Hipertiroidisme

Kepaniteraan ilmu penyakit dalamRSUD CILEGON – UNIVERSITAS YARSI

DEFINISI (Sudoyo,W Aru,dkk.2006)

TIROTOKSIKOSIS •Manifestasi klinis kelebihan hormon tiroid yang beredar dalam sirkulasi

HIPERTIROID •Tirotoksikosis yang diakibatkan hiperaktifitas dari kelenjar tiroid

Tirotoksikosisvs

hipertiroidisme

• Apapun sebabnya, manifestasi klinisnya sama• Efek ini disebabkan ikatan T3 dengan T3-inti

makin penuh

(Sudoyo,W Aru,dkk.2006)

THE THYROID GLAND

www.univ-st-etienne.fr/lbti/Mednucl/AtlasEnd/thyroide/

O OH

I

I

IIOH

O

NH2

Thyroxine (T4)

O OH

I

I

IOH

O

NH2

3,5,3’-Triiodothyronine (T3)

THYROID HORMONES

FEEDBACK REGULATIONTHE HYPOTHALAMIC-PITUITARY-THYROID AXIS

Hormones derived from the pituitary that regulate the synthesis and/or secretion of other hormones are known as trophic hormones.

Key players for the thyroid include:

TRH - Thyrophin Releasing Hormone

TSH - Thyroid Stimulating Hormone

T4/T3 - Thyroid hormones

PITUITARY-THYROID AXIS

HM Goodman, BASIC MEDICAL ENDOCRINOLOGY 3rd Ed.

– –

+

Negative Feedback Loop

• Thyroid Disease Can Have Widespread Effects

Thyroid

• Increased LDL Cholesterol

• ElevatedTriglycerides

Liver

• Constipation

• Decreased GI

Activity

Intestines

• Decreased Fertility

• Menstrual Abnormalities

• May Harm Development of Infant

ReproductiveSystem

• Depression• Decreased Concentration• General Lack of Interest

Brain

• Decreased Heart Rate• Increased/Decreased

Blood Pressure• Decreased Cardiac

Output

Heart

• Decreased Function• Fluid Retention and

Edema

Kidneys

Thyroid Disease AffectsMany Body Systems and Overall Health

Hormon tiroid berfungsi untuk mengendalikan kecepatan metabolisme tubuh. Hormon tiroid mempengaruhi kecepatan metabolisme tubuh melalui dua cara :1. Merangsang hampir setiap jaringan tubuh untuk menghasilkan protein.2. Meningkatkan jumlah oksigen yang digunakan oleh sel. (fitriani,2010)http://yosefw.wordpress.com/2008/06/10/penggunaan-obat-antitiroid-pada-pasien-hipertiroidisme/

etiologi

•

Etiologi

Hipertiroidisme primer : penyakit Graves, struma multinodosa toksik, adenoma toksik, metastasis karsinoma tiroid fungsional, struma ovarii, mutasi reseptor TSH, obat kelebihan yodium (fenomena Jod Basedow). 2

Tiroiditis silent, destruksi tiroid (tanpa amiodarone, radiasi, infark adenoma), asupan hormon tiroid yang berlebihan (tirotoksikosis factitia) 2

Hipertiroidisme sekunder: adenoma hipofisis yang mensekresi TSH, sindrom resistensi hormon tiroid, tumor yang mensekresi HCG, tirotoksikosis gestasional 2

Lebih dari 90 % hipertiroidisme adalah akibat penyakit graves dan nodul tiroid toksik.

Signs and Symptoms Of HyperthyroidismSigns and Symptoms Of Hyperthyroidism

Bulging Eyes/Unblinking Stare

Menstrual Irregularities or

Light Period

Excessive Vomiting in Pregnancy

First-Trimester Miscarriage

Family History of

Thyroid Disease

or Diabetes

Nervousness

Irritability

Difficulty Sleeping

Swelling (Goiter)

Frequent Bowel Movements

Warm, Moist Palms

Hoarseness orDeepening of Voice

Difficulty Swallowing

Rapid or Irregular Heartbeat

Infertility

Weight Loss

Heat Intolerance

Increased Sweating

PersistentSore or Dry Throat

Common Signs and Symptomsof Hyperthyroidism

• Nervousness• Irritability• Difficulty Sleeping• Bulging Eyes• Unblinking Stare• Goiter• Rapid Heartbeat

• Increased Sweating• Heat Intolerance• Unexplained Weight Loss• Scant Menstrual Periods• Frequent Bowel Movements• Warm, Moist Palms• Fine Tremor of Fingers

May Include:May Include:

TABLE1.MAJOR SYMPTOMS AND SIGNS OF HYPERTHYROIDISM AND OF GRAVES’ DISEASE AND CONDITIONS ASSOCIATED WITH GRAVES ‘DISEASE 5

