Hyperthyroid is Med It

8/17/2019 Hyperthyroid is Med It

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HYPERTHYROIDISM

GRAVES‘ DISEASE

Dr HAKIMI SpAK

Dr MELDA DELIANA SpAK

Dr SISKA MAYASARI LUBIS SpA

Dr KARINA SUGIH ARTO SpA



PHYSIOLOGY



Background• Hypr!"yro#d#$% & o'rac!#'#!y o( !"

!"yro#d g)and )ad#ng !o *c$$#'$yn!"$#$ o( !"yro#d "or%on$ andacc)ra!d %!a+o)#$% #n !" pr#p"ra)!#$$u$

• T"yro!o*#co$#$ & !" c)#n#ca) ((c!$ o( anun+ound !"yro#d "or%on, -"!"r orno! !" !"yro#d g)and #$ !" pr#%ary

$ourc



.au$$ o( !"yro!o*#co$#$ #n c"#)d"ood

• Hypr!"yro#d#$% &D#((u$ !o*#c go#!r /Gra'$0 d#$a$1

Nodu)ar !o*#c go#!r /P)u%%r d#$a$1

• TSH2#nducd "ypr!"yro#d#$%&

TSH produc#ng p#!u#!ary !u%or

S)c!#' p#!u#!ary r$#$!anc !o !"yro#d "or%on

• T"yro!o*#co$#$ -#!"ou! "ypr!"yro#d#$%&

."ron#c )y%p"ocy!#c !"yro#d#!#$ /.LT1

Su+acu! !"yro#d#!#$

T"yro#d "or%on #ng$!#on



Pa!"ogn$#$• Gn!#c c)ona) )ack o( $uppr$$or T c))$ 3 T ")pr c))$

%u)!#p)y 3 B c))$ produc TSH rcp!or an!#+od#$&

3 TSH rcp!or an!#+od#$ +#nd !o TSH rcp!or$ /T"yro#dg)and1 3 T4 and T5 /.)#n#ca) pr$n!a!#on o( "ypr!"yro#d#$%13 /P#!u#!ary g)and1 66 TSH

3 7 TSH rcp!or an!#+od#$ +#nd !o TSH rcp!or$ #n r!ro2or+#!a) connc!#' !#$$u 3 T c))$ produc #n()a%%a!orycy!ok#n$ 3 G)yco$a%#nog)ycan$ 8 Ey %u$c) an!#+od#$7 3S-))#ng #n %u$c) and connc!#' !#$$u$ +"#nd y$ 3Op"!"a)%opa!"y



9r:uncy• In !" US & +cau$ Gra'$0 d#$a$ accoun!$ (or %or !"an

;<= o( c"#)d"ood ca$$ o( "ypr!"yro#d#$%, !" (r:uncy o(Gra'$0 d#$a$ appro*#%a!$ !" (r:uncy o( a)) ca$$ o("ypr!"yro#d#$%

• Pr'a)nc & >,>?= #n c"#)d"ood, accoun!#ng (or (-r !"an <=

o( !" !o!a) ca$$ o( Gra'$0 d#$a$

• A$$oc#a!d -#!" MH. )ocu$ /HLA2B@, HLA2DR24, and po$$#+)yHLA2DAC><>1 and po)y%orp"#$%$ o( cy!o!o*#c )y%p"ocy!an!#gn /.TLA125, an #%%unorgu)a!ory %o)cu) !"a! #$*pr$$d on !" $ur(ac o( ac!#'a!d )y%p"ocy!$ and #n"#+#!$

