8/9/2012
My Core Belief
Oh Thyroid! My
Thyroid!*
(or, Thyroid 101)
Family
Physicians can safely and
competently manage the majority of
the most common thyroid problems.
8/2/12
David M Schneider, MD
*Apologies to Walt Whitman
Learning Objectives
At the end of this session, participants will
be able to:
1.
1.Perform
Perform the appropriate laboratory
tests to diagnose thyroid disease.
2.
2.Manage
Manage pharmacologic dosing of
patients with hypothyroidism and
recognize potential medication
interactions that contribute to potential
issues in drug monitoring.
Fun Thyroid Facts
An
estimated 20 million Americans
have some form of thyroid disease.
Up to 12% of Americans will develop
some form of thyroid disease during
their lifetime.
Up to 60% of those with thyroid
disease are unaware of their
condition.
http://www.thyroid.org/about/pressroom.html;
http://www.thyroidmanager.org/Chapter1/1-frame.htm
http://www.thyroidmanager.org/Chapter1/1-
Fun Thyroid Facts – 2
The
thyroid receives 2% of the
cardiac output, even though it makes
up only ~0.03% of body mass.
In certain disease states, thyroid
blood flow can increase up to 100
fold.
Thyroid hormones affect function of
virtually every organ system & every
tissue in the body.
The Thyroid as “Thermostat”
A
metaphor – most pts understand.
– When overactive, everything is turned
up – feel hot, restless/anxious,
hyperactive heart & GI, etc.
– When underactive, everything is dialed
down – slow, cool, fatigue, etc.
– Gene transcription.
– Protein synthesis.
http://www.thyroid.org/about/pressroom.html;
http://www.thyroidmanager.org/Chapter1/1-frame.htm
http://www.thyroidmanager.org/Chapter1/1-
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Review of Thyroid Hormones
T4
99.97% ProteinProtein-Bound
= thyroxine:
– 99.97% of T4 is protein bound (2 ng/
ng/dL =
free).
– Produced exclusively by thyroid.
thyroid.
– HalfHalf-life ~ 1 week.
– ~10 X more prevalent in serum than T3.
T3
= triiodothyronine:
– 99.7% of T3 is protein bound (0.4 ng/
ng/dL =
free).
– 80% comes from conversion of T4 → T3 in
peripheral tissues.
– HalfHalf-life ~ 1 day.
– 3-100 (~10) times more potent than T4.
http://www.thyroidmanager.org/Chapter6a/6a--frame.htm
http://www.thyroidmanager.org/Chapter6a/6a
Question #1
What
is the most accurate thyroid
test, and why?
Demystifying Thyroid Testing
1st
test is high sensitivity or 3rd
generation TSH (detection limit =
0.01).
Interpretation of TSH
High
TSH hypothyroid
– Pituitary thinks there’s insufficient
thyroid hormones, so it secretes more
TSH.
Low
TSH hyperthyroid
– Pituitary thinks there is plenty of thyroid
hormones, so it shuts down TSH
production.
There
are rare exceptions.
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What is the “Normal Range” of
TSH?
Each
individual has a genetically
determined set point for normal TSH.
Lower limit of range for 3rd
generation tests is 0.3 – 0.4,
regardless of population
What is the Upper Limit of Normal
for TSH?
Quest
Lab: 4.50
Sutter Lab: 5.40
National Academy of Clinical
Biochemistry: 2.5
– Based on rigorously screened euthyroid
volunteers.
Endocrine
>
JCEM 1988;66:5881988;66:588-92; NHANES III-III--JCEM
JCEM 2002;87:4892002;87:489-99; ClinChemLabMed
2005;43:102--5
2005;43:102
Society: 2.5
age 80: 7.49
Thyroid 2003;13:572003;13:57-67; JCEM 2007;92:S12007;92:S1-47; JCEM 2007;92:45752007;92:4575-4582
Confused?
