ThyroidamblectureHays - Thyroid Disease Thyroid And...

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Unformatted text preview: Thyroid Disease Thyroid And Osteoporosis Lisa Hays, MD Endocrinology Fellow Outline Outline Signs and symptoms of hyperthyroidism Diagnostic studies for hyperthyroidism Causes and treatments of hyperthyroidism General overview of hypothyroidism Evaluation of thyroid nodules Overview of osteoporosis Cellular effects of thyroid Cellular Hyperthyroidism Symptoms Hyperthyroidism Anxiety/irritability Weakness Tremors Difficulty sleeping Palpitations Increased bowel Increased movements movements Fatigue Weight loss Weight Hyperkinetic movements movements Heat intolerance Case Presentation Case 37 yo male presented to PCP w/ complaint 37 of feeling poorly for past month of Also complained of weakness, difficulty Also sleeping, increased heart rate. 10 stools per day. per What else do we need to know before What examining? examining? Case Presentation Case T 99.1, HR 92 irregular, RR 20, BP 153/75 Physical examination Mild proptosis Nontender goiter with thyroid bruit present CV: Irregularly irregular rhythm Ext: Brisk DTR’s, mild resting tremor What labs or studies do we need? Laboratory Studies Laboratory TSH <0.010 uIU/ml (nl 0.47-5.0) Free T4 >6 ng/dl (nl 0.71-1.85) Total T3 >600 ng/dl (nl 72-170) Thyroid Stimulating Antibody 130% (nl 0125%) Negative Thyroid peroxidase and Negative thyroglobulin antibodies thyroglobulin Case Presentation Case Patient was diagnosed with Graves’ Patient Disease Disease Started on Methimazole 10 mg TID Propranolol for symptom management Anticoagulation for atrial fibrillation Thyroid Antibodies Thyroid TSH receptor antibodies Can be stimulating or inhibitory Thyroglobulin antibodies Thyroid peroxidase antibodies (formerly Thyroid known as microsomal) known Anything else? Anything Radioactive Iodine Uptake Measures the amount of iodine taken up by Measures the thyroid in 24 hours the Normal 15-30% Thyroid Scan Gives an anatomic view of the thyroid Technetium used to image Differential Diagnosis Differential • High uptake Graves’ Disease Multinodular Goiter Toxic solitary Nodule TRH secreting Pituitary TRH Tumor Tumor HCG secreting tumor Low uptake Subacute Thyroiditis Silent Thyroiditis Iodine induced Iodine Exogenous LExogenous Thyroxine Struma ovarii Amiodarone Graves’ Disease Graves’ Most common cause of hyperthyroidism 60-80% of cases Autoimmune disease Caused by thyroid stimulating Caused immunoglobulins immunoglobulins Bind to TSH receptors on thyroid Cause hypersecrection of thyroid hormone Cause hypertrophy & hyperplasia of thyroid Cause follicles follicles Pathogenesis of Graves' Disease Weetman, A. P. N Engl J Med 2000;343:1236-1248 Clinical Manifestations Clinical Symptoms and signs of hyperthyroidism Ophthalmopathy Present in 50% of patients Eyelid retraction Periorbital edema Proptosis (exopthalmos) Diploplia Dermopathy (myxedema) Clinical Manifestations of Graves' Disease Weetman, A. P. N Engl J Med 2000;343:1236-1248 Graves’ Disease Graves’ Associated Conditions Type I Diabetes Mellitus Addison’s Disease Vitiligo Pernicious anemia Alopecia Areata Myasthenia Gravis Celiac Disease Graves Treatment Graves Antithyroid drugs (Thionamides) Proplythiouracil (PTU) 300-400 mg daily Methimazole 30-40 mg daily Decrease synthesis of hormone, PTU also decreases Decrease conversion of T4 to T3 conversion Permanent remission in 40-50% of treated patients Risk of agranulocytosis PTU used in pregnancy Beta-Blockers for symptoms Graves Treatment Graves Thyroidectomy Rapid cure but requires thyroid replacement Radioactive Iodine Radioactive Iodine (131I) is given Effect is typically seen in 3-6 months Hypothyroidism often develops Multinodular Goiter Multinodular Less common than Graves and effects