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Thyroid Disorders: Hyperthyroid

August 12, 2018 By Dr. G, PharmD

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  • Graves Disorder, pituitary adenomas, toxic goiter, drug-induced (excess thyroid hormone, amiodarone)
    elevated free T4, suppressed TSH
  • Can use radioactive iodine update study to diagnose. Uptake is elevated if thyroid is excessively secreting T4 or T3: Graves disease, TSH-secreting adenoma, toxic adenoma, multinodular goiter
  • Clinical presentation: weight loss, lid lag, heat intolerance, goiter, fine hair, tachycardia, nervousness, menstrual disturbances, sweating, exophthalmos
  • Normal TSH: 0.4-4 (clinically significant if less than <2.5).

Treatment:

  • Ablation is the treatment of choice
  • Can use meds in patients waiting for ablation or those who are not surgical candidates
    • propylthiouracil 100 mg TID, max 400 mg TID, may reduce to 50 mg when euthyroid.
      • PTU may cause hepatotoxicity. Routine liver tests suggested.
    • methimazole – preferred unless pregnant, 10-20 mg daily up to 40 mg TID, may reduce to 5-10 mg daily once euthyroid
    • Both drugs can cause a rash, arthralgias, fever, agranulocytosis early in therapy
    • Max effect can take 4-6 months. Remission only 20-30%.  Usually, need 12-18 month trial. Monitor every 1-3 months
  • Can use non-selective Beta-blockers (primarily propranolol, may use nadolol). Use mostly for symptom relief or acutely during Thyroid storm.
  • Iodines: Lugol solution has a limited efficacy of 7-14 days.

Thyroid Storm:

  • AVOID NSAIDS IN THYROID STORM
  • Life-threatening: caused by trauma, infection, antithyroid agent, withdrawal, severe thyroiditis, post-ablative therapy

Treatment:

  • Ablation is the treatment of choice
  • propylthiouracil – 500-1000 mg, then 250 mg every 4 hours
  • methimazole – 60-80 mg daily
  • Iodine therapy 1 hour after PTU
  • Beta-blocker therapy: propranolol or esmolol for symptoms
  • APAP for fever. No NSAIDS.  They displace protein-bound thyroid hormone
  • Prednisone 300 mg IV, then 100 mg every 8 hours.

You can use PTU in the first trimester of pregnancy (causes hepatotoxicity) and methimazole at the start of 2nd trimester (can cause embryopathy in first)

Filed Under: Endocrine Disorders Tagged With: adenoma, goiter, hyperthyroid

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acid base acidosis acute coronary syndrome alkalosis analgesics anaphylaxis aortic dissection arrhythmia Beta-Blockers biostatistics blood pressure cardiac markers CHA2DS2-VasC cocaine COVID-19 diabetes diabetes inspidius Guidelines heart failure Heparin hypersensitivity hypertension hypovolemic shock intubation ionotropes journal club lipids LMWH medication safety morphine conversions myocardial infarction needs work NOAC NSTEMI obstructive shock pharmacoeconomics pheochromocytoma pressors reference materials right mi sedation septic shock shock STEMI Updated 2020