“I’m
confused…No,
wait…maybe
I’m not….”
http://www.thyroidmanager.org/Chapter6a/6a-frame.htm
TSH Upper Limit of Normal
Most
young – middlemiddle-aged euthyroid
people have a TSH below 2.5 – 3.6
3.6..
Reducing the upper limit of TSH
range to 2.5 will likely label a sizable
number of people as “abnormal” (or
subclinical hypothyroidism).
A TSH of 5 is likely above normal for
a young, healthy person.
ClinChem 2005 Aug;51(8):1480
Aug;51(8):1480--6
TSH: The Future
TSH
normal values may be ageagerelated.
Other factors that may affect TSH:
– Gender (F>M)
– Ethnicity (Caucasians>Latinos>African(Caucasians>Latinos>AfricanAmericans)
– Smoking (lowers TSH & may be assoc’d
w/less hypothyroidism)
ClinEndocrinol 2009;70:7882009;70:788-793; JClinEndocrinolMetab 2010;95:496
2010;95:496--502;
JClinEndocrinolMetab 2002;87:4892002;87:489-499
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2nd Thyroid Test
After
TSH, the next test depends on
TSH result and what you’re looking
for.
Total T4 & T3
Total
T4 (& to a lesser extent Total
T3) assays are rarely clinically useful
in & of themselves, and should
generally only be ordered in
conjunction with an estimate of free
(vs bound) hormone.
– Some experts note that total T3 is about
as accurate as FT3 with current assays.
– Same is NOT true for T4
Measuring Free Thyroid
Hormones
Free Hormone Hypothesis
Free
hormone hypothesis: only free
hormone is available to be active in
the body,
body, whereas hormone bound
to proteins (TBG, transthyretin,
transthyretin,
albumin) is inactive.
In the days before RIA & EIA &
ELISA, we had to estimate free T4.
So:
we are trying to measure
fractions of ng
ng/ml
/ml quantities.
Note: there is NO measurement
method that is truly accurate at
measuring free thyroid hormones.
– “Index” tests (stay tuned) &
immunoassays are proteinprotein-dependent &
inaccurate if binding proteins abnormal.
– Reference methods have technical
problems & are expensive.
http://www.thyroidmanager.org/Chapter6a/6a--frame.htm
http://www.thyroidmanager.org/Chapter6a/6a
http://www.thyroidmanager.org/Chapter6a/6a--frame.htm
http://www.thyroidmanager.org/Chapter6a/6a
Who Can Describe What the T3
Resin Uptake Measures?
Having
Hint:
trouble?
it doesn’t measure anything
we care about.
Free Thyroxine Index
Total
T4 is easy to measure – but
how much is bound vs free?
Enter the “T3 resin uptake” (T3RU).
NOTE: THIS IS NOT A MEASURE OF
T3, T4, OR ANY THYROID HORMONE.
T3RU is a way to estimate free vs
bound hormone.
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8/9/2012
When to use FTI (Maybe)
FTI
may be useful in pregnant
women.
– Binding protein abnormalities in
pregnancy may shift reference ranges in
immunoassays and render “normal”
values irrelevant.
When to use FTI (Maybe) – 2
FTI
may be useful in hospitalized pts
– Ditto.
– Avoid checking thyroid in hospitalized pt
unless you think thyroid is directly
related to acute issue.
Controversial
Controversial—
—TSH
w/different
normal range may be preferred.
AmJObGyn 2009 Mar;200(3):260; Thyroid 2003;13:572003;13:57-67;
http://www.thyroidmanager.org/Chapter6a/6a--frame.htm
http://www.thyroidmanager.org/Chapter6a/6a
Thyroid Hormone Assays
Equilibrium dialysis
is the reference
method of choice.
– Expensive.
– Technically difficult.
– Most useful in
calibration,
research, and weird
pts (e.g., FT4 not
concordant with
TSH).
