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1. TREATMENT OF HYPERTHYROIDISM Presented by - Chinmoy Kakati (roll no-153) Mentor- Dr Somnath Roy Sir (Department of medicine)

2. TREATMENT OPTIONS Medication Radioactive iodine Surgery

3. CHOICE OF TREATMENT Cause and severity of disease Patient’s age Goiter size Comorbidities Patient’s preference Presence of ophthalmopathy

4. Graves disease Medication 1 . Antithyroid drugs (ATD ). The drugs include : a. Thionamides : e.g. propylthiouracil , carbimazole , methimazole . Mechanism of action : Inhibit the function of thyroid peroxidase (TPO) enzyme and block the synthesis of T3 and T4. Methimazole is the primary drug to treat hyperthyroidism. Propylthiouracil is preferred during 1 st trimester of pregnancy. Carbimazole has additional immunosuppresive action .

5. Adverse effect- Agranulocytosis Hepatotoxicity(especially with propylthiouracil ) Rash Methimazole can cause aplasia cutis,choanal atresia and other birth defect in 1 st trimester of pregnancy Relapse rate is high

6. 2.Beta adrenergic blockers Non-selective is used for immediate relief and control symptoms due to sympathetic overactivity such as anxiety, palpitation, increased bowel activity, lid retraction, finger tremors. Drug of choice : Propranolol dose: 20-40 mg 6 hourly . contraindication : pre existing heart disease, COPD, or asthma.

7. 3.Iodides Used as adjuvant. Decrease synthesis of T3 ,T4 and inhibit hormone release. Given pre operatively to make the gland small , firm and less vascular to reduce blood loss during surgery.

8. Radioactive Iodine ablation It is the mc treatment in US. 131I induces extensive tissue damage by emitting gamma radiation from within the follicles, resulting in ablation of thyroid within 6-18 weeks. Dose : 185–555 MBq Complication : irreversible hypothyroidism , infertility, secondary cancers. Contraindications : children and pregnant/lactating women patients of severe ophthalmopathy chronic smokers

9. Surgical treatment Subtotal or Total Thyroidectomy is the treatment of choice. Surgical treatment is reserved for multinodular goiter (MNG) with following features: Severe hyperthyroidism in children . Pregnant women who cannot tolerate antithyroid drugs . Large goiters with severe ophthalmopathy or with pressure symptoms . Patients who require quick normalization of thyroid function Preparation for thyroidectomy: It includes pre-treatment with propranolol or atenolol, methimazole and potassium iodide (3 drops BD for 7-10days). Postoperative complications : Hypothyroidism, hypoparathyroidism and damage to recurrent laryngeal nerve.

10. Graves’ ophthalmopathy Ophthalmopathy requires no active treatment when it is mild or moderate, because there is usually spontaneous improvement. Reversal of hyperthyroidism beta blocker , thionamide or surgery . Reduction of thyroid hormone synthesis decreases eyelid retraction and stare Radioiodine therapy is contraidicated . if it is chosen glucocorticoid should be administered concurrently . Smoking cessation Local measures : eye shades, artificial tears, and lubricants such as methylcellulose , petroleum jelly , raising the head end of bed at night..

11. Medical : Selenium 100 mcg BD in mild cases. It has a antioxidant role and also decreases inflamation . Glucocorticoids are the mainstay of immunomodulatory therapy . For moderate case – oral prednisone 30 mg/day for 4 weeks or IV methylprednisolone . For severe case – initial IV therapy is appropriate .

12. Teprotumumab ,an IGF -1 receptor inhibitor . it is administered at an intial dose of 10 mg/kg IV and thereafter 20 mg /kg IV every 3 weeks for 21 weeks Orbital decompression surgery : it is indicated when glucocorticoids are ineffective.

13. H yperthyroidism in pregnancy ATDs should be used with caution in pregnancy. Because transplacental passage of these drugs may produce foetal hypothyroidism and goitre . Propylthiouracil should be used until 14-16 weeks of gestation . As carbimazole and methimazole have been associated with rare cases of fetal aplasia cutis, choanal atresia etc,they are not used in 1 st trimester. After 1 st trimester , treatment is s witched to methimazole (or carbimazole ) .

14. Evaluation is done by TFTs , disease history,goitre size,duration of therapy and TRAb measurement . Postpartum period is a time for major risk for relapse of G raves disease. Breast feeding is safe with low doses of ATDs. Graves disease in children is usually managed intially with methimazole or carbimazole (avoid propylthiouracil ).

15. THYROID DERMOPATHY It does not usually require treatment, but it can cause cosmetic problems. Surgical removal is not indicated. If necessary, treatment consists of topical, high-potency glucocorticoid ointment . Octreotide may be beneficial in some cases .

16. THYROID STORM/THYROTOXIC CRISIS-a life threatening medical emergency

17. Treatment of Other causes of hyperthyroidism Thyroiditis: Painless and subacute thyroiditis are self limiting conditions that resolve spontaneously within 6 months . There is no role of ATDs or radioactive iodine ablation. beta blocker may be needed to control adrenergic symptoms. Pain associated can be relieved by aspirin or other NSAIDs. If this treatment is inadequate or the patient has marked local or systemic symptoms, glucocorticoids should be given .

18. Toxic adenoma or toxic multinodular goitre Antithyroid medications can control hyperthyroidism ,but do not induce remission of hyperthyroidism a/w toxic adenoma or toxic MNG. Therefore, radioactive iodine ablation and thyroidectomy are the main treatment options for these conditions .

19. D rug induced thyrotoxicosis Amiodarone induced thyrotoxcosis (AIT) is classified into type 1 and type 2 AIT.

20. In type 2 AIT, oral sodium ipodate (500 mg/d) or sodium tyropanoate (500 mg, 1–2 doses/d), rapidly reduce T4 and T3 levels. Potassium perchlorate , 200 mg every 6 h, has been used to reduce thyroidal iodide content. Hyperthyroidism a/w use of other medications (lithium , interferon- alfa,tyrosine kinase inhibitors, highly active retroviral drugs) is usually self limiting.

21. CHOICE OF THERAPY Diffuse toxic goitre Over 45 yrs – ATDs for 18 months Under 45 yrs – radioiodine therapy or surgery Toxic nodular goitre Surgery(initially –ATDs till euthyroid ) Toxic solitary nodule Surgery or radioiodine (<45 yrs ) Recurrent thyrotoxicosis after sugery Radioiodine therapy ATDs may be used in women intending to have children Failure of antithyroid drugs or radioiodine therapy surgery

22. THANK YOU