09/01/35

Salman Bin AbdulAziz University

College Of Pharmacy

Thyroid Disorders
Therapeutics I
PHCL 416

Ahmed A AlAmer
PharmD

Email: Ahmedadel.pharmd@gmail.com

Hypothyroidism

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M.W., a 70-kg, 23-year-old voice student, thinks that her neck has become fatter
over the past 3 to 4 months. She has gained 10 kg, feels mentally sluggish, tires easily,
and finds that she can no longer hit high notes.
Physical examination reveals puffy facies, yellowish skin, delayed DTRs, and a firm,
enlarged thyroid gland.
Laboratory data include FT4, 0.6 ng/dL (normal, 0.7 1.9); TSH, 60 units/mL
(normal, 0.54.7); and TPO antibodies, 136 IU/L (normal,<1).

Free thyroxine ( FT4) , Thyroid-stimulating hormone ( TSH), Thyroid peroxidase (TPO)

DTR = deep tendon reflexes

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Assess M.W.s thyroid status based on her clinical and laboratory findings.

Thyroid antibodies: Antithyroid peroxidase and antithyroglobulin

autoantibodies TPO ( . hashimotos disease )
According to the patient results ! He has low T4 and
high TSH . Hypothyroidism

Classify hypothyroid disorders ? (hypothyroidism disorders )

A. Hashimotos disease: Most common hypothyroid disorder

i. Autoimmune-induced thyroid injury resulting in decreased thyroid secretion
ii. Disproportionately affects women more than men
B. Surgery or radioiodine induced (iatrogenic)
C. Iodine deficiency or excessive intake
D. Secondary causes
i. Pituitary insufficiency (lack of TSH secretion)
ii. Drug induced (e.g., amiodarone, lithium)

This patient has hashimotos disease

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Sings and symptoms consistent with hypothyroidism ?

Subjective
thinks that her neck has become fatter over the past 3 to 4 months. She has gained
10 kg, feels mentally sluggish, tires easily, and finds that she can no longer hit high
notes.

Objective ?
reveals puffy facies, yellowish skin, delayed DTRs, and a firm, enlarged thyroid gland.

Sings and symptoms

Hypothyroidism Hyperthyroidism
a. Cold intolerance a.Weight loss/increased appetite
b. Dry skin b. Lid lag
c. Fatigue, lethargy, weakness c. Heat intolerance
d. Weight gain d. Goiter
e. Bradycardia e. Fine hair
f. Slow reflexes f. Heart palpitations/tachycardia
g. Coarse skin and hair g. Nervousness, anxiety, insomnia
h. Periorbital swelling h. Menstrual disturbances (lighter or
i. Menstrual disturbances (more frequent more infrequent menstruation,
or longer menstruation, painful amenorrhea)
menstruation, i. Sweating or warm, moist skin
menorrhagia) j. Exophthalmos, pretibial myxedema in
Graves disease

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Write a note on signs and symptoms regarding hypothyroidism and

hyperthyroidism ?

Goal of therapy ?
Therapy Goals for Both Hyperthyroid and Hypothyroid Disorders

1. Minimize or eliminate symptoms, improve quality of life

2. Minimize long-term damage to organs.
3. Normalize free T4 and TSH concentrations.

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write 3 goals when treating patient with thyroid disorder ?

Hyperthyroidism

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S.K., a 48-year-old woman, is admitted to the hospital for a possible MI.

Her complaints include chest pain that is unrelieved by NTG, increasing SOB with
exercise, nervousness, palpitations, muscle weakness, weight loss despite an
increased appetite, and epistaxis; she also bruises easily.

She has a history of deep venous thrombosis treated with warfarin (Coumadin) 5
mg/day; her last prothrombin time (PT) was 18 seconds (normal, 10.512.1), and
an international normalized ratio (INR) was 1.8 (normal, 1; therapeutic, 23). She
has angina, treated withNTG0.4 mg, and CHF, treated with digoxin (Lanoxin)
0.25 mg/day.

Physical examination
reveals a thin, flushed, hyperkinetic, nervous woman.
Blood pressure (BP) is 180/90 mmHg; pulse is 130 beats/minute, irregularly irregular;
respiratory rate is 30 breaths/min; and temperature is 37.5C.