T2)y%p"ocy! ac!#'a!#on



9r:uncy• A$$oc#a!#on$ +!-n Gra'$0 d#$a$ and o!"r

au!o#%%un d#$a$$ ar -)) d$cr#+d and

#nc)ud a$$oc#a!#on$ -#!" DM, Add#$on$ d#$a$,

'#!#)#go, SLE, RA, %ya$!"n#a gra'#$, pr#od#c

para)y$#$, ITP, and prn#c#ou$ an%#a

• T"r #$ an #ncra$d r#$k o( Gra'$0 d#$a$ #n

c"#)drn -#!" Do-n $yndro% /!r#$o%y ?1 and

D#Gorg $yndro% /??: d)!#on1



Mor!a)#!y 8 Mor+#d#!y• E*c))n! progno$#$

• Nona!a) Gra'$0 d#$a$ #$ $)(2)#%#!d, !" progno$#$ #$ con$#dra+)y-or$ !"an !"a! #n o)dr c"#)drn T" pa!#n!$ ar pron !o pr%a!ur#!y,a#r-ay o+$!ruc!#on and "ar! (a#)ur T" %or!a)#!y ra! & a$ "#g" a$ F=

• Hyprca)c%#a #$ occa$#ona))y $n #n pa!#n!$ -#!" "ypr!"yro#d#$%

• 9%a) !o %a) ra!#o F !o @ &

• Prpu+r!a) c"#)drn !nd !o "a' %or $'r d#$a$, r:u#r )ongr%d#ca) !"rapy and ac"#' a )o-r ra! o( r%#$$#on co%pard -#!"pu+r!a) c"#)drn T"#$ appar$ !o + par!#cu)ar)y !ru #n c"#)drn -"o

pr$n! a! < yar$ o( ag



Ag

• Inc#dnc #ncra$$ !"roug"ou! c"#)d"ood,-#!" a pak #nc#dnc #n c"#)drn agd > 2

< yar$



Prd#$po$#ng (ac!or$• Genetic susceptibility (including HLA lleles!• St"ess• S#$%ing (especilly ss$cited &it' $p't'l#$pt'y!• e#le se) (se) ste"$id!• P$stp"tu# pe"i$d• I$dine (including #i$d"$ne!• Lit'iu#• R"e *ct$"s + Inte"*e"$n,- t'e"py

Hig'ly cti.e nti"et"$.i"l t'e"py

(HAART! *$" HIV in*ecti$n

/#pt' 0,H #$n$cl$nl ntib$dy (*$" #ultiple scle"$sis!



.)#n#ca) (a!ur$

CSy%p!o%$C• Hypr!"yro#d#$% & Ha! #n!o)ranc, $-a!#ng, pa)p#!a!#on$, prur#!u$,

dy$pna on *r!#on /*acr+a!#on o( a$!"%a1, -#g"!)o$$ /-#!" "yprp"ag#a1, -#g"! ga#n /rar)y1,"yprd(ca!#on, !r%u)ou$n$$ and !r%or,

-akn$$, (a!#gu, ur#nary (r:uncy, noc!ur#a, !"#r$!,an*#!y, %o!#ona) )a+#)#!y, #n$o%n#a, r$!)$$n$$,#na+#)#!y !o concn!ra!, o)#go%norr"a8a%norr"a,rrc!#) dy$(unc!#on8gynco%a$!#a, dy$pp$#a,nau$a, 'o%#!#ng /rar1



.)#n#ca) (a!ur$

CSy%p!o%$C• Op"!"a)%opa!"y &

Ey #rr#!a!#on, dryn$$, *c$$#' !ar#ng,

'#$ua) +)urr#ng, d#p)op#a, r!ro2or+#!a)

d#$co%(or!, pa#n on y %o'%n!, '#$ua)

)o$$



.)#n#ca) (a!ur$

CS#gn$C• Hypr!"yro#d#$% & ar%, $%oo!", %o#$! $k#n, onyc"o)#$#$

/)oo$n#ng o( !" na#) +d, P)u%%r$ na#)$1,pa)%ar ry!"%a, !"#nn#ng o( !" "a#r, $!ar,

)#d r!rac!#on /and )ag1, +r#g"!, $"#ny y$,!ac"ycard#a, a!r#a) (#+r#)a!#on, -#dnd pu)$pr$$ur, "yprdyna%#c c#rcu)a!#on, !r%or/(#ngr$1, "yprac!#' r()*$, pro*#%a)

