Hypothyroidism (1 of 7)
Hypothyroidism (1 of 7)
1 Patient presents w/ signs & symptoms suggestive of hypothyroidism
2 DIAGNOSIS Evaluate thyroid stimulating hormone (TSH) & thyroxine (FT4) levels
High TSH & High TSH Low/normal normal FT4 & low FT4 TSH & low FT4
3 4 5 SUBCLINICAL/MILD PRIMARY CENTRAL HYPOTHYROIDISM HYPOTHYROIDISM HYPOTHYROIDISM
A Pharmacological 5 therapy THERAPY • EVALUATION DECISION Levothyroxine See next page
A FOLLOWUP Pharmacological therapy Follow-up exams • Levothyroxine • Every 6-8 weeks initially to monitor patient’s response to MIMSthe dose of Levothyroxine until TSH is normalized • en every FOLLOWUP 6-12 months Follow-up exams • Every 6-8 weeks initially to monitor patient’s response to the dose of Levothyroxine to maintain FT4 above the median value of © normal range • en every 12 months
Not all products are available or approved for above use in all countries. Specifi c prescribing information may be found in the latest MIMS.
B1 © MIMS 2020 HYPOTHYROIDISM Follow-up exams A • • 12months en every until TSH isnormalized ofLevothyroxine to the dose monitor patient’s response initiallyto Every 4-8weeks Pharmacological therapy Pharmacological • Low-dose Levothyroxine Low-dose FOLLOWUP Yes ≥10 mU/L
© TSH Not all products are available or approved for above use in all countries. all in use above for approved or available are products all Not Specifi c prescribing information may be found in the latest MIMS. latest the in found be may information Specific prescribing FOR SUBCLINICAL/MILD SUBCLINICAL/MILD FOR Hypothyroidism (2of7) THERAPY DECISION DECISION THERAPY HYPOTHYROIDISM HYPOTHYROIDISM antibody antibody present? Yes MIMS yroid B2 DETERMINE DETERMINE TSH LEVEL TSH No high total or LDL-C orLDL-C total high Presence ofgoiter,Presence level, other level, symptoms? <10 mU/L TSH TSH 3 THYROID THYROID ANNUAL © MIMS 2020 EXAM No HYPOTHYROIDISM • • • • • • • • Hypothyroidism ofDeveloping Population Risk w/Higher Special • • • • • • &Symptoms Signs • • • • • TestsOther • • • • Confi &Typesrmation ofHypothyroidism TestsLab Primary hypothyroidism: HighTSH FT &low hypothyroidism: Primary Down’s &Turner’s syndrome Sjogren’s anemia, pernicious vitiligo, Celiac disease, multiple sclerosis syndrome, - autoimmuneOther non-endocrine disorders Type mellitus adrenal (DM), 1diabetes insuffi- failure ovarian (AI), ciency Other autoimmune conditions endocrine orthyroid &neck head irradiation Patients w/previous ofautoimmune thyroid history disorders w/afamily Individuals individuals Infertile Postpartum women Galactorrhea - Anemia - Myalgia - Goiter - Pallor - edema) (non-pitting Myxedema - Menorrhagia - Others Pericardial effusion - Hyperlipidemia - Bradycardia - Cardiovascular Constipation - Gastrointestinal Slowspeech - Voice change; hoarseness - Hairloss/alopecia - - &neck Head tendon refl ofdeep relaxation Delayed exes - Poor memory - Depression - Weakness - Neurological skin dry Variable weight are fatigue, cold symptoms gain, intolerance, buttypical &symptoms signs constipation & thyroid disease orprimary disease defi hormone yroid tohypothalamic-pituitary duetounderactive thyroidciency that secondary may be - orcomputed (MRI) resonance tomography imaging studies [magnetic (CT)] Neuroradiologic (may ultrasonography doboth) scan, yroid Antithyroid antithyroglobulin peroxidase, autoantibodies - autoantibodies yroid profiLipid le HighTSH FT &normal hypothyroidism: Subclinical TSH FT &low Low/normal hypothyroidism: Central Confi thyroxine w/ measurement ofserum rm (FT hypothyroidism thyroid fordetecting serum stimulating test sensitive Most Measure (TSH): hormone Periorbital puffi ness pituitary region pituitary ofcentral inpatients the evidence Recommended hypothalamic- w/biochemical hypothyroidism toassess © 1 Hypothyroidism (3of7) HYPOTHYROIDISM 2 DIAGNOSIS 4 4
