Thyroid Clinic 2017 · Thyroid Association for the diagnosis and management of thyroid disease...
Transcript of Thyroid Clinic 2017 · Thyroid Association for the diagnosis and management of thyroid disease...
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ThyroidClinic2017
DianaMcNeillMD,FACPProfessorofMedicine
DivisionofEndocrinologyandMetabolismDukeUniversityMedicalCenter
Disclosures
• Ihavenoconflictsofinteresttoreportatthistime
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Intheclinic…
• 35yearoldfemalewithnosignificantpastmedicalhistory.
• Notes“lump”onherneckonemorningwhilebrushingherteeth
• Hasnothadanydifficultyswallowingorneckpain
• Nohistoryofneckirradiation• Motherhadsomethyroidproblems
Whatotherquestionswouldyouasktoassessthyroidstatus?(Checkallthatapply.)• Skinorhairchanges• Temperatureintolerance• Discoloredurine• Weightchanges• Emotionallability• Decreasedhearing• Changesinbowelpatterns• Useofcomplementaryoralternativemedications
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Physicalexam
• Wellappearing• BP110/70P72RR16• HEENT:nolidretractionorstare• Thyroid:visiblerightthyroidnodule;moveseasilywithswallowing
• 1.5cmindiameter;nolymphadenopathy• Cardiac:regularrateandrhythm,nomurmur• Remainderofexamnormal
Laboratory
• WBC7,500• TSH3.2uIU/ml(0.34-5.66uIU/ml)• FT40.9ng/dl(0.52- 1.21ng/dl)• Antimicrosomalthyroidantibody-negative
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Whatisthenextstepinhermanagement?
• ThyroidUS• USdirectedFineNeedleAspirate(FNA)ofnodule
• Recheckthyroidexamandlabsin6mos• Reassureandtellpatienttohavethyroidcheckedagaininoneyear
1. 1/15 women have a thyroid nodule2. 1/40 men have a thyroid nodule3. 90% benign4. Thyroid cancer incidence has been increasing
Haugen,Alexander,etal., Thyroid.Jan2016,26(1):1-133.
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ThinkBENIGN
• FamilyhistoryofHashimoto’sthyroiddisease• Hyperorhypothyroidism• Pain• Mobile,softnodule• CystonUS• Hotnoduleonthyroidscan
BenignThyroidNodules
• Cysts• Adenomas• Thyroiditis• Other:Riedelsstruma,painlessthyroiditis
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SuppressiveTherapy
• Novalueofsuppressivetherapy• (3meta-analysis,severalrandomizedcontroltrials)
• Benefitiniodine-depleteddiets
Thyroid,TheAmericanThyroidAssociationGuidelinesTaskforce.2006,109-142.
ThinkMALIGNANT
• Agelessthan20orgreaterthan70• Male• Hoarseness• Externalneckirradiation• Firmfixednodule• Coldonscan• Cervicallymphnodes
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2017Guidelines
• Norecommendationtoscreenunlesshighrisk
USPTF
WorrisomeUltrasoundFindings
• Microcalcifications• Hypervascularity• Hypoechogenicity(Darker)• Irregularborders• Tallerthanwide
Haugen,Alexander,etal., Thyroid.Jan2016,26(1):1-133.
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Followup
• PatientunderwentUSdirectedFNAofrightthyroidnodule
• Pathology:colloidnodule• RepeatthyroidUSinoneyeartoconfirmstabilityofnodule
FNA
• Nondiagnostic:REPEATwith50%successonrepeat;Nosoonerthan3months
• Benignwithcolloid:GOOD• Malignant:ExceptfollicularandHurtleCellcarcinomacannotbediagnosedbyFNA
• Suspicious:SURGERY…25%malignant
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ThyroidCancer
• Papillary60%• Follicular12%• FollicularVariantofpapillary6%• Medullary• Anaplastic• Lymphoma
MultinodularGoiter
• Sameriskofmalignancyasthosewithsolitarynodule
• Aspirationofonlypredominantnodulemaymissmalignancy
• Ultrasoundcharacteristicssuperiortosizeindiagnosingmalignancy
.Haugen,Alexander,etal., Thyroid.Jan2016,26(1):1-133.
