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hyperthyroidism Flashcards

1
Q

what is thyrotoxicosis

A

excess circulating thyroid hormones (due to any cause, incl hyperthyroidism)

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2
Q

signs and symptoms of hyperthyroidism

A
  • goitre
  • hyperactivity
  • disturbed sleep
  • fatigue
  • palpitations
  • anxiety
  • heat intolerance
  • increased appetite with unintentional weight loss
  • diarrhoea
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3
Q

which of the following is NOT a sign/symptom of hyperthyroidism
- hyperactivity
- goitre
- heat intolerance
- cold intolerance
- palpitations
- increased appetite and weight loss

A

cold intolerance is a sign/symptom of HYPOthyroidism

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4
Q

complications of hyperthyroidism

A
  • graves disease
  • thyroid storm (thyrotoxic crisis)
  • pregnancy complications
  • reduced bone mineral density
  • HF
  • AF
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5
Q

4 risk factors for hyperthyroidism

A
  • smoking
  • family history
  • co-existent autoimmune conditions
  • low iodine intake
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6
Q

which of the following is a risk factor for hyperthyroidism: female patient, 45 years, smoker, suffers from allergic rhinitis, has a diet that mainly consists of animal protein foods and sea vegetables

A

smoking = risk factor

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7
Q

what is primary hyperthyroidism

A

condition arises from thyroid gland itself rather than due to a pituitary or hypothalamic disorder

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8
Q

main cause of primary hyperthyroidism is

A

graves disease (autoimmune disorder mediated by antibodies that stimulate TSH receptor)

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9
Q

2 other causes of primary hyperthyroidism (apart from graves disease)

A
  • drug induced thyrotoxicosis
  • toxic nodular goitre - autonomously functioning thyroid nodules that secrete excess thyroid hormone
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10
Q

primary hyperthyroidism is more common in…

A

females

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11
Q

primary hyperthyroidism can be classed as

A
  • overt
  • subclinical
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12
Q

overt hyperthyroidism

A

TSH levels below reference and FT4 and/or FT3 levels above reference

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13
Q

subclinical hyperthyroidism

A

TSH suppressed but FT4 and FT3 within reference

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14
Q

suspect hyperthyroidism if features of graves orbitopathy:

A
  • excessive eye watering
  • double vision
  • change in visual acuity or colour vision
  • eyelid retraction or lid lag
  • proptosis (eyes protruding)
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15
Q

assessment of a person with suspected hyperthyroidism - what blood test

A
  • check serum TSH initially
  • then measure FT4 and FT3 in the same sample if TSH was suppressed
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16
Q

in amiodarone induced thyroiditis, what type of goitre is present

A

small goitre

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17
Q

describe the goitre present in graves disease

A

thyroid gland is usually diffusely symmetrically enlarged without nodules, and there may be a bruit (a sound)

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18
Q

does subclinical hyperthyroidism tend to be asymptomatic? if there are signs, this tends to be in which population?

A

yes - clinical symptoms and signs are absent, mild or non-specific. if they are present, they are more likely in younger people

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19
Q

can thyrotoxicosis occur without hyperthyroidism and how can it happen?

A

yes. usually transient. can occur due to excess intake of levothyroxine or OTC supplements containing thyroid hormone, or from thyroiditis

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20
Q

what is the thyrotoxic phase of postpartum and when does it typically occur and how long for

A
  • thyrotoxic PP typically overs between 1-6 months PP and usually lasts 1-2 months
  • happens when the thyroid becomes overactive after birth
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21
Q

checking TSH in suspected hyperthyroidism

A
  • if TSH below normal reference, then measure FT3 and FT4 in the same sample
  • overt: low TSH, high FT4 and/or TF3
  • subclinical: low TSH, normal FT4 and FT3
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22
Q

a patients lab reports show that they have low TSH, and normal FT4 and FT3. what is the diagnosis