Less older individuals older Discrete nodules become autonomous Discrete and hyperfunction and Treatment with thyroidectomy (often poor Treatment surgical candidates) or iodine, thionamides surgical Subacute Thyroiditis Subacute Etiology is typically viral Known as De Quervain’s thyroiditis or Known granulomatous thyroiditis granulomatous Thyroid is often enlarged, tender, painful Very low radioactive iodine uptake Self-resolving within weeks to months Treatment with NSAIDS, steroids, Beta-blockers Silent Thyroiditis Silent Also called painless or lymphocytic Also thyroiditis thyroiditis Not painful like subacute Transient Low iodine uptake Hypothyroidism Hypothyroidism Weakness Fatigue Lethargy, sleepiness Slowness of speech and thought “Puffy” appearance Dry skin, coarse hair Cold intolerance Constipation Physical Findings Physical Puffy features Dry skin Nonpitting edema Hypothermia Bradycardia Slow return of deep tendon reflexes Loss of lateral portion of eyebrows Causes of Hypothyroidism Causes Primary Hypothyroidism Iodine deficiency Iatrogenic-surgery, radioablation Autoimmune thyroid destruction Drugs interfering with hormone synthesis Infiltrative disease hemochromotosis, sarcoidosis, neoplastic disease Congenital thyroid agensis or defects in hormone Congenital synthesis synthesis Hashimotos Thyroiditis Hashimotos Most common type of thyroid disease Autoimmune damage Lymphocytic infiltrate, fibrosis, decreased Lymphocytic thyroid hormone production thyroid Autoantibodies (thyroglobulin and peroxidase) Can also be associated with polyglandular Can autoimmune disease autoimmune Adrenal insufficiency, ovarian failure, vitiligo, Adrenal diabetes diabetes Thyroid Replacement Thyroid Synthetic levothyroxine (T4) Converted to T3 in the body Studies vary on utility of using T3 Studies Typical replacement dose is 1.6 micrograms/kg (100-150 mcg typical) micrograms/kg Start with reduced dose in elderly and Start patients with history of heart disease patients Myxedema Coma Myxedema Severe untreated hypothyroidism Hypothermia, hypoglycemia, shock, Hypothermia, hypoventilation, ileus hypoventilation, 50% mortality Treat with IV levothyroxine, steroids Thyroid Nodule Thyroid 21 yo male w/ no past medical history 21 presents to his PCP complaining of gradually enlarging “knot” in his neck gradually What questions do you have? Examination reveals a firm 3 cm nodule in Examination right lobe of thyroid right What is the next step? Thyroid Nodules Thyroid Lifetime risk of palpable nodule 5-10% 50% of the population has a nodule on 50% autopsy or ultrasound autopsy Only 1 in 20 is malignant Differential Diagnosis Differential Malignancy Papillary Follicular Medullary Anaplastic Metastasis Benign follicular Benign adenoma adenoma Cyst Colloid Nodule Algorithm for the Cost-Effective Evaluation and Treatment of a Clinically Detectable Solitary Thyroid Nodule Hegedus, L. N Engl J Med 2004;351:1764-1771 Clinical Findings Suggesting the Diagnosis of Thyroid Carcinoma in a Euthyroid Patient with a Solitary Nodule, According to the Degree of Suspicion Hegedus, L. N Engl J Med 2004;351:1764-1771 Evaluation of Nodule Evaluation Measure TSH If Hyperthyroid (low TSH), do uptake and scan Treat with surgery or I-131 ablation If normal thyroid function, next step is fine If needle aspiration (FNA) needle Check Calcitonin level if family history of Check MEN2 or medullary carcinoma exists. MEN2 Algorithm for the Cost-Effective Evaluation and Treatment of a Clinically Detectable Solitary Thyroid Nodule Hegedus, L. N Engl J Med 2004;351:1764-1771 Fine Needle Aspiration Fine FNA is most effective way to distinguish FNA between benign and malignant nodules between Inexpensive, performed as outpatient Ultrasound guided FNA if not palpable or Ultrasound less than 1.5 cm in