Stase Endokrin - hyperthyroid graves disease.pptx

hyperthyroid

1. Stase Endokrin

2. REGULASI NORMAL HORMON TIROID

3. ©Bimbel UKDI MANTAP

4. Primary Hypofunction Secondary Hyperfunction Primary Hyperfunction Pituitary Failure Normal range THYROTROPIN (TSH) LEVEL Low Normal High Low Normal High THYROID HORMONE LEVEL Subclinical Hypofunction Subclinical Hyperfunction

5. Signs & symptoms hyperthyroid Thyroid dermopathy pretibial myxedema, indurated plak, orange-skin appearance 3. Thyroid acropachy manifests as clubbing finger MANIFESTASI KLINIS

6. ©Bimbel UKDI MANTAP 4. Graves ophtalmopathy Proptosis may be quantitated with an hartel exophthalmometer , an instrument that measures the position of the globes in relation to the lateral orbital rim. Exophthalmus : Bola mata bulging ke anterior  Pemeriksaan dilakukan dengan Hertel test Dalrymple’s sign : palpebra superior tampak retraksi karena fissure palpebra melebar Joffroy’s sign : kerutan dahi berkurang saat pasien melirik ke atas Mobius’ sign : Tidak dapat mempertahankan kedua mata untuk melihat satu titik objek  periksa dengan jari (convergen) Von Graefe’s sign : terdapat gap pada palpebra superior saat menutup mata Stellwag’s sign : Frekuensi berkedip yang jarang dan tidak sempurna

7. DIAGNOSIS GRAVES DISEASE

8. Thyroid storm is a rare, life-threatening condition characterized by severe clinical manifestations of thyrotoxicosis. In national surveys from the United States and Japan, the incidence of thyroid storm was 0.57 to 0.76 and 0.20 per 100,000 persons per year, respectively, and 4.8 to 5.6 per 100,000 hospitalized patients per year. It may be precipitated by abrupt discontinuation of antithyroid drugs or by an acute event such as thyroid or nonthyroidal surgery, trauma, infection, an acute iodine load, or parturition . In addition to specific therapy directed against the thyroid, supportive therapy in an intensive care unit (ICU) and recognition and treatment of any precipitating factors is essential since the mortality rate of thyroid storm is substantial (10 to 30 percent). THYROID STORM

9. Precipitatants in hyperthyroid patients: abrupt discontinuation of antithyroid drugs surgery , sepsis , iodine loads , post-partum Endocrine emergency (Mortality 20-50%) A clinical diagnosis at the end of a hyperthryoid continuum

10. thyroid stimulating immunoglobulin (TSI) - limphosit (IgG) Antibodi berikatan dengan reseptor TSH ( TRAb ) PATOGENESIS Menghasilkan T3 & T4 Diffuse growth

11. KELOMPOK OBAT EFEK INDIKASI Thioamide Propiltiuurasil (PTU) Metimazol Karbimazol Menghambat fungsi TPO Menurunkan oksidasi dan organifikasi iodide Menghambat coupling iodotirosine (+) PTU menghambat konversi T4 T3 di perifer Obat jangka pendek prabedah/praRAI Metimazol lebih disukai dari PTU karena bekerja lebih cepat dan lebih sedikit efek samping Beta blocker Propranolol 20-40 mg/6 jam Metoprolol Atenolol Nadolol Mengurangi dampak hormon tiroid pd jaringan Obat tambahan, kdg obat tunggal pd tiroiditis Bahan mengandung iodin Kalium iodida Sol lugol Na ipodat Asam iopanoat Iodine Radioactive Therapy Menghambat keluarnya T4 dan T3 Menghambat produksi T4 dan T3 serta produksi T3 ekstratiroidal Persiapan tiroidektomi. Pd krisis tiroid. Bukan utk pengobatan rutin Obat lainnya -Kalium perklorat -Litium Karbonat -Glukokortikoid Menghambat transpor yodium, sintesis dan keluarnya hormon, memperbaiki efek hormon di jar dan sifat imunologis Bukan indikasi rutin. Pada subakut tiroiditis berat, dan krisis tiroid

12. Treatment of Hyperthyroid General principles  — The principles of treatment outlined below are based upon clinical experience and case studies since there are no prospective studies. They are frequently also applied to patients with severe hyperthyroidism who do not fully meet the criteria for thyroid storm. The therapeutic regimen typically consists of multiple medications, each of which has a different mechanism of action : ● A beta blocker (if not contraindicated) to control the symptoms and signs induced by increased adrenergic tone ● A thionamide to block new hormone synthesis ● An iodine solution to block the release of thyroid hormone ● An iodinated radiocontrast agent (not available in the United States) to inhibit the peripheral conversion of T4 to T3 ● Glucocorticoids to reduce T4-to-T3 conversion, promote vasomotor stability, possibly reduce the autoimmune process in Graves' disease, and possibly treat an associated relative adrenal insufficiency ● Bile acid sequestrants may also be of benefit in severe cases to decrease enterohepatic recycling of thyroid hormones

13. Treatment For most patients with clinical features of  thyroid storm  or with  impending storm  ( ie , severe thyrotoxicosis that does not fully meet the criteria for thyroid storm), we begin immediate treatment with: ● Beta blocker  –  Propranolol  preferred. ● Thionamide  –  Propylthiouracil  (PTU) preferred.   ● Iodine  –  Potassium iodide solution  (SSKI) or  potassium iodide-iodine solution  (Lugol's solution). For patients with clinical features of  thyroid storm , we also administer: ● Hydrocortisone  – (See  'Glucocorticoids'  below.) Cholestyramine  is an additional adjunctive therapy, especially if the patient is allergic to thionamides . (See  'Other therapies'  below.)

14. ©Bimbel UKDI MANTAP TATALAKSANA KRISIS TIROID (PAPDI, 2009)

15. Am Fam Physician. 2013;88(3):193-196 Predicting Malignant Involvement in a Thyroid Nodule: Role of Ultrasonography ( Endocr Pract . 2007;13: 219-224)