– Usually
unnecessary..
unnecessary
http://www.thyroidmanager.org/Chapter6a/6a--frame.htm
http://www.thyroidmanager.org/Chapter6a/6a
Free Thyroid
Hormone
Immunoassays
– Do not truly measure
“free” thyroid
hormones, but a
reasonable estimate.
estimate.
– Labeled antibodies
(immunoassays,
immunosorbent
assays) commonly
used, provide a
reasonable estimate
of free thyroid
hormone
concentrations.
Free Thyroid Hormone Tests
TSH
is the single best thyroid test.
most clinical situations involving
discordant FT4 and TSH results, the
TSH usually provides the most
reliable results.
In
– Tune in later for exceptions.
For
most ambulatory patients, your
lab’s Free T4 & Free T3 assays
(usually EIA or related assay) are
good enough.
http://www.thyroidmanager.org/Chapter6a/6a--frame.htm;
http://www.thyroidmanager.org/Chapter6a/6a
Trust the TSH
General Rule of Thyroid Tests
Do not interpret thyroid test results in
a vacuum – you must look at the
clinical picture!
http://latimesblogs.latimes.com/funny_pages_20/2008/10/the-5-reasonsl.html; http://www.toplessrobot.com/Episode_4_Luke_Skywalker_1.jpg
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8/9/2012
Case 1
28
y.o. male presents to your office
with fatigue for ~ 6 months.
– No F/C.
– Clothes fitting tighter, but doesn’t know
if wt gain (doesn’t have a scale).
– No CP, but exertional dyspnea and
reduced exercise tolerance.
– + intermittent mild constipation.
– Endorses nonspecific arthralgias.
Case 1 – continued
PMH
neg
meds
NKA
FH/SH neg
ROS as above, o/w neg
Exam:
No
– BP 132/98, P 60
– Goiter?
– Something funny about his DTR’s
DDx
Vasc
asc:: CHF, CAD (unlikely—
(unlikely—young)
Infex
nfex//inflam:
inflam: HIV, HCV, SBE, TB
Neoplastic: CA, lymphoma; anemia
Drugs: meds, abuse
Idiopathic: chr fatigue syn,
syn, FM, OSA
Congenital: hereditary neuropathy
Allergic/
llergic/autoimm
autoimm:: RA, SLE
Trauma: head injury (no hx
hx))
Endo/met: ↓ thyr
thyr,, adrenal, pit; CKD, lytes
Degen
egen:: he’s too young
Psych: dep,
dep, anx,
anx, somatization
DDx
Vasc
asc:: CHF, CAD (unlikely—
(unlikely—young)
Infex
nfex//inflam:
inflam: HIV, HCV, SBE, TB
Neoplastic: CA, lymphoma; anemia
Drugs: meds, abuse
Idiopathic: chr fatigue syn,
syn, FM, OSA
Congenital: hereditary neuropathy
Allergic/
llergic/autoimm
autoimm:: RA, SLE
Trauma: head injury (no hx
hx))
Endo/met: ↓ thyr
thyr,, adrenal, pit; CKD, lytes
Degen
egen:: he’s too young
Psych: dep,
dep, anx,
anx, somatization
Lab Results
CBC
WNL
Na 134, o/w WNL
Lipids: TC 248, LDL 164, TG 246,
HDL 35
TSH: 47
Chem:
Hypothyroidism—
Hypothyroidism
—Epidemiology
Prevalence
= 4.6% (4.3% subclinical
= 93%!).
Up to 15% of older women (>65).
5-8 times more common in women
vs men.
JCEM 2002;87(2):4892002;87(2):489-99; JCEM 2006;91(12):49532006;91(12):4953-6; ClinEndocrinol(
ClinEndocrinol(Oxf
Oxf))
1995;43(1):55--68
1995;43(1):55
6
8/9/2012
Possible Risk Factors for
Hypothyroidism
Previous
thyroid problems (goiter,
surgery).
Family history of thyroid disease.
Other autoimmune diseases
(Sjögren’s, pernicious anemia, DM1,
RA, SLE).
Turner’s syndrome.