) MIMS B3 4 4 © MIMS 2020 HYPOTHYROIDISM • • • • • Etiologies • • Evaluation • • • Causes Other • • Autoimmune (Hashimoto’s yroiditis Disease) Etiologies • Assessment Risk • • • • Further Evaluation ofTreatment Hypothyroidism: Determination forSubclinical • • • • • • Excluded that TSH Shouldbe ofElevated Causes Other Refers to the state of slightly increased serum TSH w/ normal serum FT TSHRefers serum tothe serum w/normal state ofslightly increased Hypothalamic: Tumor,Hypothalamic: insuffi vascular infection, ciency, defi thyrotropin-releasing (TRH) hormone ciency, iatrogenic & radiotherapy) Tumor,Pituitary: insuffi vascular ciency, infi empty sella syndrome, iatrogenic infection, (surgery ltrating disease, activity biological TSH orreduced TSH secretion causing decreased axis oftheOccurs duetofailure hypothalamic-pituitary in the hypothalamus) hypothyroidism (defect is hypothyroidism gland) & tertiary (defect isin the into pituitary secondary Divided Glucocorticoid tothyroxine prior replaced administration shouldbe toavoid adrenal crisis - &precipitate an adrenal metabolism crisis administration yroxine may increase - ifadrenal adrenal insuffi status, Determine cient: axis ofthe ofthe orough hypothalamic-pituitary exam function hypothyroidismitis), neonatal Transient: Subacute thyroiditis (de Quervain’s), thyroiditis thyroid- & painless (silent, postpartum lymphocytic therapy)iodine Acquired: defi Iodine ciency, iatrogenic (post-thyroidectomy, radioactive thyroid irradiation, medications, TSH-receptor defect defiCongenital: Endemic iodine thyroid resistance, dyshormonogenesis), hormone (Athyreosis, ciency - - in95%orantithyroglobulin in60%] (TG) (TPO)- detection [anti-thyroid peroxidase antibodies yroid - Diagnosis commonMost cause - If patient is not at high risk, perform annual thyroid perform exam Ifpatient isnotat highrisk, - Treatment patients inhigher isrecommended risk - w/infertility dysfunction pregnancy, ovulatory hyperlipidemia, goiter, presence hypothyroidism ofthyroid ifTSH toovert ofprogression Higher antibodies, >10 mU/L, risk ultrasound yroid profiLipid le Physical exam fortreatment) fortreatment); >10mU/L, (ifpositive, (TSH ifnegative detection antibodies yroid Temporary inTSH intake restriction duetocalorie increase proteins mouse against Presence ofheterophilic antibodies Administration ofrecombinant human TSH adrenal insuffiUntreated primary ciency thyroiditisTransient ordestructive illness severe from inTSH recovery during increase adjustmentRecent dose Levothyroxine wherein state asteady isnotachieved © thyroiditis Presence confi & absence of thyroid of any antibodies history of the above of Hashimoto’s diagnosis rms pregnancy, change indiet cations, therapy, radioactiveiodine ofradiation exposure, history surgery,Careful neck recent medi- infection, viral Not all products are available or approved for above use in all countries. all in use above for approved or available are products all Not 3 Specifi c prescribing information may be found in the latest MIMS. latest the in found be may information Specific prescribing SUBCLINICAL/MILD HYPOTHYROIDISM SUBCLINICAL/MILD 5 4 CENTRAL HYPOTHYROIDISM CENTRAL PRIMARY HYPOTHYROIDISM MIMS Hypothyroidism (4of7) B4 4 in patients whoare usuallyasymptomatic © MIMS 2020 HYPOTHYROIDISM • • • TestsDiagnostic • • • • Factors Precipitating • • • • • • &Symptoms Signs • • LIFETHREATENING COMPLICATION MYXEDEMA COMA MYXEDEMA COMPLICATION LIFETHREATENING - figastrointestinal disturbances &metabolic dysfunction, cardiovascular precipitating event, ndings, eff neurological of hypothermia, for the for myxedema coma points scoring system degree Diagnostic gives ects, TSHHigh serum concentration Very T4concentration serum low tocold Exposure ofthyroidectomy therapy orradioiodine History event CV Infection hypothyroidism Long-standing Hyponatremia Hypercapnia ofconsciousness &loss failure Respiratory Bradycardia (<27°C) hypothermia Severe - therapy ofradioiodine orhypothyroidism history patient responsive w/athyroidectomy or madeinapoorly comaA highsuspicionofmyxedema scar be can ofthyroid isdangerous hormone highdoses tothe patient iswrong, Ifdiagnosis - present thyroid w/ altered function are coma similartomyxedema clinically also &can illnesses critical isimperative diagnosis because Correct risk for myxedema coma formyxedema risk the patient at 45 & 59 classify Score while scores between of ≥60 is highly suggestive coma, of myxedema lethargy, progressive by ere antecedent followed ofthyroid may &coma be symptoms stupor also dysfunction