A

subclinical primary hyperthyroidism

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23
Q

a patients lab reports show that they have low TSH, and high FT4 and/or FT3. what is the diagnosis

A

overt primary hyperthyroidism

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24
Q

subclinical primary hyperthyroidism - repeating TFTs to confirm diagnosis

A
  • subclinical: low TSH, and normal FT4 and FT3
  • repeat after 3 months after initial result or exclude other causes of transiently suppressed TH and to confirm diagnosis
  • if on repeat detesting there is persistently low TH and normal FT4 and FT3, diagnosis is confirmed
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25
Q

amiodarone induced hyperthyroidism typically produces the following TFTs results

A

low TSH, high FT4, raised or normal FT3

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26
Q

which OTC supplement can cause assay interference

A

OTC biotin can cause spuriously low TSH and elevate T4 and T3

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27
Q

non drug treatment options in graves disease of toxic nodular goitre

A

specialists may consider radioactive iodine or surgery. whilst awaiting these treatments, offer antithyroid drugs to control hyperthyroidism

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28
Q

symptoms of thyroid storm

A

rapid heartbeat, high temp, high BP, jaundice, loss of consciousness, severe agitation and confusion

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29
Q

what to do if a pt has signs of thyroid storm

A

medical emergency
emergency admission required

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30
Q

what to do if pituitary or hypothalamic disorder is suspected

A

refer urgently to endocrinologist

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31
Q

which class of drugs can you consider prescribing whilst awaiting specialist endocrinologist assessment to provide relief of adrenergic symptoms

A

beta blockers
titrate dose depending on clinical response
helps with adrenergic symptoms e.g. palpitations, tremor, tachycardia, anxiety

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32
Q

when to consider seeking specialist advice about starting antithyroid drugs

A
  • troublesome symptoms despite treatment with BB, or if BB not tolerated or contraindicated
  • at risk of complications
  • taking drug treatment e.g. amiodarone or lithium - may need liaison between specialistt and endocrinologist
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33
Q

what is the recommended choice of antithyroid drug

A

carbimazole

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34
Q

before starting antithyroid drugs, check the following

A

FBC and LFTs

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35
Q

name the 2 antithyroid drugs

A

carbimazole
propylthiouracil

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36
Q

why is propylthiouracil not 1st line

A
  • small risk of severe liver injury
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37
Q

when can propylthiouracil be prescribed instead of carbimazole

A

pre-pregnancy
1st trimester
specialist treatment of thyrotoxic crisis
may be used 2nd line if carbimazole not tolerated

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38
Q

antithyroid drugs can only be initiated on

A

specialist advice

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39
Q

antithyroid drugs are typically used ….. term to achieve ……

A

short term to achieve euthyroiditis

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40
Q

what does euthyroid mean

A

normal thyroid gland function

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41
Q

when would antithyroid meds be used long term?

A

if radioactive iodine treatment or surgery is contraindicated or is declined by the pt

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42
Q

in newly diagnosed graves disease that is mild and uncomplicated, how long would treatment be

A

12-18 months

43
Q

most people with graves disease become euthyroid after how many week of treatment with carbimazole

A

4-8 weeks

44
Q

which patients may require longer duration of treatment with antithyroid drugs

A

severe hyperthyroidism, large goitre, recent exposure to iodine

45
Q

after euthyroid is achieved, two different treatment regimens may be used by a specialist:

A

titration regimen
block and replace regimen

46
Q

remission rate for both regimens (titration block regimen and block and replace regimen)

A

remission rate is about 50% if treatment is continued for 6-18 months and then stopped

47
Q

what is titration-block regimen

A
  • dose adjusted regularly depending on FT4 measurements
  • dose reduction may be needed if FT4 falls to low-normal or below reference, or TSH increases, indicating development of hypothyroidism
  • aim is to titrate to lowest dose needed to maintain euthyroid state
48
Q

what is block and replace regimen

A
  • antithyroid drug used to block synthesis of thyroid hormone
  • FT4 level monitored and LT4 added in when FT4 in reference range
  • adjustments to LT4 dose are made to maintain FT4 in reference range
49
Q

how does radioactive iodine treatment work

A

induces damage of DNA leading to death of thyroid cells, causing decrease in thyroid function and/or reduced thyroid size

50
Q

what is 1st line definitive treatment for adults with graves disease and those with toxic multi nodular goitre?

