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Subclinical Hyperthyroidism

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Subclinical Hyperthyroidism

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    1. Subclinical Hyperthyroidism Cheryl P. Sterling, MD, MPH VCU/MCV Hospitals February 20, 2003

    2. Case Presentation 48 yo Black female with well controlled HTN, h/o borderline hyperthyroidism No specific complaints or concerns Meds: HCTZ for BP control FHx remarkable for HTN, DM, no other endocrine D/O’s, no known AIDz SHx unremarkable

    3. Case Presentation 48 yo Black female with well-controlled HTN, h/o borderline hyperthyroidism ROS positive for low but normal appetite, no wgt loss, no signif fatigue Pap UTD No prior BMD study Physical exam = nonobese female; no obvious features c/w hyperthyroid state

    4. Case Presentation LABS WBC 6.0, Hgb 12.4, Platelets 378 BMP unremarkable except for Ca 8.9 LFT’s wnl Fasting Lipid Profile Chol 173, HDL 45 TG 120, LDL 97 Serial thyroid testing 11/00 TSH – 0.15 3/01 TSH – 0.35 7/01 TSH – 0.22 9/02 TSH – 0.16 2/03 TFT’s TSH - 0.21 Total T4 - 8.4 T3RU – 37.2% FTI - 10

    5. Clinical Question Premenopausal female patient with hx of “borderline” hyperthyroidism, no obvious clinical signs nor subjective symptoms of thyroid hormone excess What are the management options for this patient in your practice?

    6. The Thyroid Subclinical Hyperthyroidism - Characterized by the presence of low or undetectable plasma TSH concentration and normal circulating free thyroid hormones. Also referred to as mild hyperthyroidism Exogenous vs. endogenous

    7. Common Signs/Symptoms Fatigue Weight loss Heat intolerance Hyperhidrosis Nervousness Insomnia Muscle weakness Hyperdefecation Tremor Dyspnea Palpitations Menstrual irregularity Anxiety Irritability Exophthalmos Lid lag or stare

    8. Subclinical Hyperthyroidism

    9. Etiology Presage to overt hyperthyroidism Early Graves’ disease Multinodular goiter Hashimoto’s Thyroiditis Subacute Silent Postpartum Thyroid carcinoma Iodine-associated hyperthyroidism e.g. amiodarone Solitary autonomous adenoma Nonthyroidal illness Steroid or dopamine administration Health food supplement

    10. Biochemical Assessment Thyroid stimulating hormone (TSH): Is the single most reliable test to diagnose thyroid disease. The assay is accurate, widely available, safe, and a relatively inexpensive diagnostic test. Also serum free and total T4, free and total T3. Free thyroxine index = indirect measure of free T4 T3 resin uptake = indirect estimate of unsaturated binding sites on thyroxine binding globulin

    11. Diagnostic Assessment Thyroid scan or radioactive iodine (123I) uptake “Hot” versus “Cold” nodule Thyroid ultrasound Anatomic abnormalities Does not reveal information regarding thyroid function Serial examination

    12. Diagram of thyroid testing

    13. Evidence-based Research? Detection and management of subclinical thyroid disorders Small prospective, nonrandomized studies Cross-sectional studies Case reports Meta-analyses Subgroup analysis in Framingham study

    14. Short/Long-term Effects Alteration in cardiac morphology and function Cross-sectional studies demonstrating: Increased heart rate Increased LV mass Enhanced LV function Impaired diastolic filling Increased risk of atrial fibrillation and stroke in older patients

    15. Adverse Effects Alteration in bone metabolism Postmenopausal women with subclinical hyperthyroidism have increased bone loss Neuropsychological effects Reduced quality of life Anxiety, depression Increased risk of dementia, Alzheimer’s disease

    16. Journal Article Subgroup analysis from Framingham Study Prospective study w/10 yr follow-up Purpose – Is low serum thyrotropin in clinically euthyroid older persons a risk factor for subsequent atrial fibrillation? 2007 persons, age > 60 years 4 groups: low, slightly low, normal, high thyrotropin levels

    17. Results

    18. Journal Article Cross-sectional, case-control study in Italy Purpose – Effects of endogenous subclinical hyperthyroidism in the young and middle-aged 23 patients, 23 controls from areas of mild-moderate iodine deficiency Assessment of Thyroid status S/sx of thyroid hormone excess and quality of life Cardiac morphology and function

    19. Results

    20. Conclusions

    21. Subclinical Hyperthyroidism

    22. Subclinical Hyperthyroidism

    23. Subclinical Hyperthyroidism - Individualize management - Discuss benefits vs. risks - Of each treatment option, e.g. periodic monitoring of CBC, LFT’s, TFT’s - Financial considerations - Drug interactions, potential toxicities - Also consider potential issues of nonadherence

    24. The Answer (To My Clinical Question) Continue close observation with serial TFT’s, including total and free T3 Discuss with patient possible treatment options Thyroid scan with RAIU Antithyroid medications, if necessary Refer to endocrinology for management

    25. References

    26. References

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