© coma ofmyxedema suggestive &symptoms w/signs Patient presents A Not all products are available or approved for above use in all countries. all in use above for approved or available are products all Not Specifi c prescribing information may be found in the latest MIMS. latest the in found be may information Specific prescribing Pharmacological therapy Pharmacological • • • therapy Non-pharmacological Levothyroxine IV or oral via NGT &/orLiothyronine IV NGT ororalvia IV Levothyroxine out Ifcentral ruled be hypothyroidism cannot - Glucocorticoids Treat underlying cause - Ensure adequate ventilation - ofinappropriate &forsyndrome function MonitorCV - fl IV warming gradual uids, - care &supportive monitoring Close secretion ofantidiuretic (SIADH) hormone secretion 1 Hypothyroidism (5of7) CONFIRM DIAGNOSIS CONFIRM MYXEDEMA COMA MYXEDEMA MIMS TO ICU ADMIT 1 B5 © MIMS 2020 HYPOTHYROIDISM 1 Desiccated thyroid hormones (w/ variable proportion ofT proportion thyroid (w/variable Desiccated hormones recommended fortreatmentrecommended ofhypothyroidism. • • • • Liothyronine • • • • • • Levothyroxine yroxine) (L-thyroxine, Levothyroxine s t c ffe E inmanagementUseful duration coma &short ofactionare ofmyxedema required) rapid (when onset its the ofhyperthyroidism risk morerequires frequent administration &increases for routine not recommended treatmentGenerally which & turnover rapid of hypothyroidism onset due to its areplacement as Used therapy inhypothyroidism tosubstitute thyroid hormone - activecompound (noconversion Biologically isnecessary) - - Short T Short - Actions: - the samebrandofLevothyroxine to diffDue erent bioavailability preparations patients of Levothyroxine, of the are various encouraged to use therapeutic eff peak toachieve weeks several Requires oraldosing w/regular ects - Eff ects: - areplacement as Used therapy inhypothyroidism tosubstitute thyroid hormone - Actions: inpregnancy Safe foruse tomanage coma myxedema used May be 1st-line agent fortreatment ofhypothyroidism Levothyroxine be re-titrated be Levothyroxine &dosage of the 6weeks patient’sIf achange inbrandisneeded, every TSH retested serum shouldbe (T half-life Long biologically activecompound T biologically Drug : Require 3 days to achieve peak therapeutic eff peak 3days: Require toachieve ects Safe &predictable effects ½ , rapid onset Products listed above may not be mentioned in the disease management chart but have been have but chart management disease the in mentioned be not may above listed Products placed here based on indications listed in regional manufacturers’ product information. product manufacturers’ regional in listed indications on based here placed of 4wks 25mcg/day by at intervals increased May be other day every or50mcgPO 25mcg/day PO dose: Initial hypothyroidism: orlong-standing disorders w/CV patients For patients, elderly dose: Maintenance 2-4wkly 25-50mcgevery by dose Increase 25-50mcg/day PO dose: Initial & non-elderly adults w/ normal renal & hepatic function unless otherwise stated. otherwise unless function &hepatic renal w/ normal adults & non-elderly All dosage recommendations are for non-pregnant & non-breastfeeding women, women, &non-breastfeeding non-pregnant for are recommendations dosage All ½ )