Women w/small body size at birth
&/or during childhood.
http://www.endocrine.niddk.nih.gov/pubs/Hypothyroidism/#diagnosis; JCEM
2006;91:4953-6
Symptoms of Hypothyroidism
Metabolic
slowing:
– Fatigue
– Cold intolerance
– Wt gain
– DOE
– Cognitive dysfunction
– Constipation
– Growth failure/delayed puberty in
children
http://www.utdol.com/online/content/topic.do?topicKey=thyroid/18640&selectedTi
tle=4%7E150&source=search_result
Signs of Hypothyroidism
Metabolic
slowing:
– Bradycardia
– Slowed movement & speech
– Delayed DTR return
Matrix
accumulation:
– Goiter
– Coarse skin; cool & pale (↓
(↓ blood flow)
– Puffy face,
face, periorbital edema
– Tongue enlargement
– Loss of eyebrows (esp
(esp lateral 1/3)
Possible Risk Factors for
Hypothyroidism – 2
Age
>60 years.
Pregnancy or delivery within past 6
months (esp
(esp if prior postpartum
thyroiditis).
Radiation treatment to the thyroid,
neck, or chest.
HIV
ClinInfectDis (2003);37:579-583
Symptoms of Hypothyroidism – 2
Accumulation
of matrix substances:
– Dry skin (reduced
(reduced sweating)
sweating)
– Edema
– Hoarse voice
Other:
– Arthralgias, myalgias
– Depression
– Menorrhagia or oligomenorrhea
– Hearing loss
EndocrRev 1989;10:366;
http://www.utdol.com/online/content/topic.do?topicKey=thyroid/18640&selectedTitle=4%7E150&source=sear
ch_result
More Signs of Hypothyroidism
HTN (↑
(↑ PVR)
effusions
Myxedema coma ≠ pretibial
myxedema
Anemia
Macrocytosis w/o anemia or
deficiency
Diastolic
Pleural/pericardial
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8/9/2012
More Signs of Hypothyroidism–
Hypothyroidism–2
High
output CHF or angina – in CV
pts
Celiac dz (4
(4--fold incr)
incr)
Carpal tunnel syndrome
Thinning hair
Hypothyroid Mnemonic—
Mnemonic—Mine
Macrocytosis
Edema
Thyroid
((incl
incl orbital)
Goiter
Anemia
Bradycardia
Obesity
(wt gain)
eyebrow loss
Irreg menses
Constipation
Lateral
© David M. Schneider
Lab Abnormalities in
Hypothyroidism
Hyponatremia
– ↓ free
free--H2O
clearance
Hyperlipidemia – ↓ lipid clearance incr LDL &/or TG’s
– Lipids usually correct w/correction of
hypothyroidism.
– Consider TSH in pts w/hyperlipidemia
w/hyperlipidemia..
Transient
↑ Cr (20 – 90% of pts)
ArchIntMed 1999;159(1):791999;159(1):79-82; http://www.utdol.com/online/content/
topic.do?topicKey=thyroid/18640&selectedTitle=4%7E150&source=search_result#H5; MayoClinProc
topic.do?topicKey=thyroid/18640&selectedTitle=4%7E150&source=search_result#H5;
1993;68(9):860--6; ArchIntMed 1995;155(14):14901993;68(9):860
1995;155(14):1490-5
Causes of Hypothyroidism
Hashimoto’s
(chronic autoimmune
thyroiditis): >90%
Iatrogenic:
– Radioiodine therapy
– Subtotal or total thyroidectomy
– ATD’s
– Drugs (amiodarone
(amiodarone,, Li, interferon)
Thyroiditis
Iodine
http://www.ncbi.nlm.nih.gov/bookshelf/br.fcgi?book=endocrin&part=A235;
http://www.utdol.com/online/content/topic.do?topicKey=thyroid/7938&selectedTitle=2%7E150&so
urce=search_result
When to Suspect 2°
2°
Hypothyroidism
Secondary Hypothyroidism
Low
TSH & low Free T4
– May have normal or slightly high TSH –
inappropriate for low level of FT4
(tricky—
(tricky
—FT4 reliability).
