Transcript Module 3 - 1.04 MB

ENDOCRINE DISORDERS in
the ELDERLY
Module #2
THYROID DISEASES
Ed Vandenberg, MD, CMD
Geriatric Section OVAMC
&
Section of Geriatrics
981320 UNMC
Omaha, NE 68198-1320
[email protected]
Web: geriatrics.unmc.edu
updated 11-17-06
PROCESS
A series of modules and questions
Step #1: Power point module with voice
overlay
Step #2: Case-based question and answer
Step # 3: Proceed to additional modules or
take a break
OBJECTIVES:
Upon completion, the learner will be able to:
1) Describe the evaluation and treatment of
hypothyroidism in the elderly
2) Describe the evaluation and treatment of
hyperthyroidism in the elderly
3) List the evaluation and treatment of
nodular thyroid disease and thyroid
cancer
Hypothyroidism:
Overview
• Age related changes are negligible
• Hypothyroidism:
1.4% of all women over age 50
• Symptoms nonspecific so test with the
slightest suspicion
Test patient with declines in:
-cognitive
-functional
-clinical
Hypothyroidism: Common Causes
• Autoimmune (primary thyroid failure)
• Following therapy for hyperthyroidism
• Pituitary or hypothalmic disorders
(secondary thyroid failure)
• Medications;
-amiodarone (rare after first 18 mo of therapy)
-lithium
.
EVALUATION
Initial testing
-TSH, free T4
Confirm Diagnosis
-Elevated TSH and decreased Free T 4
or
-Persistently elevated TSH
or
-TSH > 10 mIU/L
.
SUB CLINICAL
HYPOTHYROIDISM
Incidence:
15 % over 65 yo.
Criteria:
TSH; elevated
Free T4; normal
When to treat: (any of the following)
-elevated antimicrosomal antibody titer
-TSH > 10 mIU/L
-symptoms consistent with hypothyroidism
.
“TRAPS”
Low T4 syndrome
Setting:
Severe nonthyroidal illness
Lab:
-Free T4 index..decreased
-TSH………….. normal
-Free T4……….normal
-reverse T3……increased
Patient is Euthyroid
Secondary Hypothyroidism
Setting: hypopituitarism
( other pituitary hormones
deficient)
Lab:
-TSH……….Normal or low
-Free T4…...Low
-reverseT3...Decreased
Primary hypothyroidism & the
Drug-disease “masquerade”
Lab:
Normal TSH, Decreased FreeT4
Setting; -fasting,
-acute illnesses
-dopamine
-phenytoin
-carbamazepine
-rifampin
-glucocorticoids.
Pharmacologic Therapy (1)
Levothyroxine (T4, levothyroxine Eltroxin, Levo-T, Levothroid,
Levoxyl, Synthroid]).
-Start at 25 mcg and increase by 25 mcg intervals q 6-8 wk
For myxedema coma:
-Load 400 mcg IV or 100 mcg q 6–8 h for 1 d, then 100 mcg/d for 4
d; then start usual replacement regimen.
To convert thyroid USP to thyroxine:
-60 mg USP = 50 mcg thyroxine.
PO to IV
If patients are NPO and must receive IV thyroxine;
-dose should be half usual po dose.
.
MONITORING
PRIMARY HYPOTHYROIDISM,
Goal; maintain plasma TSH within the normal range.
Maintenance therapy
-TSH level at least q 12 mo in patients on chronic thyroid
replacement therapy.
-Following dose adjustment, recheck TSH in 6-8 wk.
-FYI; Average daily dose 110 mcg a day
Benefits/complications of euthyroid state
-increased drug clearance of digoxin, phenytoin, and opiates
-improved cardiac and cognitive function
-improved TC and LDL
HYPERTHYROIDISM
HYPERTHYROIDISM
Symptoms
vague, atypical, or
nonspecific symptoms
• atrial fibrillation
• congestive heart failure
• constipation
• anorexia
• muscle atrophy
• weakness
• weight loss
Apathetic thyrotoxicosis
• Depression
• Inactivity
• Lethargy
• Withdrawn behavior
• Tremor (coarse)
COMMON CAUSES
•
•
•
•
Graves' disease
Toxic nodule
Toxic multinodular goiter
Medications, especially amiodarone (can occur any
time during therapy) and lithium
.
Source: with permission of Images.md
(2)
Evaluation
• Screen with;
– TSH
• Confirm with:
Free T4, when indicated free T3
• Evaluate further with:
Thyroid auto antibodies; (3)
Anti-TSHR Ab* ……..Grave’s disease specific
*Anti-TSHR Ab: Anti-thyrotropin receptor antibodies
Anti-Tg Ab** & Anti-TPO Ab#….Graves,
Autoimmiune thyroiditis,
Relatives of pt’s with thyroiditis
**Anti-Tg Ab: Anthyrogloin antibodies
# Anti-TPO Ab Antithyroid peroxidase antibodies
• Radioactive iodine uptake.