© bioconversion regular which isappropriately the tothe by tissues onset, , slow regulated Not all products are available or approved for above use in all countries. all in use above for approved or available are products all Not Specifi c prescribing information may be found in the latest MIMS. latest the in found be may information Specific prescribing A PHARMACOLOGICAL THERAPY 3 Dosage 100-200 mcg PO 24hrly 100-200 mcgPO Dosage Guidelines THYROID HORMONES Hypothyroidism (6of7) 3 MIMS &T B6 4 ), combinations ofthyroid &T hormones • • Instructions Special • • Reactions Adverse failure adrenal hyperthyroidism, uncorrected inrecentContraindicated MI,untreated absorption) (due toirregular breakfast before Administer onempty stomach, 30-60min fever, heat intolerance) loss, wt muscular weakness (muscle cramps, tremors); Other effinsomnia, ects eff nervousness, (headache, ects GI eff vomiting);CNS (diarrhea, ects palpitations); tachycardia, arrhythmias, effCV pain,cardiac (anginal ects ofoverdoses Usually onlyoccur incases 1 Remarks 3 aloneare generally not © MIMS 2020 HYPOTHYROIDISM Liothyronine (Cont’d) Levothyroxine extract yroid Drug Products listed above may not be mentioned in the disease management chart but have been have but chart management disease the in mentioned be not may above listed Products placed here based on indications listed in regional manufacturers’ product information. product manufacturers’ regional in listed indications on based here placed tolerate oraldoses untilgiven patient stable isclinically &can Further may of50-100mcg/day be IV doses 300-500mcgIV dose: bolus Initial For coma: ofmyxedema management onTSH levels based necessary as Adjust dose 1mcg/kg/day PO hypothyroidism: For management ofsubclinical to 25mcg12hrly 8 hrly until improvement, then reduce 25mcgIV by followed IV 50 mcgslow (usually 12hrly) or required 4-12hrly as IV 5-20 mcgslow dose: Initial For coma: ofmyxedema management 2wk 5 mcg/day by every May increase 24 hrly 5 mcgPO dose: Initial hypothyroidism: orlongstanding disorders w/CV patients For elderly patients, 24 hrly 25-75 mcgPO dose: Maintenance wk 1-2 upto25 mcg/day by every May increase 24 hrly 25 mcgPO dose: Initial 30-250 mg/day PO & non-elderly adults w/ normal renal & hepatic function unless otherwise stated. otherwise unless function &hepatic renal w/ normal adults & non-elderly All dosage recommendations are for non-pregnant & non-breastfeeding women, women, &non-breastfeeding non-pregnant for are recommendations dosage All © Not all products are available or approved for above use in all countries. all in use above for approved or available are products all Not Specifi c prescribing information may be found in the latest MIMS. latest the in found be may information Specific prescribing Please see the end of this section for the reference list. reference the for section this of end the see Please THYROID HORMONES(CONT’D) Dosage Dosage Guidelines MIMS Hypothyroidism (7of7) B7 • • Instructions Special • • Reactions Adverse • Instructions Special • • Reactions Adverse • • Instructions Special • Reactions Adverse • uncorrected adrenal failure uncorrected untreated hyperthyroidism, in recentContraindicated MI, absorption) irregular (due to breakfast 30-60 minbefore Administer onempty stomach or fever, heat intolerance) loss, wt muscular weakness (muscle cramps, tremors); Other effinsomnia, ects eff nervousness, (headache, ects GI eff vomiting);CNS (diarrhea, ects palpitations); tachycardia, arrhythmias, effCV pain,cardiac (anginal ects ofoverdose Usually occur onlyincases (monitor TSH &FT results tests &biochemical response on patient’s based Adjust dose clinical For ofhypothyroidism: management fever, heat intolerance) loss, wt muscular weakness, muscle cramps, Other effinsomnia); (tremors, ects eff nervousness, (headache, ects GI eff vomiting);CNS (diarrhea, ects palpitations); tachycardia, arrhythmias, effCV pain,cardiac (anginal ects ofoverdose Usually occur onlyincases hypertension, cardiac disease, DM disease, cardiac hypertension, Use w/ caution inpatients w/ (or meals) 0.5-1 hrbefore taken onanemptyShould be stomach loss) wt tremors, insomnia, nervousness, vomiting); Other eff (headache, ects GIeffarrhythmias); (diarrhea, ects effCV cardiac (tachycardia, ects disorders Use w/ caution inpatients w/CV Remarks 4 levels regularly) levels © MIMS 2020