Rare
– ≤1% of hypothyroidism.
Causes:
– Brain lesion (tumor, cyst, abscess).
– Pituitary hemorrhage or infarction.
– Iatrogenic – surgery, radiation.
– Infiltrative – sarcoidosis, TB, other.
deficiency/excess
agenesis
Thyroid
Known
hypothalamic or pituitary
disease.
Mass lesion in the pituitary.
Symptoms and signs of
hypothyroidism are associated with
other hormonal deficiencies.
Very
few pts. Most don’t have 2°
2°.
http://www.utdol.com/online/content/topic.do?topicKey=thyroid/19559&sou
rce=related_link
8
8/9/2012
Hashimoto’s Autoimmune
Thyroiditis
F:M
= 8 – 10:1
May begin with transient
hyperthyroidism – “Hashitoxicosis.”
Thyroid Autoantibodies
Anti
Anti--thyroglobulin
(anti
(anti--Tg).
– 5-20% of general population.
Anti
Anti--thyroid
peroxidase (anti
(anti--TPO).
– 8-27% of general population.
http://www.utdol.com/online/content/image.do?imageKey=ENDO%2F5488;
http://www.utdol.com/online/content/topic.do?topicKey=thyroid/7938&selectedTitle=2%7E150&source=se
arch_result
Thyroid Autoantibodies – 2
Why Get Antithyroid Ab’s?
Generally
Hashimoto’s:
– TPO: 90% +
– Tg: 8080-90% +
Graves’:
– TPO: 5050-90% +
– Tg: 5050-70% +
DM1:
30--40% + for each.
30
Relatives of Hashimoto’s: 3030-50% +
for each.
unnecessary.
– If hypothyroid, 90+% Hashimoto’s.
– Most of the rest are thyroiditis or
iatrogenic.
– 2° will still get same treatment.
May
provide prognostic info in pts @
high risk:
– Such as pregnant women w/thyroid
dysfunction – may predict later Graves’.
– May help in dx & prediction of subclinical
thyroid dz.
http://www.utdol.com/online/content/topic.do?topicKey=thyroid/7938&selectedTitle=2%7E150&sour
ce=search_result; http://www.utdol.com/online/content/image.do?imageKey=ENDO%2F5488
Treatment of Hypothyroidism
Levothyroxine
(LT4).
– Mean dose is 1.6 mcg/kg/day (lean
body wt more accurate).
112
mcg for avg 70 kg pt.
& healthy: begin w/near target dose.
>50 or CV dz:
dz: start @ 25 – 50 mcg daily.
Young
Monitoring of LT4 Treatment
Goal
= TSH of 0.5 – 2.0.
TSH q 6 weeks. TSH takes
6 weeks to equilibrate after change
in thyroid meds (or change in
endogenous function).
Measure
– Wide variability.
– Take on empty stomach.
stomach.
– Do not take with soy flour (soy formulas
in infants).
JCEM 2005;90(1):1242005;90(1):124-7; EndocrPract 1999;5(5):2331999;5(5):233-8; JCEM
2009;94(10):3905--12
2009;94(10):3905
9
8/9/2012
Monitoring of LT4 Treatment – 2
What About T3 Therapy?
If
TSH still high, increase LT4 dose
by 12 – 25 mcg. Repeat TSH 6 wks.
If pt still feels awful, can check FT4
+ TSH at 3 wks and incr LT4 dose –
caution, as TSH will still be high, &
FT4 not yet steady state.
