Thyroid disorders in primary care - Steve Hyer Consultant Endocrinologist Epsom & St Helier University Hospitals Trust - GP Training Schemes
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Thyroid disorders
in primary care
Steve Hyer
Consultant Endocrinologist
Epsom & St Helier University Hospitals Trust
Plan
• Hypothyroidism –
Dear Doctor
overt, subclinical Please see this
• Hyperthyroidism- patient with…..
overt, subclinical
• Thyroid nodules
Scenarios A-N
The Endocrine Approach
• History including
drugs
• Examination
including fluid
status, blood
pressure
• Screening tests
• Confirmatory tests
Thyroid Disease Spectrum
Overt Hypothyroidism
TSH >10.0 IU/mL, Free T4 Low
Subclinical hypothyroidism
TSH >4.0 IU/mL, Free T4 Normal
Euthyroid
TSH 0.4-4.0 IU/mL, Free T4 Normal
Subclinical hyperthyroidism
TSH
Spectrum of thyroid disease
Hypothyroidism
Presentations hypothyroid
High
lipids
Memory
Constipation loss
Hypothyroid
Heavy Obesity,
menses weight
Carpal gain
tunnel
“Routine testing” of thyroid function • Previous RAI • On amiodarone • Type 1 diabetes • Dyslipidaemia • Unexplained hyponatraemia • Macrocytic anaemia
Clinical Scenarios
Dear Doctor
Please see well
person with TSH Dear Doctor
slightly raised (5.5) Please see
A polysymptomatic
person with TSH
slightly raised (5.5)
BClinical Scenario A- asymptomatic
subclinical hypothyroidism
NHANES III Study (N=17 353)
• Common esp 18
16
older females 14
12
• Iodine/ kelp/ 10
8
contrast/ 6
4
amiodarone 2
• Check TPO 0
13- 20- 30- 40- 50- 60- 70- >80
19 29 39 49 59 69 79
antibodies
Age, y
Males Females
Hollowell JG, et al. J Clin Endocrinol Metab. 2002;87:489-499.Clinical Scenario A-
treatment with L-thyroxine?
• TSH may BTA/ ETA/ ATA
spontaneously recommend treat with
normalise LT4 if TSH>10
• CV risk factor benefit especially in presence
(lipids) but limited of TPO antibodies
evidence of CV events • Caution >70 yrs olds
reduced • Monitor if TSH 4-10
• No benefit for cognitive • Consider LT4 at
function, QoL, lower TSH in woman
depression if TSHClinical Scenario B- symptomatic
subclinical hypothyroidism
• No evidence of clinical BTA/ ETA/ ATA
benefit for LT4 recommend treat
(cognitive function, with L-T4 if TSH>10
depression, quality of especially in
life) if TSHHypothyroidism and Depression
Have Many Common Features
Depression Hypothyroidism
• Constipation
• Appetite decrease • Bradycardia
• Decreased concentration • Cardiac and lipid
• Sleep decrease • Decreased libido abnormalities
• Suicidal ideation • Delusions • Cold intolerance
• Weight loss • Depressed mood • Delayed reflexes
• Appetite increase/ • Diminished interest • Goitre
decrease • Sleep increase • Hair and skin
• Weight increase changes
• Fatigue
Nemeroff CB, J Clin Psychiatry. 1989;50(suppl):13-20.Clinical Scenarios
Dear Doctor
Please see this
patient who is on 250 Dear Doctor
mcg of L-thyroxine Please see this
and despite this her woman who is 8
TSH is 100! weeks pregnant on
C L-thyroxine. Her
TSH is 4.0
DScenario C: High TSH despite high dose L-T4
Thyroxine absorption test
Patient with very high TSH Normal
testIron Ingestion and
Levothyroxine Therapy
Ferrous Sulfate Effect on TSH Levels in
Patients With Hypothyroidism
6
PScenario D- Early pregnancy
• TSH must beClinical Scenarios
Dear Doctor
Please see this Dear Doctor
patient with normal Please see this
thyroid function. The woman with
TPO antibody is high normal thyroid
E function. The TPO
antibody was high
(66) and is now
150.
FScenarios E,F: Positive TPO antibodies
• +ve TPO antibodies • No evidence of benefit
are common to start LT4 if euthyroid
• Presence of TPO • Long term follow-up
antibody identifies with yearly TSH; start
person more likely to LT4 treatment if
become hypothyroid TSH>10
over next 10-20 years
• No need to keep
• Peroxidase is selenium repeating TPO titre
dependent; selenium • Consider selenium
supplements reduce supplements
TPO titreHyperthyroidism
Thyrotoxicosis vs Hyperthyroidism • Thyrotoxicosis –The clinical syndrome of hypermetabolism that results when the serum concentrations of free T4, T3, or both are increased • Hyperthyroidism –Sustained increases in thyroid hormone biosynthesis and secretion by the thyroid gland
Presentations hyperthyroid
Atrial
Fibrillation
Weight
Osteoporosis loss
Hyperthyroid
Apathy,
weakness Heart
(elderly) failure
Worsening
diabetesClinical Scenarios
Dear Doctor
Please see this
patient who was
found to have FT4
very high; FT3 very
high; TSH normal
(1.8). He is surprising
well.