Manifestations of hyperthyroidismSymptomsHyperactivity, irritability, altered mood, insomniaHeat intolerance, increased sweatingPalpitationsFatigue, weaknessDyspneaWeight loss with increased appetite (weight gainin 10 percent of patients)PruritusIncreased stool frequencyThirst and polyuriaOligomenorrhea or amenorrhea, loss of libidoSignsSinus tachycardia, atrial fibrillationFine tremor, hyperkinesis, hyperreflexiaWarm, moist skinPalmar erythema, onycholysisHair lossMuscle weakness and wastingCongestive (high-output) heart failure, chorea, periodicParalysis (primarily in Asian men), psychosis*

Manifestations of Graves’ diseaseDiffuse goiterOphthalmopathyA feeling of grittiness and discomfort in the eyeRetrobulbar pressure or painEyelid lag or retractionPeriorbital edema, chemosis, scleral injectionExophthalmos (proptosis)Extraocular-muscle dysfunctionExposure keratitisOptic neuropathyLocalized dermopathyLymphoid hyperplasiaThyroid acropachy

Conditions associated with Graves’ diseaseType 1 diabetes mellitusAddison’s diseaseVitiligoPernicious anemiaAlopecia areataMyasthenia gravisCeliac diseaseOther autoimmune disorders associated with the HLA-DR3Haplotype

Diagnosis

• Diawali oleh kecurigaan klinis. Berdasarkan indeks klinis Wayne and Newcastle yang didasarkan anamnesis dan pemeriksaan klinis yang teliti.

• Dilanjutkan dengan pemeriksaan penunjang untuk konfirmasi diagnosis anatomis, status tiroid dan etiologi

diagnosis

• Untuk fungsi tiroid diperiksa kadar hormon beredar TT4, TT3, dalam keadaan tertentu sebaiknya fT4 dan fT3, dan TSH

Untuk fase awal penentuan diagnosis, perlu T4, T3, dan TSH

Namun pada pemantauan hanya T4 saja.

Investigations

• Thyroid function test:• TSH- Undetectable• T4 - Raised• T3 - Raised• RAIU- Raised• TSH-receptor antibodies(TRAb)-elevated in Graves’s

disease• Isotope scanning- Increased uptake

Treatment of Hyperthyroidism

A n ti thy ro id d ru gsB e ta b lo cke rs

M E D IC A L

S u b to ta l thy ro id ec tom y

S U R G IC A L

R ad io ac tive io d ineL ug o l's so lu tion

IO D IN E

H Y P E R T H Y R O ID IS MT ype t i t le he re

Anti thyroid drugs

• Chemically block hormone synthesis• Enhance evolution to remission• Best indicated for children,adolescents,young adults

and pregnant women.• Propylthiouracil-100-150mg every 6or 8 hrs• Carbimazole- 40-60mg daily initially for 3 weeks,then

reduce to 20-40mg for another 8 weeks and maintain at 5-20mg daily for 18-24 months.

• Methimazole-active metabolite of Carbimazole

Duration of treatment

• 18-24 months• Side effects- Rash Leukopenia Agranulocytosis

Control of adrenergic symptoms

• Adrenergic antagonists:• Propranolol-40-120mg/day

Ablative therapy(Surgery & Iodine)

• Indications:• Relapse or recurrance following drug therapy• A large goiter• Failure to follow medical regimen.• Radioactive iodine is simple,effective and

economical

Complications of ablative therapy

• Immediate complications of surgery:• Bleeding,injury to recurrant laryngeal nerve

and thyroid crises.• Other complications• Hypothyroidism• Radiation thyroiditis

Complications of thyrotoxicosis• 1)Cardiac- Heart failure Atrial fibrillation

• 2)Thyrotoxic crises: or ‘storm’:• Fulminating increase in signs and symptoms of

thyrotoxicosis.• Occurs in medically untreated or inadequately

treated patients.May be precipitated by surgery or sepsis

• The syndrome is characterized by extreme irritability,delirium or coma,fever 41°C or more,tachycardia,restlessness,hypotension,vomiting and diarrhea.

Treatment of thyroid crisis• Provide supportive care;• Treat dehydration• Administer glucose and saline• Vitamin B complex and glucocorticoids• Digitalization is required in those with atrial

fibrillation• Immediate and large doses of anti thyroid

agents(Eg-propylthiouracil 100mg every 2h)• Iodine intravenously or by mouth• Propranolol 40-80mg every 6h• Dexamethasone(2mg every 6h) and to be tapered

later.

Treatment of ophthalmopathy and Dermopathy

• Methylcellulose eye drops• Tinted glasses• Persistant diplopia can be corrected by surgery• Papilloedema,loss of visual field or acuity requires

urgent treatment with prednisolone 60 mg daily.• Majority of patients require no treatment other than

reassurance.• Dermopathy of Graves rarely requires treatment