diameter less What results will I see? Benign-75% of the time Malignant-4% of cases Suspicious or inadequate-22% Algorithm for the Cost-Effective Evaluation and Treatment of a Clinically Detectable Solitary Thyroid Nodule Hegedus, L. N Engl J Med 2004;351:1764-1771 Management of Nodules Management Malignant Total thyroidectomy Suspicious Thyroidectomy Benign Discuss with the patient Ultrasound surveillance Surgery Consider levothyroxine suppression (varying results) Case Presentation Case FNA revealed papillary thyroid carcinoma Patient underwent total thyroidectomy Treatment with I-131 ablation after surgery Osteoporosis Osteoporosis Case Presentation Case 70 year old female asks her PCP if she 70 should have a bone density done. should What questions should her PCP ask? No history of fractures Menopause was surgical at age of 55 Mother fractured her hip at 74 Osteoporosis Osteoporosis Definition Microarchitectural deterioration of bone tissue Microarchitectural leading to decreased bone mass leading Bone fragility Susceptibility to fracture A problem of decreased peak bone mass problem and accelerated bone loss and Affects 10 million in the United States Hip Fractures Can Lead to Disability, Hip Loss of Independence, and Even Death Loss Hip fracture is associated with Hip increased risk of: risk Disability: 50% never fully Disability: recover1,2 recover Long-term nursing home Long-term care required: 25%2 care Increased mortality within 1 Increased year due to complications: up to 24%3 up Lifetime risk of death: Lifetime comparable to that of breast cancer4 of 1. Consensus Development Conference. Am J Med. 1993;94:646-650. 2. Riggs BL, Melton LJ III. Bone. 1995;17:505S–511S. 3. Ray NF et al. J Bone Miner Res. 1997;12(1):24–35. 4. Cummings SR et al. Arch Intern Med. 1989;149:2445–2448. Osteoporosis Osteoporosis Primary osteoporosis Unrelated to chronic illness Related to aging and decreased gonadal Related function function Secondary osteoporosis Secondary to chronic illnesses that cause Secondary accelerated bone loss accelerated Examples: Glucocorticoid use, celiac sprue, Examples: hyperthyroidism hyperthyroidism Risk Factors for Osteoporotic Fracture Fracture Nonmodifiable Personal history of fracture as an adult Potentially Modifiable Current cigarette smoking Low body weight (<127 lbs) History of fracture in first-degree relative Estrogen deficiency, including menopause onset <age 45 Caucasian race Alcoholism Advanced age Female sex Low calcium intake (lifelong) Impaired eyesight despite adequate correction Recurrent falls Dementia Poor health/frailty Inadequate physical activity Poor health/frailty Gold color denotes risk factors that are key factors for risk of hip fracture, independent of bone density. National Osteoporosis Foundation, Physician’s Guide to Prevention and Treatment of Osteoporosis . Belle Mead, NJ: Excerpta Medica, Inc.; 1998. Diagnosis of Osteoporosis Diagnosis History and physical examination to History exclude secondary osteoporosis exclude Laboratory studies if suspect secondary Laboratory osteoporosis osteoporosis Measurement of Bone Mineral Density Measurement (BMD) (BMD) Dual X-ray Absorptiometry (DEXA scan) Provides most reproducible values of bone density g/cm2 Forearm Relative BMD (%) 100 Spine Hip and Heel 90 80 70 60 30 40 50 60 70 80 90 Age Faulkner KG. J Clin Densitom. 1998;1:279–285. Annual Fracture Incidence BMD and Fracture Risk Are BMD Inversely Related Inversely Colles' 4000 Vertebrae Hip 3000 2000 1000 0 3539 85+ Age Cooper C. Baillières Clin Rheumatol. 