients in whom carbimazole is unsuitable

Question 14

Before starting antithyroid drugs, check ________ and ________

Answer 14

FBC

LFTs

Question 15

Under specialist care, ____________ is recommended as first-line definitive treatment for Graves’ disease unless it is unsuitable or remission is likely to be achieved with antithyroid drugs.

Answer 15

radioactive iodine

Question 16

For patients with Graves’ disease in whom an antithyroid drug is likely to achieve remission (such as in mild and uncomplicated cases), a choice of either ___________ or _____________ should be offered.

Answer 16

carbimazole

radioactive iodine

• Carbimazole should be offered as first-line definitive treatment if radioactive iodine and surgery are unsuitable treatment options

Question 17

What is the “block and replace” regimen used to treat hyperthyroidism?

Answer 17

Combination of fixed high-dose carbimazole in combination with levothyroxine

Question 18

What can be offered as an alternative to the “block-and-replace” regimen used to treat hyperthyroidism?

Answer 18

A titration regimen; dose of carbimazole or other antithyroid drug is modified based on thyroid function tests

Question 19

If patients with Graves’ disease have persistent or relapsed hyperthyroidism despite antithyroid drug treatment, consider ____________ or ___________

Answer 19

radioactive iodine

surgery

Question 20

PTU should be considered over carbimazole in which patients? (3)

Answer 20

1. Patients who experience side-effects from carbimazole
2. Patients who are pregnant or trying to conceive
3. Patients with a history of pancreatitis

Question 21

If ___________ develops during antithyroid treatment, stop and do not restart treatment

Answer 21

agranulocytosis

Question 22

What is the first-line definitive treatment for patients with hyperthyroidism secondary to multiple nodules?

Answer 22

Radioactive iodine under specialist care

Question 23

What treatment should be offered to patients with toxic multinodular goiter in whom radioactive iodine is not suitable? (2)

Answer 23

1. Total thyroidectomy OR

2. Life-long antithyroid drugs

Question 24

For patients with hyperthyroidism secondary to a single nodule, offer _________ or __________ as first-line definitive treatment

Answer 24

radioactive iodine

surgery (hemithyroidectomy)

If these options are unsuitable, offer life-long antithyroid drugs

Question 25

Consider treatment with a ________ regimen of carbimazole when offering life-long antithyroid drugs.

Answer 25

titration

Question 26

Consider measuring TSH every ____ months for patients with untreated subclinical hyperthyroidism.

Answer 26

6 For patients who have 2 TSH readings lower than 0.1 mIU/litre at least 3 months apart and evidence of thyroid disease or symptoms of thyrotoxicosis, consider seeking specialist advice.

Question 27

Transient thyrotoxicosis without hyperthyroidism usually only needs __________

Answer 27

supportive treatment (for example, beta-blockers)

Question 28

What are the causes of thyrotoxicosis without hyperthyroidism? (3)

Answer 28

1. Excess intake of levothyroxine 2. Excess of over-the-counter supplements containing thyroid hormone 3. Thyroiditis *usually transient

Question 29

What is the management of hyperthyroidism in pregnancy?

Answer 29

All pregnant females should be referred urgently to a specialist Females with hyperthyroidism who are planning a pregnancy should be referred to an endocrinologist and advised to use effective contraception until specialist advice has been sought; advise patients to seek immediate medical advice if pregnancy is suspected or confirmed

Question 30

Pregnant females with severe signs and symptoms of hyperthyroidism (such as thyroid storm) should be __________________.

Answer 30

admitted to hospital

Question 31

Females who have recently received radioactive iodine should be advised to avoid becoming pregnant for at least __________ after treatment.

Answer 31

6 months

Question 32

What are the major safety concerns regarding the use of carbimazole? (3)

Answer 32

1. Neutropenia and agranulocytosis 2. Increased risk of congenital malformations 3. Risk of acute pancreatitis

Question 33

What is the main contraindication to the use of carbimazole?

Answer 33

Severe blood disorders

Question 34

When substituting, carbimazole 1 mg is considered equivalent to PTU ______ mg but the dose may need to be adjusted according to response

Answer 34

10

Question 35

What additional information should be given to patients and carers regarding the use of carbimazole?

Answer 35

Warn patient or carers to tell doctor immediately if sore throat, mouth ulcers, bruising, fever, malaise, or non-specific illness develops.

Question 36

What severe reaction is associated with PTU?

Answer 36

Severe hepatic reactions have been reported, including fatal cases and cases requiring liver transplant—discontinue if significant liver-enzyme abnormalities develop.

Question 37

Can the “block-and-replace” regimen be used for the treatment of hyperthyroidism in pregnancy?

Answer 37

NO; the lowest dose that will control the hyperthyroid state should be used and NO MORE because PTU crosses the placenta and in high doses may cause fetal goiter and hypothyroidism

Question 38

Is PTU safe in breastfeeding?

Answer 38

Present in breast milk but does not preclude breast-feeding as long as neonatal development is being closely monitored and the lowest effective dose is used Monitor infant’s thyroid status

Question 39

Is PTU safe to prescribe in hepatic impairment?

Answer 39

Consider dose reduction due to risk of increased half-life

Question 40

What are the monitoring requirements for PTU?

Answer 40

Monitor for hepatotoxicity

Question 41

What additional information should be given to patients and carers regarding PTU?

Answer 41

Patients should be told how to recognise signs of liver disorder and advised to seek prompt medical attention if symptoms such as anorexia, nausea, vomiting, fatigue, abdominal pain, jaundice, dark urine, or pruritus develop.