only disease management presented here

1. DISEASE MANAGEMENT
(HYPERTHYROIDISM)
Muhammad Arslan Tahir (13635)

2. DISEASE MANAGEMENT
 Disease management is a system of coordinated heath care
interventions and communications for defined patient populations
with conditions where self-care efforts can be implemented.
Disease management empowers individuals, working with other
health care providers to manage their disease and prevent
complications.

3. TREATMENT OPTIONS
1. Medication
2. Radioactive iodine
3. Surgery

4. 1- MEDICATIONS
 Anti-thyroid drugs
 Beta blockers
 Iodides

5. ANTI-THYROID DRUGS
 Methimazole and propylthiouracil are most commonly used ATDs
INDIACTIONS
 Patients with sustained forms of hyperthyroidism
 Elderly or other patients with comorbidities, surgical risk or limited
life expectancy
 Moderate to severe active Graves’ ophthalmopathy
 Before surgery
 Soon after starting radioactive I-131 therapy for 6 to 12 weeks

6. ANTI-THYROID DRUGS

7. ANTI-THYROID DRUGS
HOW LONG TO GIVE ATDs
 Most patients have improved symptoms in 2 weeks and become
euthyroid in 6 weeks
 Check TSH and FT4 every 4-6 weeks
 In Graves, many go into remission after 12-18 months
 Once ATD therapy is discontinued, patient should be monitored
every 3 months for first year, and then annually
 40% experience recurrence in 1 year
 MNG and toxic adenoma will not get cured by ATD

8. BETA BLOCKERS
 Used as adjuvant
 Propranolol is the most commonly prescribed medication in doses
of about 20 to 40 mg q.i.d
 Used for relief of neurological and cardiovascular symptoms
 CCBs can be used for same purpose when beta blockers are
contraindicated or poorly tolerated
 These therapies should be tapered and stopped once thyroid
functions are within the normal range

9. BETA BLOCKERS
INDICATIONS
 Prompt control of symptoms
 Treament of choice for thyroiditis
 First-line therapy before surgery, radioactive iodine and ATDs
CONTRAINDICATIONS
o Older patients
o Patients with pre-existing heart disease, COPD or asthama

10. IODIDES
 Used as adjuvant
 Block the conversion of T3 to T4 and inhibit hormone release
INDICATIONS
 Preoperatively when other medications are ineffective or
contraindicated
 To reduce gland vascularity before surgery for Graves’ disease
 During pregnancy when ATDs are not tolerated
COMPLICATIONS
o Paradoxical increase in hormone release with prolonged use
o Common side effects are sialadenitis, conjunctivitis or acniform rash

11. 2- RADIOACTIVE IODINE
 Concentrates in thyroid gland and destroys thyroid tissue
 High cure rates with single dose treatment (80%)
 Treatment of choice for:
~ Graves disease in adults in the US
~ Multi-nodular goiter, toxic nodules in patients older than 40
years
~ In recurrent thyrotoxicosis
 It is effective, safe and does not require hospitalization
 Given orally in a single dose in a capsule or liquid form

12. 2- RADIOACTIVE IODINE
DRAWBACKS
o Delayed control of symptoms
oPost-treatment hyperthyroidism in majority of patients with Graves’
disease regardless of dosage (82% after 25 years)
o Contraindicated in pregnancy and lactation
o Can cause transient neck soreness, flushing; radiation thyroiditis (in
1% of patients)
o May exacerbate Graves’ ophthalmopathy
o May require pre-treatment with ATDs in older or cardiac patients

13. 3- SURGERY
GENERALLY RESERVED FOR SPECIAL CIRCUMSTANCES
 Patient preference
 Severe hyperthyroidism in children
 Pregnant women who cannot tolerate ATDs
 Child or adolescent intolerance to ATDs
 Patients with large goiter
 Severe Graves’ ophthalmopathy
 Patients who refuse radioactive iodine therapy

14. 3- SURGERY
PREOPERATIVE PREPARATION
 Standard preparation
Make the patient euthyroid or near euthyroid using ATDs
 Alternate method
Rapid control of thyroid status can be achieved with a combination of
thionamides, SSKI, dexamethasone (1-2mg b.d) and beta blockers
 Very rapid control  operation within a weak
 Lugol’s iodide solution or saturated potassium iodide for 7-10 days

15. 3- SURGERY
EXTENT OF THYROIDECTOMY
 Determined by desired outcome
 Total or near-total thyroidectomy
For patients with coexisting thyroid cancer, severe opthalmopathy,
life-threatening reactions to ATDs
 Subtotal thyroidectomy
Recommended for the rest

16. 3- SURGERY

17. 3- SURGERY
POST-OPERATIVE MANAGEMENT
 Following surgery, thyroid hormone replacement should be started
 TSH should be measured every 1-2 months until stable, and then
annually
 Following thyroidectomy, serum calcium hormone levels should be
measured and oral calcium supplements be administered based on
these results

18. CHOICE OF THERAPY
 Cause and severity of disease
 Patient’s age
 Goiter size
 Coexisting medical illness
 Treatment desires
 Presence of ophthalmopathy

19. CHOICE OF THERAPY
Diffuse Toxic Goiter
 Over 45 yrs.  Radioactive iodine
 Under 45 yrs.
~ Surgery for large goiter
~ ATDs or radioactive iodine for small goiter
Toxic Nodular Goiter
 Surgery
Toxic Nodule
 Surgery or radioactive iodine
Recurrent Thyrotoxicosis After Surgery
 Treatment of choice  Radioactive iodine
 Young women intending to have children  ATDs

20. CHOICE OF THERAPY

21. LIFESTYLE MODIFICATIONS
DIET
 Diet or supplements containing excess amount of iodide should be
avoided because iodide interferes with or complicates the
management of antithyroid and radioactive iodine therapies
PYSICAL ACTIVITY
 Exercise tolerance is not effected in patients with mild to moderate
hyperthyroidism. For these patients, no reduction in physical activity
is required
 For elderly patients or patients with severe hyperthyroidism, a
decrease in physical activity is necessary until hyperthyroidism is
medically controlled

22. SAFETY PRECAUTIONS
 Most of the radioactive iodine is eliminated from the body in urine,
saliva and feces within 48 hours; however, double flushing of the
toilet and frequent hand washing are recommended for several
weeks.
Close contact with others, especially children and pregnant women,
should be avoided for 24 to 72 hours.