GScenario G: Beware the “normal” TSH • Thyroid hormone • Avoid resistance antithyroid • Mutation of thyroid drugs, thyroid hormone receptor (b) surgery, RAI • Usually asymptomatic • May require b- • May have mild goitre or blocker tachycardia • Often attention deficit disorder
Clinical Scenarios
Dear Doctor
Please see this Dear Doctor
patient who recently Please see this
delivered and is now woman who
hyperthyroid recently delivered
H and is now
hypothyroid
IPost-partum thyroiditis (H,I) • May occur up to 1 year after delivery • Typically hyperthyroid 1-4m after delivery • Then becomes hypothyroid up to 6m • Then recovers (occ permanent)
Management of post-partum thyroiditis • TSH-Receptor • Avoid carbimazole in antibody is negative hyperthyroid phase (unlike Graves’) • May require LT4 in • TPO often +ve hypothyroid phase • Painless • Withdrawal LT4 after • Likely to recur in 6m to check if future pregnancies recovered
Clinical Scenarios
Dear Doctor
Please see this Dear Doctor
patient with Please see this
hyperthyroidism. patient on
CT scan normal amiodarone who is
J hyperthyroid
KIodine-induced hyperthyroidism J,K • Iodine in X-ray contrast media or in amiodarone • Hypothyroid and suppression of normal gland • Hyperthyroid if Amiodarone: underlying nodular Each 200mg tablet thyroid contains 75mg iodine
Iodine-induced hyperthyroidism J,K
Temporary
hyperthyroidism
▪ Contrast: 4 weeks
▪ Amiodarone: Up to
18m
▪ Management is to
withdraw iodine
exposure if
possible (eg stop
amiodarone)
▪ b-blockers
Autonomous noduleClinical Scenarios
Dear Doctor Dear Doctor
This patient with This patient with
Graves’ is very Graves’ is very
worried about her hair worried about his
L eyes
M
Dear Doctor
..her weight
NHair Loss (L) • Diffuse hair loss • Don’t blame (telogen) with hyper/ medication or RAI hypo thyroid • Avoid iodine • Patchy is alopecia containing areata preparations to • Comes on months restore hair after onset of thyroid • Reassurance • Usually resolves over months
Eyes (M) • Lid retraction is not thyroid eye disease • Congestive (proptosis, chemosis) and motor (ophthalmoplegia) signs • Clinical Activity Score • Ophthalmologist for IOP • MR Orbits esp unilateral
Thyroid eye disease • STOP smoking • Avoid hypothyroidism • Selenium 100mcg bd if mild • Prednisolone or pulsed methyl - prednisolone • Orbital radiotherapy • Orbital decompression • (Rituximab)
Scenario N- weight gain
Weight gain after
treatment of Graves’
• Mean weight gain at
2yrs, 5.4kg
• Mean BMI rise 8%
• Most weight gain if Cold/ hyperthyroidism
became hypothyroid at activate brown fat
any time (8.1kg)
• Subnormal energy Diet/ reassure
Adequate LT4 replacement
expenditure after
treatment (muscle)Over-Replacement Risks • TSH
Under-Replacement Risks
• TSH >5.0 IU/mL
– Continued hypothyroid state
– Hyperlipidemia
– Decreased heart rate and ventricular
contractility
– Increased diastolic pressure
– Memory loss, fatigue,
weight gain
– DepressionThyroid Status of Treated Patients
Colorado Thyroid Disease Prevalence Study
100
Overtreated Undertreated
80 >20% >18%
Participants, %
60.1
60
40
20.7 17.6
20
0.9 0.7
0
Hyperthyroid Subclinical Euthyroid Subclinical Hypothyroid
Hyperthyroid Hypothyroid
Canaris GJ, et al. Arch Intern Med. 2000;160:526-534.Clinical Scenario
Dear Doctor
Please advise on this
patient from the
Royal Marsden with
history of thyroid
cancer. FT4 always
slight elevated and
TSH unrecordable.
PThyroid cancer scenario (P) • High risk thyroid cancers need to be on TSH suppressive doses of LT4 • Low risk papillary thyroid cancers have TSH targets defined • Seek advice from RMH before changing
Thyroid nodules
Clinical scenario: thyroid nodules
Dear Doctor Dear Doctor
This patient with TIA Please see urgently
had carotid Dopplers this young lady with
which reveal multiple an incidental 0.2mm
nodules in thyroid. nodule in right lobe
Largest is 0.5mm. of the thyroid.
Please see and
advise R
QThyroid nodules • Ultrasound is very sensitive • US grading now used • U1-2 are considered benign and don’t need FNAC (BTA guidelines) • U3-5 are suspicious and require FNAC
Referring nodules • High risk- older, M>F, exposure to Chernobyl, FH • Solid • Vascular • >1cm • Associated LN • TSH elevated
Results of FNAC • Thy 1-5 • Thy1: Inadequate- repeat • Thy2: Benign; reassure. Repeat only if associated with U3-5 • Thy3-5: Refer for MDT surgery
Summary • There are many causes of hyperthyroidism with different management strategies • Interpreting thyroid tests needs to be done in the context of the clinical picture • Many myths surrounding the treatment of thyroid disease including LT4, LT3 , Armour, RAI • Specialist advice may be needed (thyroid absorption tests, thyroid uptake scans, FNAC)
Enough already!
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