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BenignThyroidNoduleFollow-up
• Palpable- 6-18monthclinicalfollow-up• Notpalpable- serialUS6-18monthsafterFNA
• Ifstablesize- subsequentfollow-upmaybelonger
• Iflargernodule- repeatFNA
Haugen,Alexander,etal., Thyroid.Jan2016, 26(1):1-133.
TakeHomePoints
• 7-15%ofthyroidnodulesaremalignant• Incidenceofthyroidcancerincreasinginpartduetoimprovedimagingtechniques
• ThyroidUScanhelpidentifyhighrisknodules• FNAofnodulenecessaryfordiagnosisbasedonsize,shape,appearance,otherriskfactors.
Haugen,Alexander,etal., Thyroid.Jan2016,26(1):1-133.
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27yearoldfemaleG3P3Ab0withgoiter
• 6monthspostpartum• Notbreastfeeding,mensesnotyetresumed• Isbeingtreatedforpostpartumdepression
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Physicalexam
• Anxiousappearingfemale,jittery• BP150/70P110regularRR18T99°F• Bilateralstarewithlidretraction• Visiblethyroid• Thyroidbruitappreciated• COR:RRR,S1S2noS3,S4• Bilateralrestingtremorupperextremities
• FT46ng/dl(0.52-1.21ng/dl)• FT3normalrange• TSHundetectable• Positivethyroidstimulatingimmunoglobulin• Positivethyroidperoxidaseantibodies• WBC9,400Hemoglobin12• Negativeurinepregnancytest
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Whatarethepossiblecausesofherabnormalthyroidlaboratories?
• Grave’sDisease• Post-partumthyroiditis• Laberror• Toxicmultinodulargoiter• Depression
Clinicalevaluation
• Nodulargland• Thyroidscananduptake-1-2%(low)
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Thyroidchangesinpregnancy
• TSHhassimilarstructuretopregnancyhormoneBHCG,whichmayhaveslighteffectonthyroid
• Increaseinthyroidbindingglobulinwhichincreasestotalhormonelevels
• FT4andFT3levelsremainunaffected
Fetalthyroid
• Notsynthesizingthyroidhormoneuntil18weeksgestation
• Priortothattimedependsonmother’sthyroidhormone
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Abnormalthyroidfunctioninpregnancy
• Earlyrecurrentmiscarriage• Subclinicalhypothyroidism(elevatedTSHwithnormalFT4andFT3)mayneedtobetreated.
CurrentOpinioninObstetrics&Gynecology:December2015- Volume27- Issue6- p406–415
Thyroidlevelsinpregnancy
• FirsttrimesterTSH<2.5mIU/ml• SecondtrimesterTSH<3.0mIU/ml• 15%ofpregnantwomenhavesubclinicalhypothyroidism.
Thyroid.2011.21:1081-1125
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ShouldSubclinicalhypothyroidismbetreatedinpregnancy
• Cochranereview-No2013• SystematicReview- maybe2016
Thyroid.2016.26:580-589CochraneDatabaseSystRev5:CD007752
Diagnosis
• Thyroiditis:Postpartum• Needtor/oGrave’sdisease• Grave’sDiseaseoftenhasanelevatedFT3/FT4
• Treatmentisdifferentdependentondiagnosis
TagamiT.,etal.TheincidenceofgestationalhyperthyroidismandpostpartumthyroiditisintreatedpatientswithGraves'disease.
Thyroid. 2007;17:767–772.
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ButifshehadGrave’sdisease…Whatarethesideeffectsof
methimazole?
• Rash• Transaminitis(abnormalliverfunctiontests)• Photosensitivity• Idiosyncraticleucopenia(rare)
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BreastFeeding?
• Canbreastfeedonmethimazoleupto20mgdaily
Stagnaro-GreenA,etal.GuidelinesoftheAmericanThyroidAssociationforthediagnosisandmanagementofthyroiddiseaseduringpregnancyandpostpartum.Thyroid.2011;21:1081-125,
PostpartumthyroiditisandDepression
• Noevidenceofclearassociation• NoevidencethattreatmentwithT4orT3hormonescanresolvedepressivesymptoms.