Clinical vs Sub clinical
hyperthyroidism
Clinical (overt)
hyperthyroidism)
Lab:
• TSH…. Depressed
• Free T4. .Elevated
• Free T3...Elevated
Sub clinical
hyperthyroidism
Lab:
• TSH….. Depressed
• Free T4.. Normal or
slightly elevated
Most have no symptoms &
are detected on
screening TSH.
If need to confirm use:
24 hr thyroid radioiodine
uptake
CLINICAL (OVERT)
HYPERTHYROIDISM
T4 thyrotoxicosis
Lab:
T3 thyrotoxicosis
Lab:
• TSH……. Depressed
• Free T4… Elevated
• Free T3….Normal
• TSH……Depressed
• T4…….. Normal
• Free T3. Elevated
Minority of patients
Associated with
-Toxic adenoma
-Toxic multinodular goiter
“TRAPS”
Masqueraders;
That have;
Central hypothyroidism
• TSH… Depressed Nonthryoid illness
• Free T3.. Normal
• Free T4…Normal
Malnutrition
Medications
High dose glucocorticoids, dopamine
agonists, and phenytoin
Recovery from Hyperthyroidism
*glucocorticoids, dopamine agonists, and phenytoin;
+ if TSH again normal, discontinue monitoring
Subclinical Hyperthyroidism; treatment controversial, if diagnosed, assess for findings consistent with
thyrotoxicosis i.e. atrial fibrillation, osteoporosis and neuropsychiatric symptoms. If these findings are
present consider further evaluation as for T3 toxicosis. Otherwise in six months checkTSH, free T4 and free T3 an
monitor for clinical symptoms of thyrotoxicosis.
Adapted from Gruenewald DA; Endocrine and
Metabolic disorders GRS, 6th edition p 372
HYPERTHYROIDISM
Pharmacologic Therapy
• Radioactive iodine ablation is usual treatment
surgery or medical therapy are options.
• Propylthiouracil (PTU):
Start 100 po tid, then adjust up to 200 po tid as needed
• Methimazole (Tapazole):
Start 5–20 mg po tid, then adjust
• β-blockers) or calcium antagonists:
adjunctive therapy....for symptomatic improvement.
..
Nodular Thyroid Disease and
Thyroid Cancer
Multinodular goiter
Solitary thyroid nodules
• Women > 70 y.o. = 90%
• Men
> 70 y.o. = 60%
Most nonpalpable
Autonomously functioning areas
At risk for thrytoxicosis with
-radiocontrast dye
-amiodarone
Risk of malignancy
Types:
• Anaplastic (only in elders)
• Follicular & papillary
-more aggressive
-increased mortality
Diagnosis;
• Fine needle aspiration
Key; RAI = radioactive iodine,FNA = fine needle aspiration biopsy, US = ultrasound
* Repeat FNA if specimen inadequate
Note; always evaluate with endocrinologists consultation
Adapted from Gruenewald DA; Endocrine and Metabolic disorders GRS, 6th edition p 374
The End of Module Two
on
Endocrine Disorders in the
ELDERLY
THYROID DISEASES
Post-test
• A 76-year-woman, who recently relocated,
comes to your office for an initial visit. She lives
alone in an apartment and has no impairments
of activities of daily living. Current medications
are a thiazide diuretic, calcium and vitamin D
supplements, and a multivitamin. Her pulse rate
is 104 per minute. Generalized muscle
weakness and 2+ ankle edema are noted. Her
Mini–Mental State Examination score is 30/30.
Serum thyroxine is 16.8 µg/dL, and thyrotropin is
less than 0.01 µg/dL. Which of the following
therapies is most appropriate for this patient?
Which of the following therapies is most
appropriate for this patient?
A. No treatment
B. Propylthiouracil
C. Tapazole
D. Radioactive iodine
E. Surgical ablation of the thyroid gland
Used with permission from: Murphy JB, et. al. Case Based Geriatrics Review: 500 Questions and
Critiques from the Geriatric Review Syllabus. AGS 2002 New York, NY.
Answer; D. Radioactive iodine
Although many older adults with elevated levels of serum
thyroid hormone are asymptomatic (apathetic
hyperthyroidism), patients without cardiac conduction
abnormalities will often have resting tachycardia.
Treatment with radioactive iodine is indicated for this
patient. Antithyroid drugs such as propylthiouracil and
methimazole commonly are used in younger patients
who may have spontaneous remission. In older adults,
long-term complications of radiation (ie, malignancy) are
less relevant, and the major goal is complete remission
of hyperthyroidism. Surgery rarely is indicated in older
patients, who are at high risk for complications; an
exception might be the presence of a large toxic
multinodular goiter.
end
Readings and Resources
Recommended readings and resources;
Gruenewald DA, Matsumoto AM. Endocrine and metabolic
disorders . GRS sixth edition 2004-06 PPG 368-381
Geriatrics at Your Fingertips 8th edition 2006-2007
Resources
(1) Epocrates accessed 2-2-05
(2) Micrormedex accessed 2-2-06
(3) Up To Date; accessed 2-9-06