1993;7:459–477. Central DXA Measurement Central Measures multiple skeletal sites Spine Proximal femur Forearm Total body Office based Considered the clinical standard Who Should Be Considered for BMD Who Testing? Testing? National Osteoporosis Foundation Guidelines Women ≥ 65 years of age regardless of additional risk Women 65 factors factors Postmenopausal women <65 years of age with at least Postmenopausal one risk factor for osteoporosis (in addition to menopause) menopause) Postmenopausal women ≤ 65 years of age with fractures Postmenopausal 65 (to confirm diagnosis and determine disease severity) (to Women considering therapy for osteoporosis, if BMD Women testing would facilitate the decision testing National Osteoporosis Foundation, Physician’s Guide to Prevention and Treatment of Women who have been on HRT for prolonged periods Osteoporosis. Belle Mead, NJ: Excerpta Medica, Inc.; 1998. Other Populations To Consider for Assessment of Osteoporosis Assessment Men Patients on long-term high-dose Patients glucocorticoids glucocorticoids Interpreting BMD Measurement Interpreting Reports Reports T-Score Is Key A clinically relevant value on the BMD report Describes bone mass compared with the mean peak Describes bone mass of healthy young adult women in terms of Standard Deviation (SD) Standard Can help confirm the diagnosis of low bone mass or Can osteoporosis osteoporosis For every SD below the young adult normal, the risk For of fracture approximately doubles of 1. National Osteoporosis Foundation, Physician’s Guide to Prevention and Treatment of Osteoporosis. Belle Mead, NJ: Excerpta Medica, Inc.; 1998. 2. Marshall D. Johnell O, Wedel H. Meta-analysis of how well measures of bone mineral density predict occurrence of osteoporotic fractures. BMJ. 1996;312:1254–1259. Visualizing a Patient’s T-Score 2 1 Peak Bone Mass SD 0 –1 –2 –3 –4 T-score = –3.0 –5 –6 20 30 90 40 50 60 Age (years) 70 80 T-score = Number of standard deviations (SDs) by which the patient’s T-score bone mass falls above or below the mean peak bone mass for normal young adult women young = T-score for patient, a 60-year-old woman; here, T = –3.0 T-score Light line: Change in mean bone mass over time in women Heavy line: Mean peak bone mass for young normal adult women Heavy National Osteoporosis Foundation, Physician’s Guide to Prevention and Treatment of Osteoporosis. Belle Mead, NJ: Excerpta Medica, Inc.; 1998. Recommendations for Treatment Recommendations Based on BMD Testing Results Based National Osteoporosis Foundation Guidelines for postmenopausal Women T-SCORE ACTION < –2.0 therapy Initiate < –1.5 therapy (with at least 1 additional risk factor) Initiate National Osteoporosis Foundation, Physician’s Guide to Prevention and Treatment of Osteoporosis. Belle Mead, NJ: Excerpta Medica, Inc.; 1998. Treatment of Osteoporosis Treatment Adequate Calcium (1200 mg elemental) Adequate Vitamin D (at least 400 IU) Weight-bearing exercise Pharmacologic Agents Pharmacologic Bisphosphonates Inhibit osteoclastic bone resorption Increased BMD and decreased fractures Ex: alendronate, risedronate Calcitonin Nasal spray or injection Decreased vertebral fractures No hip fracture data Raloxifen SERM Decreased vertebral fracture Osteoporosis Summary Osteoporosis Osteoporosis is a disease with serious consequences. Bone loss associated with osteoporosis increases Bone fracture risk, which may lead to disability, loss of independence, and death. independence, Patients at risk for osteoporotic fracture should be Patients considered for BMD testing. considered T-score is the most clinically relevant measure of T-score fracture risk. fracture According to NOF guidelines, consider therapy in According patients with a T-score of <–2.0 and those with a T-score patients 2.0 of <–1.5 with at least one risk factor. of ...
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This note was uploaded on 12/24/2011 for the course STEP 1 taught by Professor Dr.aslam during the Fall '11 term at Montgomery College.

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