TSH once yearly when stable.
http://www.stopthethyroidmadness.com/
Less stamina than others
Less energy than others
Long recovery period after any activity
Inability to hold children for very long
Arms feeling like dead weights after activity
Chronic Low Grade Depression
Suicidal Thoughts
Often feeling cold
Cold hands and feet
High or rising cholesterol
Heart disease
Palpitations
Fibrillations
Plaque buildup
Bizarre and Debilitating reaction to exercise
Hard stools
Constipation
No eyebrows or thinning outer eyebrows
Dry Hair
Hair Loss
White hairs growing in
No hair growth, breaks faster than it grows
Dry cracking skin
Nodding off easily
Requires naps in the afternoon
Sleep Apnea (which can also be associated with low cortisol)
Air Hunger (feeling like you can’t get enough air)
Inability to concentrate or read long periods of time
Forgetfulness
Foggy thinking
Inability to lose weight
Always gaining weight
Inability to function in a relationship with anyone
NO sex drive
Failure to ovulate and/or constant bleeding (see Rainbow’s story)
Moody periods
PMS
Inability to get pregnant; miscarriages
Excruciating pain during period
Nausea
Swelling/edema/puffiness
Aching bones/muscles
Osteoporosis
Bumps on legs
Acne on face and in hair
Breakout on chest and arms
Hives
Exhaustion in every dimension–
dimension–physical, mental, spiritual,
emotional
Inability to work fullfull-time
Inability to stand on feet for long periods
Complete lack of motivation
Slowing to a snail’s pace when walking up slight grade
Extremely crabby, irritable, intolerant of others
Handwriting nearly illegible
Internal itching of ears
Broken/peeling fingernails
Dry skin or snake skin
Major anxiety/worry
Ringing in ears
Lactose Intolerance
Inability to eat in the mornings
Joint pain
Carpal tunnel symptoms
No Appetite
Fluid retention to the point of Congestive Heart Failure
Swollen legs that prevented walking
Blood Pressure problems
Varicose Veins
Dizziness from fluid on the inner ear
Low body temperature
Raised temperature
Tightness in throat; sore throat
Swollen lymph glands
Allergies (which can also be a result of low cortisol–
cortisol–common with
hypothyroid patients)
Headaches and Migraines
Sore feet (plantar fascitis);
fascitis); painful soles of feet
now how do I put this one politely….a cold bum, butt, derriere,
fanny, gluteus maximus,
maximus, haunches, hindquarters, posterior, rear,
and/or cheeks. Yup, really exists.
colitis
irritable bowel syndrome
painful bladder
Extreme hunger, especially at nighttime
Dysphagia, which is nerve damage and causes the inability to
swallow fluid, food or your own saliva and leads to “aspiration
pneumonia”.
Caveat and Interesting Info
There
may be a subgroup who
respond to T3 (deiodinase gene
polymorphism).
polymorphism
).
– Up to 16% may have a deiodinase gene
polymorphism. Some of these pts may
feel better w/appropriate
w/appropriate T3
supplementation.
Evidence: T3 Doesn’t Help
Neurocognitive
function & psych
well-being may not return to normal
wellw/LT4.
The vast majority of studies show no
advantage to T3 supplementation or
partial replacement (10/12 + metametaanalysis).
Risk of hyperthyroidism & longlong-term
effects.
EurJEndol 2005;153(6):747
2005;153(6):747--53; ClinEndo(Oxf) 2002;57(5):5772002;57(5):577-85; NEJM 1999;340(6):4241999;340(6):424-9; JCEM 2003;88(10):45432003;88(10):4543-50;
JCEM 2003;88(10):45512003;88(10):4551-5; JAMA 2003;290:29522003;290:2952-8; ClinEndocrinol(
ClinEndocrinol(Oxf
Oxf)) 2004;60:7502004;60:750-7;
AnnIntMed 2005;142:4122005;142:412-24; JCEM 2005;90:8052005;90:805-12; JCEM 2005;90:26662005;90:2666-74;
EndocrPract 2005;11:2232005;11:223-33; JCEM 2005;90:49462005;90:4946-54; JCEM 2006;91(7):25922006;91(7):2592-9;
http://www.utdol.com/online/content/topic.do?topicKey=thyroid/2117&selectedTitle=3%7E150&source=search_result#H13
Animals Have More T3
– Physiologic T4:T3 ratio in humans is ~
10
10--14:1.