HarrisB.,etal.,Randomizedtrialofthyroxinetopreventpostnataldepressioninthyroid-antibody-positivewomen. BrJPsychiatry.2002;180:327–330.
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Backtoourpatient…
• Diagnosedwiththyroiditis• Propranolol10mgevery6hoursasneededforsymptomsofhyperthyroidism
• Rechecklabsin4-6weeks• Noindicationtostartantithyroidmedications
Takehomepoints
• Thyroiddiseaseismorecommoninwomen• Synthroiddosesneedtobeadjustedbothduringandafterpregnancyduetochangesinthyroidbindingprotein
• Autoimmunethyroiddiseaseoftencanpresentduringorafterpregnancy
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48y/ofemalewithhistoryofHypothyroidism
• Feelspoorly• 20poundweightgainoverpasttwoyears• Noenergy• Poorsleeppattern• Losinghair
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Medications
• Levothyroxine50microgramsdaily• Atorvastatin10mgdaily• Women’sMultivitaminonedaily
Physicalexam
• Tiredappearing,flataffect• BP110/75P80afebrile• HEENT:noexophthalmos• Neck:firmthyroidwithoutpalpablenodule• COR:RRRnoS3,S4,Nomurmur• Neuro:Brachioradialisreflexesslightlydelayed• Skin:norash• Remainderofexamnormal
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Whatwouldyoudotobeginevaluationofthispatient’sconcerns?
• TSH• FSH• TSHandFT4• Sed rate• 2and3
• TSH12uIU/ml(0.34-5.66uIU/ml)• FSH50uIU/ml(postmenopausal)• CBCnormal• Chemistriesacceptable
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Whatdoyounowaskthepatientbeforeadjustingherlevothyroxine
dose?
• Misseddoses• Takingseparatelyfromcalcium,statin,iron,protonpumpinhibitor
• Changedbrandsofthyroidhormonereplacement
• Additionalsymptoms:missedmenses,hotflushes,checkforpregnancy
• Biotinuse
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ThyroidPhysiology
• Thyroxine(T4)andtriiodothyronine(T3)arereleasedbythethyroidgland.
• MostoftheT3isfromperipheralconversionofT4toT3.
• FreeT4andfreeT3(notboundtoproteins)feedbacktothepituitaryandhypothalamustoaffectthyroidstimulatinghormonerelease(TSH)fromthepituitary.
Hypothyroidismtreatment
• T4usedbecauseoflonghalflife• T3(Cytomel)mustbegivenseveraltimesaday
• NogoodevidenceforcombinationT4/T3replacement
JonklaasJ,etal.Thyroid. 2014Dec;24(12):1670-751.ThyroidAssociationTaskForceonThyroidHormoneReplacement.
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ThyroxineDose
• 1.6ug/kgdaily• Staywithsamebrandorgeneric(mayhavedifferentcosts)
• Increasethedoseforpregnancyorotherconditionswithincreasedbindingglobulin
• Decreasedosefor– Elderly– Patientswithknownheartdisease– Patientswithsignificantcomorbidhealthissues
Whentorecheckthyroidlabs
• 6-12weeks• TSHrecoverylagsbehindT4normalization
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MenopauseandtheThyroid
• Decreasingestrogenlevelsleadtodecreaseinthyroidbindingglobulin
• TherewillbemorefreehormoneavailablesooftenT4dosemayneedtobedecreased.
Otherthyroidpreparations
• Grains• Compoundedformulations• T3• Other
JonklaasJ,etal.Thyroid. 2014Dec;24(12):1670-751.ThyroidAssociationTaskForceonThyroidHormoneReplacement.
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Backtoourpatient
• Pregnancytestisnegative• Menopausalsymptomsdiscussedwithpatient
• Exerciseencouraged• Levothyroxineincreasedto75mcgdaily• Repeatthyroid(TSH)labsorderedfor3mos.
Takehomepoints
• Hypothyroidismsymptomsarecommontomanyotherconditions.
• T4istheacceptedreplacementhormoneatthistimeforhypothyroidism.
• T4replacementmustbetakenatseparatelyfromothermedicationsthatmaydelayabsorption