The term thyrotoxicosis refers to an excessive amount of circulating thyroid hormones from any source. Increased levels of thyroid hormones can occur in the setting of an otherwise normal thyroid function.
For example, when there is inappropriate exogenous thyroid hormone or excessive release of stored hormone from an inflamed thyroid gland. It decreases the secretion of thyroid hormones by inhibiting proteolysis of Tg. Beta-blockers : Indications include tachycardia and supraventricular arrhythmias, eyelid retraction, tremor, and hyperhidrosis. If antithyroid drugs alone are effective, beta-blockers are not required. Oral propranolol is used at doses of 10 to 40 mg tid ; larger doses may be used in treatment of thyrotoxic crisis.
Other oral beta 1 -selective drugs are usually used since they are much more convenient, especially if there is no thyroid storm: bisoprolol, metoprolol, or atenolol. RAI I Treatment. Effects and risks : RAI I emits radiation limited to the thyroid gland. A portion of the administered I that has not been taken up by the thyroid gland is rapidly excreted with urine.
Radiation exposure of sensitive organs bone marrow, gonads is low. Contraindications : Pregnancy and breastfeeding; confirmed or suspected thyroid malignancy in a patient with hyperthyroidism; large thyroid goiter; patients unable to follow the recommended safety precautions, including contraception.
After completing the treatment, female patients should not become pregnant for 6 months; the recommended 6-month contraception also applies to male patients treated with I. There is no risk of permanent fertility impairment or congenital malformations in children; therefore, reproductive age is not a contraindication to RAI treatment.
If RAI treatment is used in patients with active thyroid-associated orbitopathy, especially if moderate, concomitant prophylactic glucocorticoid therapy should be used see below. RAI treatment should probably be avoided in severe orbitopathy.
Preparation for RAI treatment :. Management after RAI therapy : Euthyroidism is achieved within 6 weeks to 6 months after I administration.
Some patients require continued antithyroid treatment throughout this time. A final evaluation of treatment efficacy is performed at 1 year. Monitoring of thyroid function is required for early detection and treatment of hypothyroidism. Prevention of overt hypothyroidism with early detection can avoid or decrease symptoms of GO.
Thyroidectomy by an experienced surgeon may be a life-saving procedure in thyroid storm if other therapies have been unsuccessful, resulted in significant adverse effects, or are contraindicated. In patients with vascular goiters, administration of Lugol solution may facilitate surgery by reducing goiter size and vascularity: give 3 to 7 drops of Lugol solution tid for 7 to 10 days before surgery.
In patients with large goiters titrate the dose up to 10 to 15 drops tid; 1 to 2 drops of SSKI tid can be given instead of Lugol solution. Evidence 4 Strong recommendation benefits clearly outweigh downsides; right action for all or almost all patients. High Quality of Evidence high confidence that we know true effects of intervention. Total thyroidectomy vs bilateral subtotal thyroidectomy in patients with Graves' diseases: a meta-analysis of randomized clinical trials.
Epub Apr Less extensive procedures carry a high risk of recurrence. Temporary complications, usually lasting several weeks to months, are more common and include hypoparathyroidism see Hypoparathyroidism and iatrogenic injury of the recurrent laryngeal nerve with resulting vocal cord paralysis most commonly unilateral and causing hoarseness; very rarely bilateral paralysis with serious respiratory compromise, which may require emergency tracheotomy.
Postoperative L-T 4 replacement therapy should be started immediately after surgery calculated dose 1. Treatment of Thyrotoxic Crisis Thyroid Storm. Start treatment immediately, without waiting for confirmation by laboratory tests.
Continue treatment at an intensive care unit. Both drugs may be specially prepared for rectal or IV use. Alternatively use IV iohexol 0. Administer oxygen as needed. Increase oxygen flow if necessary. Correct water-electrolyte disturbances while monitoring volume status and assess serum electrolyte levels every 12 hours.