A

radioactive iodine treatment

51
Q

how long after radioactive iodine treatment do most pt with graves become euthyroid and hypothyroid

A

euthyroid and then hypothyroid within 6weeks to 6 months after completing iodine treatment

52
Q

radio protective measures to follow after radioactive iodine treatment

A

avoid close prolonged contract with children and pregnant women for after 3 weeks after standard dose radioactive treatment

53
Q

which subset of patients with graves disease is radioactive iodine treatment contraindicated in and why (3)

A
  • contraindicated in pt with graves disease with active to severe orbitopathy as it can cause exacerbation of orbitopathy or de novo development
  • pregnant or planning to become pregnant in the next 4-6 months as it crosses placenta and can cause severe hypothyroidism in foetus
  • contraindicated in breastfeeding
54
Q

advice about pregnancy after having radioactive iodine treatment

A
  • women to avoid becoming pregnant for at least 6 months after treatment
  • men to not father children for at least 4 months after treatment
55
Q

why is pre-op treatment with antithyroid drugs, aiming for euthyroid given?

A

reduces risk of thyrotoxic crisis which may be precipitated by surgery

56
Q

post op complications

A

hypothyroidism
hypocalcaemia due to hypoparathyroidism (often transient)
vocal cord paresis due to damage to recurrent laryngeal nerve

57
Q

1st line graves disease

A

radioactive iodine under specialist care
recommended as definitive treatment unless unsuitable or remission likely to be achieved with antithyroid drugs

58
Q

1st line in pt with graves disease in pt whom an antithyroid drug is likely to achieve remission (e.g. mild and uncomplicated cases)

A

carbimazole or radioactive iodine

59
Q

carbimazole 2 types of regimens for graves disease (e.g. if pt has mild and uncomplicated case graves disease and antithyroid drug is likely to achieve remission)

A
  • 12-18 month course either using block and replace or titration regimen and review need for further treatment
  • block and replace: fixed high dose carbimazole with levothyroxine
  • titration regimen: dose based on TFTs
60
Q

what to do if a pt with graces disease has persistent or relapsed hyperthyroidism despite antithyroid treatment

A

consider radioactive iodine or surgery

61
Q

what to do in pt with graves disease who have side effects to carbimazole, pregnant or trying to conceive within following 6 months, or history of pancreatitis

A

consider propylthyiouracil

62
Q

what to do if agrunolycytosis develops during antithyroid treatment

A

stop and do not restart

63
Q

management of suspected graves orbitopathy if diagnosis is suspected

A
  • arrange emergency admission or seek immediate advice from ophthalmologist with special interest in thyroid eye disease if pt has suspected sight threatening complication
  • arrange routine referral to ophthalmologist with special interest in thyroid eye disease for all other people
64
Q

whilst waiting for specialist assessment regarding pt with suspected graves orbitopathy, advice pt on

A
  • smoking cessation
  • artificial tears to lubricate eyes
  • avoid irritation and damage to eyes e.g. use dark glasses, avoid dust, wear eye protectors during sleep
  • elevate head of bed to relieve morning eye swelling if needed
65
Q

treatment of transient thyroxoticosis without hyperthyroidism

A

usually only needs supportive treatment (for example, beta-blockers).

66
Q

1st line definitive treatment for pt with toxic nodular goitre and alternative

A
  • 1st line under specialist care is radioactive iodine
  • if unsuitable, offer total thyroidectomy or life long antithyroid drugs
  • when offering lifelong antithyroid drugs, consider treatment with titration regimen of carbimazole
67
Q

when to consider seeking specialist advice for pt with subclinical hyperthyroidism

A

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.

