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Diabetes Control in Thyroid Disease

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Diabetes Control in Thyroid Disease In Brief Thyroid disease is commonly found in most types of diabetes. This article defines the prevalence of thyroid disease in diabetes and elucidates through case studies the assessment, diagnosis, and clinical management of thyroid disease in diabetes. Diabetes Control in Thyroid Disease Thyroid disease is a pathological state abnormality. Several studies, including that can adversely affect diabetes con- the Colorado study, have documented trol and has the potential to negative- a higher prevalence of thyroid disease Jennal L. Johnson, MS, RNC, FNP, ly affect patient outcomes. Thyroid in women, with prevalence rates rang- BC-ADM, CDE disease is found commonly in most ing from 4 to 21%, whereas the rate in forms of diabetes and is associated men ranges from 2.8 to 16%.1 with advanced age, particularly in Thyroid disease increases with age. In type 2 diabetes and underlying the Colorado study, the 18-year-olds autoimmune disease in type 1 dia- had a prevalence rate of 3.5% com- betes. This article defines the preva- pared with a rate of 18.5% for those lence of thyroid disease in diabetes, ≥ 65 years of age. discusses normal physiology and The prevalence of thyroid disease in screening recommendations for thy- diabetes has been estimated at 10.8%,2 roid disease, and elucidates through with the majority of cases occurring as case studies the assessment, diagnosis, hypothyroidism (~ 30%) and subclini- and clinical management of thyroid cal hypothyroidism (~ 50%).2 Hyper- disease and its impact on diabetes. thyroidism accounts for 12%, and postpartum thyroiditis accounts for Thyroid Disease Prevalence 11%.2 Of the female patients with The prevalence of thyroid disease in type 1 diabetes, 30% have thyroid dis- the general population is estimated to ease, with a rate of postpartum thy- be 6.6%, with hypothyroidism the roid disease three times that of the most common malady.1 Participants normal population. Ostensibly, this is attending a health fair in Colorado (n because of the higher prevalence of = 25,862) were screened for thyroid thyroid disease in women, as well as disease, using thyroid-stimulating hor- the link to autoimmune disease. Once mone (TSH) and thyroxine (T4) mea- one autoimmune disease occurs, it is surements. Of the participants, 9.5% not uncommon for a different autoim- were found to have an elevated TSH mune disease to be present. level. Also, 6% of study participants There are also reports that the were diagnosed with thyroid disease prevalence of thyroid disease in type 2 before the screening. However, 40% diabetes is higher than in the general of those already diagnosed had elevat- population.3 Whereas the Fremantle ed TSH levels, indicating inadequate Diabetes Study found a 8.6% preva- treatment. In the undiagnosed popula- lence of subclinical hypothyroidism in tion with TSH elevations, 9.9% were women with type 2 diabetes in found to have an unrecognized thyroid Australia,4 a study of the prevalence 148 Diabetes Spectrum Volume 19, Number 3, 2006 8 of autoimmune thyroid disease in type children. Iodine deficiency leads to ations in thyroid hormone secretion to Practice Research From / Diabetes and Diseases Coexisting 2 diabetes in Jordan reported an over- decreased thyroid hormone synthesis, rates, facilitating a more steady state. all prevalence rate of 12.5%, with which in turn leads to increased TSH Standard laboratory assays measure subclinical hypothyroidism at 5%.5 secretion and increased gland growth the total free and bound thyroid hor- or goiter. Gland size, however, does mone levels of T4 and T3 unless free Thyroid Anatomy and Physiology not indicate thyroid function. hormone levels are specifically A thorough understanding of the Therefore, a goiter can be present in requested. Free hormone levels are anatomy and physiology of the thy- hypothyroidism, hyperthyroidism, or helpful in evaluating thyroid function roid gland allows diabetes clinicians euthyroidism. in states of decreased or increased to understand the rationale for specif- The thyroid gland is divided into TBG. ic assessments and to rapidly identify lobules that have a distinct vascular Thyroid hormone exerts influences thyroid abnormalities. The thyroid is supply. Each lobule has 20–40 follicles, on numerous body systems, including the largest endocrine gland, weighing and follicles are the basic functioning growth and development, muscular ~ 20 g. It is shaped like a butterfly or unit of the thyroid gland. The lumen of function, sympathetic nervous system shield and is derived from the base of each follicle is filled with viscous col- function, cardiovascular system, and the tongue.6 The thyroid gland has loid identified as the glycoprotein thy- carbohydrate