Thyroid Function Tests
Vinushree.B.N.
4th year
Pharm D
• The thyroid gland is a butterfly-shaped
organ located in the base of your neck. It releases
hormones that regulate metabolism, growth and
development of human body. The thyroid's hormones
regulate vital body functions, including:
• Breathing
• Heart rate
• Central and peripheral nervous systems
• Body weight
• Muscle strength
• Menstrual cycles›
• Body temperature and cholesterol levels.
Introduction
Thyroid hormones:
tetra iodothyronine / thyroxine (T4)
tri iodothyronine (T3)
Binds to:
thyroxine binding globulin (TBG)
thyroxine binding pre albumin (TBPA)
albumin
apolipoproteins
Free fractions are metabolically active
Differences between T3 and T4
T3 T4
Secretion 30 microgram /day 80 microgram /day
Source 20 – 25% by gland Solely by gland
75 - 80% by
conversion
Half-life 1 day 7 days
Potency 3-4 times more potent Potent
than T4
Binding 0.2% in unbound 0.02% in unbound
Thyroid disorders
Hypothyroidism
Primary
Secondary
Tertiary
Hyperthyroidism
Thyroid disorders
Symptoms of hypothyroidism
Lethargy
Constipation
Dry and coarse skin and hair
Facial puffiness
Cold intolerance
Decreased sweating
Impaired memory
Confusion
Dementia
Low speech and motor activity
Anemia
Thyroid disorders
Causes of hypothyroidism
Primary Secondary Tertiary
Iodine deficiency Hypopituitarism Hypothalamic
Excess iodide intake - Adenoma dysfunction
Thyroid ablation - Ablative therapy
(Surgery) - Pituitary destruction
Hashimoto’s
thyroiditis
Sub acute thyroiditis
Genetic abnormalities
Goiterogenic food
(cabbage)
Drugs
– Lithium
– Amiodarone
– Anti thyroid agents
Thyroid disorders
Symptoms of hyperthyroidism
Nervousness
Fatigue
Weight loss
Heat intolerance
Increased sweating
Tachycardia
Atrial fibrillation
Warm and moist skin
Exophthalmos
Thyroid disorders
Causes of hyperthyroidism
a) Overproduction of thyroid hormones
a) Grave’s disease
b) TSH secreting pituitary adenomas
c) Multi nodular goiter
b) Leaking thyroid hormone due to thyroid destruction
a) Lymphocytic thyroiditis
b) Sub acute thyroiditis
c) Radiation
c) Drugs
a) Thyroid replacement drugs
b) Amiodarone
c) Iodinated radio contrast agents
d) Metastatic thyroid carcinoma
Thyroid tests
Measure the concentration of products secreted by the
thyroid gland
Total T4 (TT4) and Free T4 (FT4)
Serum T3 resin uptake
Free T4 index
Total serum T3
The T4 test measures the concentration of thyroxine in the
serum, including both the protein bound and free hormone.
The total T4- Reference range: 4 - 12 microgram/dl
The total (but not the free) hormone concentration is
dependent on the concentration of thyroid transport
proteins, specifically thyroid binding globulin (TBG),
albumin, and thyroid binding prealbumin (transthyretin).
Thus any conditions that affects levels of thyroid binding
proteins will affect the total (but not the free) T4 hormone
levels
For example, estrogens and acute liver disease will
increase thyroid binding – hyperthyroidism
while androgens, steroids, chronic liver disease
and severe illness can decrease it -
hypothyroidism.
Free T4
• Reference range: 0.8 - 2.7 nanogram/dl
• The free T4 (FT4) assay measures the
concentration of free thyroxine, the only
biologically active fraction, in the serum
(about 0.05% of the total T4). The free
thyroxine is not affected by changes in
concentrations of binding proteins. Thus
such conditions as pregnancy, or estrogen
and androgen therapy do not affect the FT4.
• TT4 and FT4 are not always reliable indicators of thyroid
disease. For example, a substantial proportion of seriously
ill patients will have abnormal thyroid function in the
absence of true thyroid disease, due to "sick euthyroid
syndrome." Also, screening with TT4 or FT4 will
generate many false-positive results in healthy
populations. And, because TT4 and FT4 are normal by
definition in subclinical thyroid dysfunction, they are not
useful as screening tests for this condition.
• Decreased direct equilibrium dialysis (method) T4 and
increase TSH is suggestive of - primary hypothyroidism
• Increase DED free T4 and TSH of less than 0.01
milliunits/L is suggestive of - non-pituitary
hyperthyroidism
Thyroid tests
Serum T3 resin uptake (thyroid hormone binding ratio):
Reference range: 25 – 35%
Indirectly estimates the number of binding sites on
thyroid binding proteins occupied by T3
The T3 resin uptake is high when thyroid –binding
protein is low and vice versa
Thyroid tests
Free thyroxine (T4) index:
Reference range: 1.2 – 4.2
Free T4 index = Total serum T4 (mg/dl) X T3 resin uptake (%)
The index is high in hyperthyroidism
The index is low in hypothyroidism
Thyroid tests
Total serum T3:
Reference range: 78 - 195 nanogram/dl
Used to detect T3 toxicosis (increase T3 and normal T4)
Thyroid tests
Evaluate the integrity of the hypothalamic – pituitary -
thyroid axis:
Assessed by measuring TSH and TRH
Thyroid tests
TSH:
Ref range: 0.3 - 5 microunits /ml or milliunits /L
Symptomatic primary hypothyroidism: >20 mu/L
Mild symptomatic hypothyroidism: 10 to 20 mu/L
Primary hyperthyroidism: <0.05 mu/L
Thyroid tests
TRH:
Regulates the TSH secretion from pituitary
TRH test measure the ability of TRH to stimulate the
pituitary to secrete TSH
TSH rise of 5 micro units/ml over baseline - euthyroid state
A significant increase rules out – hyperthyroidism
Is performed by drawing baseline serum TSH concentration and then
administer approximately 200-400 microgram of TRH by iv over 30 – 60
seconds. Then TSH concentration drawn at 30 – 60 minutes
Thyroid tests
Assess inherent thyroid gland function
Radioactive iodine uptake test is used to assess
intrinsic function of the thyroid gland
This test is not specific and the reference range
should be adjusted based on local population
This test is indirect measure of thyroid activity
Thyroid tests
Subject with normal thyroid gland
12 – 20% of radio active iodine is absorbed after 6
hours
5 - 25% of radio active iodine is absorbed after 24
hours
Thyroid tests
Increased radio active iodine uptake noted in:
Thyrotoxicosis
Iodine deficiency
Post thyroiditis
Withdrawal rebound after thyroid hormone/ anti
thyroid drug therapy
Decreased radio active iodine uptake noted in:
Acute thyroiditis
Euthyroid patients
Patients on exogenous thyroid hormone therapy
Patients taking anti-thyroid drugs
hypothyroidism
Thank you