68
Q

what to consider for pt with untreated subclinical hyperthyroidism

A

Consider measuring TSH every 6 months

69
Q

pt taking carbimazole or prophylthiouracil should seek urgent medical advice if

A
  • they develop possible symptoms of agranulocytosis or neutropenia e.g. fever, sore throat, mouth ulcers, febrile or non-specific illness, bruising, malaise and to STOP the medication immediately
  • will need urgent blood test for differential white cell count
70
Q

a pt comes into the pharmacy asking to buy some strepsils and paracetamol because she is feeling under the weather. you check her PMR and see that she takes carbimazole/prophylthiouracil. upon further questioning, she tells you that she has a fever, sore throat and malaise. what do you

A
  • tell her to stop taking her carbimazole/propylthiouracil
  • refer to gp for urgent tests. could be agranulocytosis or neutropenia, so will need an urgent blood test
71
Q

a patient comes into the pharmacy to buy bonjela. he tells you that he has developed some mouth ulcers and has been unwell lately. you look at his pmr and see that he takes carbimazole/propylthiouracil. what do you do

A
  • stop taking the meds
  • refer urgently to gp - mouth ulcers can be a sign of agranulocytosis/neutropenia so will need an urgent blood test
72
Q

a patient who is taking carbimazole should seek urgent medical advice if…

A
  • stop medicine and seek urgent medical advice if sore throat, bruising, mouth ulcers, malaise, etc - may be a sign of neutropenia or agranolocytosis
  • signs of acute pancreatitis e.g. sudden severe pain in abdomen which is centre of belly, fever n/v - if this is suspected on assessment, stop immediately and manage appropriately
73
Q

if a pt is taking prophylthioruacil, advice them to seek urgent medical advice if

A
  • signs of neutropenia/agranulocytosis e.g. sore throat, malaise, fever, mouth ulcers etc
  • symptoms of liver disease e.g. anorexia, n/v, fatigue, abdominal pain, jaundice, light coloured stool, dark urine, itch - arrange for LFTs and if abnormal seek specialist advice
74
Q

a patient on an antithyroid drug has had abnormal LFTs. which drug are they on?

A

prophylthiouracil

75
Q

a patient presents with fever, nausea and vomiting, and says they have sudden and severe pain in the centre of their stomach. you look at their pmr and see that they are on an antithyroid drug. which one is it and what do you do?

A

carbimazole
refer
if suspected on assessment, stop taking

76
Q

a patient comes in and says their stool is clay coloured. upon further questioning, they reveal that they also have abdominal pain and feel itchy. you look at their pmr and notice they are on an antihtyroud drug. which one is it and what do you do

A

propylthiouriacil
refer to gp for urgent LFTs - if abnormal, stop taking and seek specialist advice

77
Q

before starting treatment with carbimazole or prophylthiouracil, what tests need to be performed

A

full blood count including white cell count and differential
liver function tests

78
Q

do you need routine monitoring of FBC and LFTs in pt taking antithyroid drugs for hyperthyroidism

A

no unless clinical suspicion of liver damage or agranulocytosis

79
Q

monitoring of antithyroid drug regimens

A

TSH, FT4 and FT3 every 6 weeks until TSH within reference, then TSH (with cascading to check ft4 and ft3) every 3 months until drugs stopped

80
Q

monitoring after stopping antithyroid drugs

A

TSH with cascading within 8 weeks of stopping drug, then TSH with cascading every 3 months for a year, then TSH with cascading once a year

81
Q

a female who is taking antithyroid drugs comes to the pharmacy and tells you she is planning a pregnancy. what do you do

A

refer to endocrinologist and advise to use effective contraception until specialist advice has been bought

82
Q

a female on antithyroid medication comes in to buy a pregnancy test. what do you do

A

seek immediate medical advice if pregnancy suspected or confirmed

83
Q

a patient on antithyroid drugs comes in and says she is pregnant. what do you do

A

refer urgently to specialist

84
Q

how long should females who have recently received radioactive iodine be advised to avoid becoming pregnant

A

for at least 6 months after treatment

85
Q

dose equivalence when substituting carbimazole and propylthioruacil

A

When substituting, carbimazole 1 mg is considered equivalent to propylthiouracil 10 mg but the dose may need adjusting according to response.

