Faculty of Pharmacy Mansoura University
Thyroid disorders
Presented by
Dhafer Hadi Ali
Pharmacology and Toxicology Department
Faculty of Pharmacy
Mansoura University
Functions of the Thyroid gland
Thyroid hormone pathway
Regulation Thyroid Hormones Synthesis
6
Patients with thyroid disease
3
1 2
Thyroid enlargement Symptoms of Symptoms of
(goiter) hypothyroidism hyperthyroidism
diffuse or nodular
4
Complications of a specific
form of hyperthyroidism-
Graves’ disease-which may
present with:
-Striking prominence -Thickening of the skin
of the eyes over the lower leg
(exophthalmos) (thyroid dermopathy) 8
Causes of Hypothyroidism Vs Hyperthyrodism
Thyroid disorders
Symptoms
Hypothyroidism Vs Hyperthyrodism
Thyroid Agents
•Thyroid agents
• Thyroid hormones
• levothyroxine (Synthroid, Levoxyl)
• liothyronine (Cytomel, Triostat)
• liotrix (Thyrolar)
• thyroid desiccated extract (Armour
Thyroid)
•Antithyroid agents
• Thioamides
• methimazole (Tapazole)
• propylthiouracil (PTU)
• iodine solutions (Sodium iodide I131)
• strong iodine solution, potassium iodide
(Thyro-block)
Treatment
Hypothyroidism Vs Hyperthyrodism
HYPERTHYROIDISM &
THYROTOXICOSIS
(Overactive Thyroid)
Iodine states
⚫ Normal Thyroid
⚫ Inactive Thyroid
⚫ Hyperactive Thyroid
Diagnosis
⚫ Low serum FT4
⚫ Elevated serum TSH
⚫ Thyroid antibodies
⚫ TRH stimulation test
Individual and median values of
thyroid function tests in patients
with various grades of
hypothyroidism.
Discontinuous horizontal lines
represent upper limit (TSH) and
lower limit (FT4,T3) of the normal
reference ranges. Reproduced with
permission from Ord WM: On
myxedema, a term proposed to be
applied to an essential condition in
the "cretinoid" affection
occasionally observed in middle-
aged women. Medico-Chir Trans
1878; 61: 57.
Treatment of Hypothyroidism
A- Levothyroxine (T4).
- Follow serum Free T4 and TSH
- Take dose in AM
- Do blood test fasting before taking the daily dose
- Adults: 1.7 ug/kg/d, but lower in elderly (1.6 ug/kg/d)
- For TSH suppression (nodular goiters or cancer): 2.2
ug/kg/d
- Increase dose of T4 in malabsorptive states or
concurrent administration of aluminum preparations,
cholestyramine, calcium, or iron compounds
- Increase dose of T4 in pregnancy and lactation
- The t1/2 of levothyroxine is 7 days
Complications
⚫ 1- Myxedema coma
- The end stage of untreated hypothyroidism
- Progressive weakness, stupor, hypothermia, hypoventilation,
hypoglycemia, hyponatremia, water intoxication, shock, and death.
- Associate illnesses and precipitating factors: pneumonia, MI, cerebral
thrombosis, GI bleeding, ileus, excessive fluid administration, and
administration of sedatives and narcotics.
- Three main issues: CO2 retention and hypoxia, fluid and electrolyte
imbalance, and hypothermia.
⚫ 2- Myxedema and heart disease
⚫ 3- Hypothyroidism and neuropsychiatric
disease
Treatment of Hypothyroidism
B- Myxedema coma
- Acute medical emergency
- Monitor blood gases
- Patient may need intubation and mechanical ventilation
- Treat associated medical problems
- Avoid excessive hydration
- Asses adrenal function and treat if needed
- In pituitary myxedema, glucocorticoid replacement is essential
- IV levothyroxine: loading 300-400 ug, daily maintenance 50 ug
- Be cautious in patients with coronary artery disease
- Active rewarming of the body in contraindicated
Treatment of Hypothyroidism
C- Myxedema with heart disease
- Start treatment slowly in long standing hypothyroidism and in elderly patients
particularly those with known cardiovascular disease
- 25 ug/d x 2 weeks, increase by 25 ug every 2 weeks until a daily dose of 100-
125 ug is reached
⚫ Toxic effects of levothyroxine therapy
- No allergy has been reported to pure levothyroxine
- If FT4 and TSH are followed and T4 dose is adjusted, no side effects are reported
- If FT4 is higher than normal: hyperthyroidism symptoms may occur:
⚫ Cardiac symptoms
⚫ Osteopenia and osteoporosis
Recommendations for the treatment of myxedema
coma
large initial intravenous dose of 300-500 µg
• hypothyroidism
T4; if no response within 48 hours, add T3
intravenous hydrocortisone 200-400 mg
• hypocortisolemia
daily
don’t delay intubation and mechanical
• hypoventilation
ventilation too long
• hypothermia blankets, no active rewarming
• hyponatremia mild fluid restriction
cautious volume expansion with crystalloid
• hypotension
or whole blood
• hypoglycemia glucose administration
identification and elimination by specific
• precipitating event
treatment (liberal use of antibiotics)
Treatment of Graves’ disease
⚫ Antithyroid drug therapy
- Propylthiouracil or methimazole
- Spontaneous remission 20-40%
- Relapse 50-60%
- Duration of treatment 6 months – years
- Reactions to antithyroid drugs
⚫ Surgical treatment
- Subtotal thyroidectomy
- Preparation for surgery
- Complications:
* hypothyroidism/ hypoparathyroidism
* Recurrent laryngeal nerve injury
Treatment of Graves’ disease
⚫ Radioactive iodine therapy
- 131I is most commonly used
- Dose:
131I(uci/g) x thyroid weight x 100
24-hr RAI
uptake
Treatment of Graves’ disease
⚫ −blockers
⚫ SSKI
Treatment of Graves’ disease complications
⚫ Thyrotoxic crisis
⚫ Orbitopathy
⚫ Thyrotoxicosis and
pregnancy
Goiter and thyroid nodules
⚫ Goiter
⚫ Fist described in China in 2700 BC
Wolff-Chaikoff Effect
⚫ Increasing doses of I- increase
hormone synthesis initially
⚫ Higher doses cause cessation of
hormone formation.
⚫ This effect is countered by the
Iodide leak from normal thyroid
tissue.
⚫ Patients with autoimmune
thyroiditis may fail to adapt and
become hypothyroid.
Jod-Basedow Effect
⚫ Opposite of the Wolff-Chaikoff effect
⚫ Excessive iodine loads induce hyperthyroidism
⚫ Observed in hyperthyroid disease processes
⚫ Graves’ disease
⚫ Toxic multinodular goiter
⚫ Toxic adenoma
⚫ This effect may lead to symptomatic thyrotoxicosis in
patients who receive large iodine doses from
⚫ Dietary changes
⚫ Contrast administration
⚫ Iodine containing medication (Amiodarone)
Other thyroid disorders
⚫ Nontoxic goiter
⚫ Subacute thyroiditis (De Quervain’s)
⚫ Chronic thyroiditis
⚫ Acute thyroiditis
⚫ Thyroid nodules
⚫ Thyroid cancer
Treatment of other forms of
thyrotoxicosis
⚫ Toxic adenoma
⚫ TMN
⚫ Amiodarone
⚫ Subacute thyroiditis
⚫ Thyrotoxicosis factitia
⚫ Struma ovarii