Armour
Thyroid has 2.8:1 molar ratio of
T4:T3.
Thyrolar has 4:1 ratio of T4:T3.
Trial of ~10:1 ratio of T4:T3 may be
reasonable.
– Reduce LT4 dose by the amount of added T3.
T3
(Cytomel™)
(Cytomel
™) best taken bid (or slow
release – unavailable in US). 2nd dose
midday or afternoon.
Avoid overtreating to hyperthyroidism.
MONITOR!!
MONITOR
JCEM 2009;94:16232009;94:1623-9; AmJPhysiol 1990;258:E7151990;258:E715-26; Thyroid 2004;14:2712004;14:271-5
10
8/9/2012
Unstable Control &/or TSH
Adherence.
Drug interactions.
Food interaction (Ca++).
Other endocrine (adrenal, pituitary) or
other conditions.
Brand/generic changes.
– ATA & Endocrine Society recommend that pts
be maintained on the same brandbrand-name LT4
product.
– If change from one brand to another, from
brand to generic, or from one to another
generic, check TSH in 6 weeks, adjust med as
needed.
http://www.thyroid.org/professionals/advocacy/04_12_08_thyroxine.html
http://www.thepharmacytechnician.com/?p=1
9
Close Your Eyes if You Hate
Mnemonics
Adherence
Brand…
Change
Drug
interactions
Endocrine
Food
interaction
Drugs That Interfere w/LT4
Acid
reducers (PPI, probably H2,
sucralfate)
Bile acid sequestrants (cholestyramine)
Ca++, Carbamazepine
Dilantin
Estrogen derivatives
Fe
Screening for Thyroid Disorders
American Thyroid Association (ATA)
recommends screening every 5 years
beginning at 35.
Check drug interactions when prescribing
Screening for Thyroid Disorders
USPSTF, AAFP: “evidence
“evidence is insufficient to
recommend for or against routine
screening for thyroid disease in
[nonpregnant
nonpregnant]] adults.”
– No proven outcome advantage to screening.
– No association w/function, depressive sx
sx,,
disability in ADLs in an elderly population.
– Subclinical hypo
hypothyroidism
thyroidism was assoc’d
w/lower
w/lower allall-cause/CV mortality, despite higher
baseline chol(!).
chol(!).
Consider
targeted screening – risk
factors.
http://www.ahrq.gov/clinic/uspstf/uspsthyr.htm; AnnIntMed 2004 Jan 20;140(2):12820;140(2):128-41; JAMA
2004 Dec 1;292(21):25911;292(21):2591-9
http://www.ahrq.gov/clinic/uspstf/uspsthyr.htm; AnnIntMed 2004;140:1282004;140:128-41; JAMA 2004;292:25912004;292:2591-9
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8/9/2012
Risk Factors for Thyroid Dz
Hyper--/hypoHyper
/hypo– Female gender
– Age,
Age, esp older women
> 60 – 65
– Pregnancy/postpartum
(be on the lookout for
sx
sx))
– Prior thyroid problems
– FH
Hyper--:
Hyper
– Smoking
– Life stressors (?!)
Hypo--:
Hypo
– Autoimmune
– Turner’s
– Small at birth or in
childhood
– Neck/chest
radiation
– HIV
http://www.uptodate.com/contents/disorders-that-cause-
What Have We Learned?
Laboratory
dx of thyroid disorders.
Signs & symptoms of hypothyroidism.
Lab values in hypothyroidism
(remember hyperlipidemia).
Management of hypothyroidism.
Consider trial of T3.
Why therapy might not be working.
hyperthyroidism?source=search_result&selectedTitle=1~150
Shameless SelfSelf-Promotion
www.BlogTalkRadio.com/DrDaveS
Facebook:
search for “To Your
Health With Dr Dave Schneider”
http://www.krsh.com/pages/878721
2.php
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