86
Q

carbimazole MHRA risk of congenital malformations

A
  • when used during pregnancy, esp 1st trimester and at high doses (15mg daily or more)
  • women of CB potential to use effective contraception during treatment
  • only consider in pregnancy after thorough risk-benefit assessment and use lowest effective dose without additional admin of thyroid hormones
  • close maternal, foetal and neonatal monitoring recommended
87
Q

carbimzole MHRA risk of acute pancreatitis

A
  • stop immediately and permanently if it ioccurs
  • do not use in pt with history of acute pancreatitis associated with previous treatment as re exposure can result in life threatening acute pancreatitis
88
Q

carbimazole contraindicated in

A

severe blood disorders

89
Q

which trimester should carbimazole be avoided in for sure

A

1st trimester

90
Q

carbimazole in pregnancy and bf

A
  • only use in pregnancy after through risk-benefit assessment
  • use lowest effective dose in breastfeeding
91
Q

carbimazole safety info - neutropenia and agranolycotiss

A
  • Important: recognise bone marrow suppression induced by carbimazole and the need to stop treatment promptly
  • Pt to report any signs and symptoms suggestive of infection - esp sore throat
  • WBC count performed if any clinical evidence of infection
  • Stop promptly if any clinical or laboratory evidence of neutropenia
92
Q

titration regimen of carbimazole for hyperthyroidism dose

A

-15-40mg daily, continue until euthyroid (normal thyroid function with normal TSH and T4)
- euthyroid usually after 4-8 weeks of treatment
- high dose under specialist supervision only
- then reduce to 5-15mg daily
- reduce dose gradually
- usually 12-18 months

93
Q

blocking replacement regimen of carbimazole for hyperthyroidism dose

A
  • in combo with levothyroxine
  • 40-60mg daily
  • usually 18 months
94
Q

pt and carer advice carbimazole

A

Contact Dr IMMEDIATELY if sore throat, mouth ulcers, bruising, fever, malaise, non specific illness develops

95
Q

dose of propylthiouriacil for hyperthyroidism

A

initially 200-400mg daily in divided doses until pt euthyroid
then reduce to 15-150mg daily in divided doses
initial dose should be gradually reduced to maintenance dose

96
Q

use of propylthiouracil in pregnancy

A
  • can be given but DO NOT GIVE BLOCKING REPLACEMENT REGIMEN
  • given 1st trimester as crbimzole is especially teratogenic during this period
  • only use lowest dose that will control hyperthyroid state
  • requirements in graves disease tend to fall during pregnancy
97
Q

which regimen of propylthiouracil is not suitable in pregnancy

A

blocking replacement regimen

98
Q

a patient is in her second trimester of pregnancy. what antithyroid drug is suitable

A

carbimazole

99
Q

use of proylthiouracil in pregnancy

A

use lowest effective dose

100
Q

monitoring of proptylthuouracil in breastfeeding

A

monitor infants thyroid status

101
Q

monitoring requirements of propylthiouracil

A

monitor for hepatoxicity

102
Q

pt and carer advice - propylthiouracil

A

Recognise signs of liver disorder and advised to seek prompt medical attention if symptoms such as anorexia, n/v, fatigue, abdominal pain, jaundice, dark urine or pruritis develop

103
Q

dose of levothyroxine in blocking replacement regimen in combination with carbimazole

A

50–150 micrograms daily therapy usually given for 18 months.

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