%yopa!"y



.)#n#ca) (a!ur$

CS#gn$C

• Op"!"a)%opa!"y &

Pr#or+#!a) d%a, conJunc!#'a) ry!"%a,

c"%o$#$ /conJunc!#'a) d%a1, prop!o$#$,op"!"a)%op)g#a, )o$$ o( co)our '#$#on /op!#c

nuropa!"y1, pap#))d%a /op!#c nuropa!"y1



La+ora!ory 'a)ua!#on• Pa!#n!$ -#!" Gra'$0 d#$a$ "a' )'a!d )')$ o( T5, T4, and T4RU

and )o- or und!c!a+) )')$ o( TSH

• I( !" d#agno$#$ o( Gra'$ d#$a$ #$ unc)ar, TSH rcp!or A+$ $"ou)d+ %a$urd

• Tg and 8 or TPO A+$ ar o(!n pr$n! +u! ar )$$ $n$#!#' and $pc#(#c!"an TSH rcp!or A+$ #n !" d#agno$#$ o( Gra'$ d#$a$ #n c"#)d"ood

• Rad#oac!#' #od#n up!ak and $can ar nc$$ary !o con(#r% !"d#agno$#$ o( Gra'$ d#$a$ on)y #n a!yp#ca) ca$$ /(or *a%p), #(%a$ur%n! o( TSH rcp!or A+$ #$ nga!#' and #( !" !"yro!o*#cp"a$ o( #!"r .LT or $u+acu! !"yro#d#!#$ or (unc!#on#ng !"yro#d nodu)#$ $u$pc!d1 In Gra'$ d#$a$, !" up!ak #$ )'a!d and d#((u$



La+ora!ory 'a)ua!#on

• O+!a#n#ng a .B. +(or !" #n#!#a!#on o(an!#!"yro#d %d#ca!#on$ %ay + 'a)ua+) (or

$para!#ng pa!#n!$ -#!" undr)y#ng

Lukopn#a or !"ro%+ocy!opn#a (ro%

pa!#n!$ -"o d')op drug !o*#c#!y



T"rapy

• T" c"o#c o( -"#c" o( !" !"r !"rapu!#c op!#on$/%d#ca) !"8, rad#oac!#' #od#n, or $urgry1 !o u$$"ou)d + #nd#'#dua)#d and d#$cu$$d -#!" !"pa!#n! and "#$8"r (a%#)y

• Md#ca) !"rapy -#!" on o( !" !"#ourac#) dr#'a!$/PTU or MMI1 #$ !" #n#!#a) c"o#c o( %o$!pd#a!r#c#an$, a)!"oug" rad#o#od#n #$ ga#n#ng#ncra$#ng accp!anc, par!#cu)ar)y #n non2co%p)#an!ado)$cn!$, #n c"#)drn -"o ar %n!a))y r!ardd,

and #n !"o$ a+ou! !o )a' "o%



T"rapy

• PTU, MMI, and car+#%ao) /con'r!d !o MMI1*r! !"#r an!#!"yro#d ((c! +y #n"#+#!#ng !"

organ#(#ca!#on o( #od#n and !" coup)#ng o(

#odo!yro$#n r$#du$ on !" Tg %o)cu) !o

gnra! T4 and T5

• PTU +u! no! MMI, #n"#+#!$ !" con'r$#on o( T5 !o !"

%or ac!#' #$o%r T4, a po!n!#a) ad'an!ag #( !"