Treat hyperthermia : Use noninvasive external cooling and acetaminophen INN paracetamol. Salicylates should be avoided as they displace T 4 from thyroid hormone—binding globulin, leading to an increase in FT 4. Aggressively treat the precipitating condition , such as infection, ketoacidosis, pulmonary embolism, or other conditions. Use thromboprophylaxis see Primary Prevention of Venous Thromboembolism if indicated, for instance, in atrial fibrillation, severe heart failure, or immobilization.
Plasmapheresis may be considered if there is no effect of treatment after 24 to 48 hours. Lithium carbonate has questionable efficacy. It decreases the secretion of thyroid hormones. Housten: : Rice University Kalhan A, Page M. Thyroid and parathyroid disorders. In: Whittlesea C, Hodson K, eds. Clinical Pharmacy and Therapeutics. London: : Churchill Livingstone The Lancet ; — The incidence of thyroid disorders in the community: a twenty-year follow-up of the Whickham Survey.
Clin Endocrinol ; 43 — Samuels M. Hyperthyroidism in Aging. Endotext [ebook]. South Dartmouth Clinical Knowledge Summaries: Hyperthyroidism. National Institute for Health and Care Excellence.
British Thyroid Foundation. Management of amiodarone-related thyroid problems. Therapeutic Advances in Endocrinology ; 2 — Thyroid function tests.
European Journal of Endocrinology ; :R— BMJ Best Practice. Diagnosis and management of thyrotoxicosis. BMJ ; :g—g British National Formulary online. Patients with thyroid storm require urgent stabilization in critical care settings with fluids, beta blockers , antithyroid medications propylthiouracil , potassium iodide , and parenteral glucocorticoids , active cooling, and management of tachyarrhythmias. Definitive therapy with RAIA or surgery is considered once they are stable.
While thyrotoxicosis and hyperthyroidism are often used interchangeably, the two terms are not synonymous. Overview of common etiologies in hyperthyroidism and thyrotoxicosis [2] [3] [4] [5] [6] [7] [8]. References: [11] [12].
Epidemiological data refers to the US, unless otherwise specified. References: [2] [13] [14]. The hypothalamus , anterior pituitary gland , and thyroid gland , together with their respective hormones , make up a self-regulating circuit known as the hypothalamic-pituitary-thyroid axis.
Indicated if the diagnosis remains uncertain after clinical assessment and initial evaluation. The choice and priority of studies depends on the clinical picture, patient characteristics and test availability. These additional tests are not routinely required but may be performed depending on the suspected underlying etiology. The symptoms of thyrotoxicosis are nonspecific and overlap significantly with other common conditions.
If there is any clinical uncertainty, TSH should be assessed. References: [2] [4] [5] [6] [7] [8] [14]. The treatment of hyperadrenergic symptoms is important for decreasing the risk of cardiac complications in thyrotoxicosis , such as atrial fibrillation and heart failure. Antithyroid drugs can effectively render a patient euthyroid.
The efficacy of antithyroid drugs and RAIA has reduced the need for thyroid surgery. Suspect a molar pregnancy or choriocarcinoma if severe hyperthyroidism manifests during pregnancy! References: [33] [34] [35]. Thyroid storm has a high mortality rate and patients should receive aggressive treatment to manage complications and restore normal thyroid function.
If thyroid storm has led to congestive heart failure , esmolol is the preferred beta blocker. All patients receiving beta blockers should be monitored carefully for signs of heart failure. Expand all sections Register Log in. Trusted medical expertise in seconds. Find answers fast with the high-powered search feature and clinical tools. Try free for 5 days Evidence-based content, created and peer-reviewed by physicians.
Read the disclaimer. Hyperthyroidism and thyrotoxicosis. Summary Thyrotoxicosis refers to the symptoms caused by the excessive circulation of thyroid hormones. Definition While thyrotoxicosis and hyperthyroidism are often used interchangeably, the two terms are not synonymous. A Clinician's Guide.
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