metabolism. For exam- significant blood flow; when com- roglobulin. Thyroglobulin contains the ple, thyroid hormone is necessary for pared by tissue weight, it has more molecular structure of thyroid hor- maturation and differentiation during blood flow than the kidney.7 mones and is the precursor of all thy- development. Children with hypothy- roid hormones.9 Thyroperoxidase roidism show bone maturation delays Understanding the Role of the (TPO) is a membrane-bound enzyme as well as delayed or absent puberty. Thyroid found on the surface of the follicular Children with thyroid deficiency have Thyroid physiology is based on a reg- cell. It is necessary to catalyze iodide stunted growth because inadequate ulatory feedback system typically into an active intermediate, an impor- thyroid hormone secretion lowers found in endocrine systems.7 The tant step in thyroid hormone growth hormone. Thyroid hormone hypothalamus secretes thyrotropin- synthesis.7 Thyroglobulin and TPO also plays an important role in lung releasing hormone (TRH), which antibodies are useful thyroid laborato- maturation.7 stimulates the anterior pituitary gland ry test evaluations that can identify Thyroid hormones are necessary to secrete thyrotropin or TSH. TSH potential harm to the synthesis of thy- for normal fetal and neonatal brain increases iodide uptake and oxidation roid hormone from an autoimmune development by regulating neuronal that leads to organification and cou- process. proliferation and differentiation, pling, which are necessary steps to The follicle is surrounded by a sin- myelinogenesis, neuronal outgrowth, produce the thyroid hormones T4 and gle layer of epithelial cells and and synapse formation. The critical triiodothyronine (T3). TSH also stim- enclosed by a basement membrane. time for brain development starts in ulates growth and vasculature of the The basement membrane has parofol- utero and continues to age 2. thyroid that could potentially lead to licular cells that have contact with Deficiency of thyroid hormone during a goiter if excessive. Of the thyroid follicle cells and produce calcitonin.7 this important time can lead to struc- hormone secreted, 90% is T4, and Iodine is taken up as inorganic iodide tural and physiological impairment 9% is T3.7 T3 derives from deiodina- via the “iodide trap” in the follicular resulting in brain damage or severe tion of T4; therefore, 80% of circulat- cell. This aspect of thyroid physiology neurological impairment.7 This ing T3 is from T4.7 During serious is important because the thyroid is process cannot be reversed once com- debilitating illness or starvation, T3 the only gland that takes up iodine, pleted, which is the reasoning behind production is reduced, possibly as a which allows for scanning and treat- universal screening for congenital control mechanism to reduce the ment of the thyroid gland using hypothyroidism. metabolic rate, which may be useful radioiodine. Hypothyroidism in adults can lead during recovery. After thyroid hormones are synthe- to dullness, decreased reflexes, lethar- Thyroid hormones enter cells by sized and secreted into the serum, they gy, delayed cognitive function, and diffusion and carrier-mediated trans- are bound to serum carrier proteins excessive sleep, as well as psychologi- port and bind to nuclear TSH recep- TBG, thyroxine-binding prealbumin, cal disturbances. Correcting the tors. TSH receptors are found on the and albumin. The affinity of the T3 underlying thyroid abnormality can surface of the follicular cells within receptor is much higher (~ 10 times) reverse impaired neurological func- the thyroid as well as on adipocytes, than that of T4.7 The majority of T4 tioning in adults. Hyperthyroidism in lymphocytes, fibroblasts, and gonads. (99.96%) and T3 (99.6%) are bound, adults can also result in insomnia, This is important because TSH stimu- and binding is affected by certain decreased reflex time or hypereflexia, lates adipocyte lipolysis. T4, and to a physiological or pathological states restlessness, excitability, and lack of small degree T3, circulating in the that increase or decrease TBG. focus and concentration.7 serum inhibits secretion of TSH and Estrogen increases found in pregnan- Thyroid hormones have metabolic TRH, thereby completing the feed- cy, estrogen replacement, and birth functions that serve to control the back cycle. Transport and binding of control pills increase TBG, whereas basic hormone metabolic rate. Basic thyroid hormone is carried out by thy- androgens, glucocorticoids, and mal- hormone metabolic rate is decreased roxine-binding globulin (TBG). nutrition decrease TBG.7 in hypothyroidism and increased in Normal thyroid hormone synthesis Free or unbound thyroid hormone hyperthyroidism. Thyroid hormones requires an adequate iodine intake of enters cells and exerts
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