Other pertinent findings include a lid lag with stare, proptosis with tearing, a
diffusely enlarged thyroid gland without nodules, a bruit in the left lobe of the
thyroid, positive jugular venous distention (JVD), bibasilar rales, warm moist skin
with multiple bruises, new-onset atrial fibrillation (AF), slight diarrhea,
hepatomegaly, acropachy, 2+ pitting edema, a fine tremor, proximal muscle
weakness, and irregular scant menses

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Laboratory data
FT4, 2.9 ng/dL (normal, 0.71.9); TSH,<0.5 units/mL (normal, 0.54.7); RAIU at 24
hours, 80% (normal, 5%35%); PT, 40 seconds (normal, 10.512.1); INR, 4.8
(normal, 1; therapeutic, 23); TPO, 200 IU/mL (normal,<1); alkaline phosphatase,
200 units/L (normal, 41133); total bilirubin, 1.1 mg/dL (normal, 0.11.2); AST, 60
units/L (normal, 726); and alanine aminotransferase (ALT), 55 units/L (normal,
323).

A scan shows a diffusely enlarged gland, three to four times normal size.

Assess M.W.s thyroid status based on her clinical and laboratory findings. ?

FT4, 2.9 ng/dL (normal, 0.71.9); TSH,<0.5 units/mL (normal, 0.54.7);

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if thyroid gland is actively and excessively secreting T4 and/or T3

Radioactive iodine (Graves disease, TSH-secreting adenoma, toxic adenoma,
multinodular goiter)

in disorders caused by thyroiditis or hormone ingestion.

RAIU at 24 hours, 80% (normal, 5%35%)..(Elevated )

BesideTPO this patient has Graves disease

Signs and symptoms support diagnosis of hyperthyrodism in this patient ?

include chest pain that is unrelieved by NTG, increasing SOB with exercise, nervousness,
palpitations, muscle weakness, weight loss despite an increased appetite, and epistaxis;
she also bruises easily.
Blood pressure (BP) is 180/90 mmHg; pulse is 130 beats/minute, irregularly irregular;
respiratory rate is 30 breaths/min

a lid lag with stare, proptosis with tearing, a diffusely enlarged thyroid gland without
nodules, a bruit in the left lobe of the thyroid, positive jugular venous distention (JVD),
bibasilar rales, warm moist skin with multiple bruises, new-onset atrial fibrillation (AF),
slight diarrhea, hepatomegaly, acropachy, 2+ pitting edema, a fine tremor, proximal
muscle weakness, and irregular scant menses

FT4, 2.9 ng/dL (normal, 0.71.9); TSH,<0.5 units/mL (normal, 0.54.7); RAIU at 24
hours, 80% (normal, 5%35%); PT, 40 seconds (normal, 10.512.1); INR, 4.8

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Sings and symptoms

Hypothyroidism Hyperthyroidism
a. Cold intolerance a.Weight loss/increased appetite
b. Dry skin b. Lid lag
c. Fatigue, lethargy, weakness c. Heat intolerance
d. Weight gain d. Goiter
e. Bradycardia e. Fine hair
f. Slow reflexes f. Heart palpitations/tachycardia
g. Coarse skin and hair g. Nervousness, anxiety, insomnia
h. Periorbital swelling h. Menstrual disturbances (lighter or
i. Menstrual disturbances (more frequent more infrequent menstruation,
or longer menstruation, painful amenorrhea)
menstruation, i. Sweating or warm, moist skin
menorrhagia) j. Exophthalmos, pretibial myxedema in
Graves disease

Classification

Toxic diffuse goiter (Graves disease)

i. Autoimmune disorder
ii. Thyroid-stimulating antibodies directed at thyrotropin receptors mimic thyroid-
stimulating hormone (TSH) and stimulate triiodothyronine/thyroxine (T3/T4)
production.

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Classification

Pituitary adenomas:

Excessive TSH secretion that does not respond to normal T3 feedback

Classification

Toxic adenoma

Hot nodule in thyroid, autonomous of pituitary and TSH

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Classification

Toxic multinodular goiter (Plummer disease):

Autonomous follicles, if large enough, cause excessive thyroid hormone secretion.

Classification
Painful subacute thyroiditis: Self-limiting thyroiditis caused by viral invasion of the
thyroid parenchyma, resulting in release of stored hormone
Drug induced (e.g., excessive thyroid hormone use, amiodarone)

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Goal of therapy ?
Therapy Goals for Both Hyperthyroid and Hypothyroid Disorders

1. Minimize or eliminate symptoms, improve quality of life

2. Minimize long-term damage to organs.
3. Normalize free T4 and TSH concentrations.

References
I. Koda Kimble , applied therapeutics
II. Pharmacotherapy Bedside Guide Christopher P. Martin,
Robert L. Talbert
III. Updates in Therapeutics: The Pharmacotherapy
Preparatory Review
VI. American Association of Clinical Endocrinologists: AACE

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