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• Hypothyroidism
• Hyperthyroidism
Typical Thyroid Hormone Levels
in Thyroid Disease
TSH T4 T3
Hypothyroidism High Low Low
Subclinical Hypothyroidism
TSH >4.7 IU/mL, Free T4 Normal
Euthyroid
TSH 0.5-4.7 IU/mL, Free T4 Normal
Hyperthyroidism
TSH <0.5 IU/mL, Free T3/T4 Normal or Elevated
0 5 10
TSH, IU/mL
Braverman LE, et al. Werner & Ingbar’s The Thyroid. A Fundamental and Clinical Text. 8th ed. 2000.
Canaris GJ, et al. Arch Intern Med. 2000;160:526-534.
Vanderpump MP, et al. Clin Endocrinol (Oxf). 1995;43:55-68.
Prevalence of Abnormal Thyroid
Function
The Colorado Thyroid Disease Prevalence study
• Used thyroid stimulating hormone (TSH) levels as a
measure of thyroid function
• Prevalence of elevated TSH levels (hypothyroidism)
was 9.5% and the prevalence of decreased TSH
levels (hyperthyroidism) was 2.2%
• Lipid levels increased as thyroid function declined
• 40% of patients taking thyroid medications had
abnormal TSH levels
14 Females
12 similar between
10 males and
8 females
6
4 • At ≥40 years of
2 age, a higher
0 percentage of
13- 20- 30- 40- 50- 60- 70- >80 female patients
19 29 39 49 59 69 79 have elevated
Age, y TSH levels
• 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 • Goiter
decrease • Sleep increase • Hair and skin
• Weight increase changes
• Fatigue
Bravernan LE, Utiger RE, eds. Werner & Ingbar's The Thyroid.
8th ed. Philadelphia, Pa: Lippincott Williams & Wilkins; 2000.
Persani L, et al. J Clin Endocrinol Metab. 2000; 85:3631-3635.
Primary Hypothyroidism:
Underlying Causes
• Congenital hypothyroidism
– Agenesis of thyroid
– Defective thyroid hormone biosynthesis due to enzymatic defect
• Thyroid tissue destruction as a result of
–Chronic autoimmune (Hashimoto) thyroiditis
–Radiation (usually radioactive iodine treatment for thyrotoxicosis)
–Thyroidectomy
–Other infiltrative diseases of thyroid (eg, hemochromatosis)
• Drugs with antithyroid actions (eg, lithium, iodine, iodine-
containing drugs, radiographic contrast agents, interferon alpha)
TSH
Normal
Range
T3
T4
Years
• Hyperlipidemia
• Depression
• Gynecological conditions
• Aging
300
250 Hypothyroid
Lipid Levels, mg/dL
100 Subclinical
Hyperthyroid
50 Hyperthyroid
0
Total-C* LDL-C* HDL-C* Triglycerides
50
-5
-10
(mg/dL), %
-15
-20
-25
-30
-35
-40
LDL-C (mg/dL)
150
TC (mg/dL)
10
240
8
6 145
4
2
0 230 140
LT4 Placebo LT4 Placebo LT4 Placebo
Before After
AACE MEDICAL GUIDELINES FOR CLINICAL PRACTICE FOR THE EVALUATION AND TREATMENT OF HYPERTHYROIDISM AND
HYPOTHYROIDISM. ENDOCRINE PRACTICE Vol 8 No. 6 2002
JAMA 2004; 291:228-238
Treatment of Hypothyroidism
Hypothyroidism Treatment Goal
Euthyroidism
6-8 Weeks
Singer PA, et al. JAMA. 1995;273:808-812. Demers LM, Spencer CA, eds.
Demers LM, Spencer CA, eds. The National Academy of Clinical Biochemistry Web site.
Available at: http://www.nacb.org/lmpg/thyroid_lmpg.stm. Accessed July 1, 2003.
Caution in Patients With Underlying
Cardiac Disease
• Using LT4 in those with ischemic heart disease increases
the risk of MI, aggravation of angina, or cardiac
arrhythmias
• For patients <50 years of age with underlying cardiac
disease, initiate LT4 at 25-50 g/d with gradual dose
increments at 6- to 8-week intervals
• For elderly patients with cardiac disease, start LT4 at
12.5-25 g/d, with gradual dose increments at 4- to 6-week
intervals
• The LT4 dose is generally adjusted in 12.5-25 g
increments
6 P<.001
TSH Level, IU/mL
0
Before Ingestion After Ingestion
Campbell NR, et al. Ann Intern Med. 1992;117:1010-1013.
Is there any role for T3
supplementation in the
management of
hypothyroidism?
NO!
AACE Position Statement on the
Management of Hypothyroidism
Family History of
First-Trimester Miscarriage/
Thyroid Disease
Excessive Vomiting in Pregnancy
or Diabetes
Initial Evaluation of a Patient with
Hyperthyroidism
Braverman LE, Utiger RD, eds. The Thyroid: A Fundamental and Clinical Text. 8th ed.
Philadelphia, Pa: Lippincott, Williams & Wilkins; 2000;1001.
Potential Consequences of
Subclinical Hyperthyroidism
• Beta blockers
• Corticosteroid therapy
• Bile acid sequestrants
• Iodide
Which Treatment to choose?
Depends on:
• Patient preference
• Severity of hyperthyroidism
• Evidence of complications of
hyperthyroidism
• Pregnancy
• The cause of hyperthyroidism
Unusual Thyroid Studies
iTSH but FT4 also i
Get FT3
• T3 toxicosis is not uncommon in Grave’s
disease- an elevated or high normal FT3
would be suggestive, as would a positive TSI
and diffuse goiter
• Sometimes seen in acute/chronic illness
• Central hypothyroidism is very rare in the
absence of risk factors or suspicious history
but would be suggested if FT3 also low
iFT4, but Normal TSH and FT3
• Thyroiditis
• Iodine induced thyrotoxicosis
• Factitious Hyperthyroidism
• Central Hypothyroidism