!"yro!o*#co$#$ #$ $'r



T"rapy

• T" u$ua) #n#!#a) do$ag o( MMI #$ >< %g8kg8dayg#'n onc or !-#c da#)y and !"a! o( PTU #$ <%g8kg8day g#'n !"r#c da#)y .ar+#%ao) #$ +$!g#'n #n a do$ o( >2?> %g !-#c or !"r#c da#)ydpnd#ng on !" concn!ra!#on o( (r T5

• In $'r ca$$, a +!a2adrnrg#c +)ockr/proprano)o), ><2?> %g8kg8day g#'n 'ry @ "1 can+ addd !o con!ro) !" . o'rac!#'#!y un!#) a

u!"yro#d $!a! #$ o+!a#nd



T"rapy

• T" $ru% concn!ra!#on$ o( T5 and T4nor%a)# #n 42F -k$, +u! TSHconcn!ra!#on %ay no! r!urn !o nor%a) un!#)$'ra) %on!"$ )a!r

• Appro*#%a!)y <>= o( c"#)drn -#)) go #n!o)ong2!r% r%#$$#on -#!"#n 5 yar$, -#!"con!#nu#ng r%#$$#on ra! o( ?<= 'ry ?

yar$ (or up !o F yar$ o( !ra!%n!



T"rapy

• Lo-r #n#!#a) dgr o( "ypr!"yro*#n%#a /T5 ?> ug8dL or ?<5 n%o)8L, T48T5 ra!#o ?>1,

BMI, and o)dr ag "a' +n a$$oc#a!d

-#!" an #ncra$d )#k)#"ood o( pr%ann!

r%#$$#on

• Pr$#$!anc o( TSH rcp!or A+$ #nd#ca!$ a

"#g" )#k)#"ood o( r)ap$



T"rapy

• Many au!"or$ a)$o rco%%nd c"ck#ng !"-"#! +)ood c)) coun! and )#'r (unc!#on !$!$

+(or !"rapy +cau$ Gra'$ d#$a$

#!$)( can + a$$oc#a!d -#!" a+nor%a)#!#$ #n

!"$ para%!r$



T"rapy

• Rad#oac!#' #od#n !"rapy $"ou)d + u$d-#!" cau!#on #n c"#)drn > yar$ o( ag

and par!#cu)ar)y #n !"o$ < yar$ o( ag or

)$$ +cau$ o( !" #ncra$d $u$cp!#+#)#!y

o( !" !"yro#d g)and #n !" young !o !"pro)#(ra!#' ((c!$ o( #on##ng rad#a!#on



T"rapy

• A)!"oug" a do$ o( <>2?>> u.# o( 4 I 8

$!#%a!d gra% o( !"yro#d !#$$u "a$ +n u$d,!" "#g"r do$ag #$ rco%%ndd, par!#cu)ar)y#n youngr c"#)drn, #n ordr co%p)!)y !o a+)a!!" !"yro#d g)and and !"r+y rduc !" r#$k o((u!ur nop)a$#a

• T" (or%u)a u$d #$& /$!#%a!d !"yro#d -#g"! #ngra%$1 * <>2?>> u.# 4 I 8 (rac!#ona) 4 I ?52"

up!ak1



T"rapy

• On u$ua))y $$ a !"rapu!#c ((c! -#!"#nF -k$ !o 4 %on!"$

• I( $#gn#(#can! op"!"a)%opa!"y #$ pr$n!, RAI!"rapy $"ou)d + u$d -#!" cau!#on, and

!ra!%n! -#!" cor!#co$!ro#d (or F2@ -k$

a(!r RAI ad%#n#$!ra!#on %ay + -#$



T"rapy

• Surgry #$ appropr#a! (or pa!#n!$ -"o "a' (a#)d%d#ca) %anag%n!, !"o$ -"o "a' %arkd)yn)argd !"yro#d, !"o$ -"o% r(u$ RAI, and (or !"rar pa!#n! -#!" $#gn#(#can! y d#$a$ #n -"o% RAI #$con!ra#nd#ca!d

• T" c"#)d %u$! + u!"yro#d +(or $urgry Iod#d$/Lugo)$ $o)u!#on, <2> drop$ !-#c a day, or po!a$$#u%#od#d, ?2> drop$ da#)y1 ar addd (or 25 day$ +(or$urgry #n ordr !o dcra$ !" 'a$cu)ar#!y o( !" g)and



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Hyperthyroid is Med It

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