Treatment of Thyroid Disease

A) HYPERTHYROIDISM Medical Iodide Uptake Inhibitors Potassium perchlorates Examples

Iodide Oxidation & Coupling Inhibitors (Thiouracils) Carbimazole Methimazole Propylthiouracil

Mechanism Of Action

Competitively inhibits iodide uptake by the thyroid Used in hyperthyroidism when there is hypersensitivity reaction to thiouracil drugs and amiodarone induced thyroid alteration

Fatal aplastic anemia Side Effects

Inhibit iodide oxidation to iodine Due to inhibition of peroxidase enzyme Inhibit iodine organification Blocks coupling of iodotyrosines Carbimazole Inhibit release of lymphocyte antibodies, so it very effective in Graves disease Propylthiouracil Inhibit peripheral conversion of T4 to T3 Bone marrow depression Agranulocytosis Hypersensitivity Teratogenicity Cholestatic jaundice Hepatitis Headache & diarrhea

Hormone Release Inhibitors Iodide Potassium iodine Lugol iodine Ipodate Tincture iodine Iodide povidine Inhibit thyroid hormone release Inhibition of proteolytic enxyme that cleave T3 & T4 from thyroglobulin Inhibit organic iodine formation Inhibit TSH release & its stimulant effect on thyroid Prevention of stimulation of adenyl cyclase Ipodate Inhibits peripheral conversion of T4 to T3 Iodine escape Nausea, vomiting, diarrhea & metallic taste Hypersensitivity Conjunctivitis & rhinorrhea Salivary glands swelling, mucus membrane ulceration

Adjuvant Therapy Beta blockers Calcium channel blockers Barbiturates Vitamins Propranolol Decreases symptoms & signs of sympathetic overactivity in thyrotoxicosis Decreased peripheral conversion of T4 to T3 Barbiturates Enhance T4 metabolism Sedative & anti convulsant Vitamins Combat high metabolic rate Bradycardia Hypotension Fatigue Dizziness Insomnia

Treatment of Thyroid Disease

Surgery Subtotal Thyroidectomy Ipsilateral Total Lobectomy Failure of medical treatment Solitary toxic nodule Malignant hyperthyroidism Huge multinodular goiters Infectious or hemorrhagic hyperthyroidism Mutlinodular goitre Patient must be well prepared for surgery by Methimazole or propylthiouracil for 7-10 weeks until euthyroid state K iodide for 710 days before surgery to decrease size and vascularity of the gland B-Blocker and barbiturate Radioactive Iodine Mechanism of Action Diseased nodule concentrate I131 more than other nodules I131 is localized in diseased nodule (because of its low penetration) Destroys thyroid gland by radiation of gamma-rays Not affect the surrounding nodule Has slow onset action (1-2 months) Acute (in early therapy) Nausea, vomiting, and pain in thyroid Delayed Hypothyroidism (TTT: replacement with L-thyroxin) May induce malignancy (due to metaplasia) esp. leukemia

Side Effects

B) MYXOEDEMA COMA ICU with endotracheal tube and ventilation IV fluids Loading dose of L-thyroxine 300-400 ug followed by 50 ug daily IV T3 (more cardiotoxic and difficult to be monitored)

IV hydrocortisone (esp. with adrenal or pituitary insufficiency) Opioids and sedative (very cautiously) TTT of associated diseases (infection, HF)