ARTICLE PRESENTATION

THE MANAGEMENT OF HYPERTHYROIDISM

BY
JAYNE A.FRANKLYN
M.D,Ph.D.
IN THE NEW
ENGLAND
JOURNAL OF
MEDICINE
EDITED BY
AlASTAIR J.J.Wood

Objectives
At the end of this presentation learners
will be able : To understanding the knowledge given
in the article about the management of
hyperthroidism.
To describe the antithyroid drugs,betaantagonist and radioiodine therapy its
effects,dosage and complications given
in the article .

The Management of
Hyperthyroidism
Hyperthyroidism is common,affecting
approx 2 percent of women and 0.2
percent of men

There are three principle treatments

-Antithyroid drugs
-Radiodione
Surgery

INVESTIGATIONS
Diagnosis should be confirmed by
mseasurement of serum thyro-tropin and
total of free thyroxine.
If thryotropin level
thyroxine level=Normal
Serum triiodothyronine should be
measured since the patient may have
triiodothyronine toxicosis

Cont..
Serum total thyrxine concentrations
-in patients with increased serum
concentrations of thyroixine-binding
globulin.
Like pregnant women taking
estrogens or persons with inherited
increase thyroxine binding globulin
having high affinity for thyroxine.

Investigation cont

All the patients with these latter

conditions are clinically euthyroid
and have normal serum
concentrations of thyrotropin.

Cont..
Graves disease is the most common cause of
hyperthyroidism
It is obvious if a diffuse goiter and
ophthalomopathy are present.
Other causes ,a multinodular goiter,toxic
thyroid adenoma and subacute thyroiditis.
Should be evident from the history or by the
measurement of uptake of radioiodine by the
thyroid.

Antithyroid drugs
Methimazole,carbimazole and
propylthiouracil are the main drugs of
antithyroid drug therapy.
Their principle action is to inhibit the
coupling of iodothronines and hence
the synthesis of thyroid hormones.

Antithyroid drugs
Methimazole has a longer duration of
action ,although both of the drugs are
effective for more than 5 hours as they
accumulate in thyroid cells.

Indications for Antithyroid drug therapy and

treatment Regimens

The three main drugs are prescribed for

Graves in the hope that the pt will have a
remission during the therapy.

Our policy is to give an ant thyroid

drug ,hope of achieving remission in
pt(those 40 years old or younger).before
treating with radioiodine.

Cont..
Treatment stared with 10 to 20 mg of
methimazole once a day or 75 to 100
mg of propylthiouracil three times a
day.
The dose should be reduces after 4-6
weeks as improvement occurs and
adjusted every 4-6 weeks to maintain
normal thyroid secretions.

Side effects
Serious effects occure in 3/1000
pt,whether they receive meth or propyl.
Agranulocytosis is more common over
40 yrs old with fever & sore throat.
Pt adviced to discontinue therapy and
recover after 3 weeks after the drug is
stopped/some had also rash and
pruritus.

Outcome of Treatment
In one study, the rate of remission
one year after treatment was
stopped was 31 percent among
patients treated for 6 months and 82
percent among patients treated for 2
years.
Relapse is most likely within the first
six months after withdrawl of therapy
and may occur years after.

Beta-AndrenergicAntagonist Drugs
They are useful adjunctive agents,in
patents with Graves hyperthyroidism
In this Propanolol,metoprolol,atenolol
and nadolol are all effective in pt with
hyperthyroidism
Caution exercised in pt with asthma or
heart failure.

Inorganic Iodide
Iodine given as (Lugols solution) inhibits
the release of thyroid hormones for few
days or weeks.
This drug is not used routinely but the
short term therapy is useful in the prep of
pt for surgery.
The useful dose (5% iodine and 10 %
potassium iodide in H2O) ,potassium

Radioiodine Therapy
The objective of this therapy is to
destroy sufficient thyroid tissue to
cure hyperthyrodism.
The regimens used include low doses
(2 mCi),fixed doses of 5 to 10 mCi
and doses on the basis of size of the
thyroid.

Post-Treatment Thyroid
Function
Hypothyroidism occurring within the
first six months in 50 % of the pt
given high doses by 1 year and in
50% of those given lower doses by
25 yrs.

Other Side Effects

Aside from radioiodine therapy ,it also has
few adverse effects like radiation
thyroiditis includes thyroid pain
,tenderness and swelling.

Opthalmopathy:A recent study of pt more

than 35 years old treated with
meth,surgery or radioiodine and the eye
disease was higher among pt treated with
radioiodine.

Subtotal Thyroidectomy
Pt with Graves hyperthyroidism subtotal
thyroideectomy is appropriate treatment
only for those who refuse radioiodine
therapy.
Preoperative:-It includes methimazole
combined with potassium iodide (60 mg
TDS) for 10 days and short term therapy
with propranolol.

Post Op Thyroid Function

Relapse occurring atleast 10% of pt
most often during the first 5 years
after surgery.
Pt with elevated serum thyrotropin
level but a normal serum thyroxine
concentration (subclinical
hypothyroidism) within the 1 year
should not be considered as
permanent hypothyroidism.

Management of toxic Adenoma or

Toxic Nodular Goiter a
Hyperthyroidism due to thyroid nodular
disease is permanent ,there are no
spontaneous remission.
The most appropriate therapy due to
this disease is radioiodine.

Management of Hyperthyroidism

PREGNANCY

Treatment of
Thyrotoxic Crisis

Prevelance of Hypothyroidism after treatment with

radioiode or

thyroidectomy

60
RADIOIODINE

40

20

Thyroidectomy

Prevalence
Of hypothyroidism%

10

15

20

25

OVER ALL SUMMARY

THERAPEUTIC AGENT

ACTIONS

INDICATIONS

Antithyorid drugs
-Propylthiouracil
-Methimazole
-Carbimazole

Inhibit thyroid hormone

synthesis

First line therapy for

graves hyperthyroidism

B-Andrenergicantagonist drugs
Propranolol,Metoprolol,A
tenolol,Nadolol

Ameliorate action of
thyroid hormone in
tissues

Often only therapy

required for thyroiditis

Iodine-containing
compounds
Lugols sol,potassium
iodide

Inhibit T4 and T3 release Prep for surgery ,no

routine indications

Miscellaneous agents
Glucocorticoids
Potassium Perchlorate
Lithium carbonate

Inhibit iodine transport

and thyroid hormone
synthesis

Thyrotoxic crisis.

References
http://www.nejm.org/doi/pdf/10.10
56/NEJM199406163302407