Baseline serum thyroid stimulating hormone (TSH) normal suppressed - - PowerPoint PPT Presentation

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Baseline serum thyroid stimulating hormone (TSH) normal suppressed - - PowerPoint PPT Presentation

Dec 29, 2022 565 likes •721 views

Johannes Gutenberg University Medical Center, Mainz, Germany GRAVES DISEASE George J Kahaly, MD, PhD Hyperthyroidism Causes / Types Graves disease > 60% Toxic nodular goiter < 30% Subacute thyroiditis (early) 5-10%

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SLIDE 1

Johannes Gutenberg University Medical Center, Mainz, Germany

GRAVES‘

DISEASE

George J Kahaly, MD, PhD

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SLIDE 2

Hyperthyroidism – Causes / Types

 Graves’ disease

> 60%

 Toxic nodular goiter

< 30%

 Subacute thyroiditis (early)

5-10%

 Other

< 1-2%

  • Nutritional / Drugs / Intoxication
  • Transient neonatal
  • Inherited TSH receptor mutations
  • Thyroid hormone resistance (thyrotoxic variant)
  • TSH secreting pituitary adenoma
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SLIDE 3

Baseline serum thyroid stimulating hormone (TSH)

suppressed normal

Euthyroidism

Thyroid stimulating immunoglobulins (TSI) positive negative

Graves´ hyperthyroidism Other causes of thyrotoxicosis (e. g. toxic nodules, thyroiditis)

Earlier Differential Diagnosis for Thyrotoxicosis

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SLIDE 4

TSH-Receptor Graves’ disease 90-99%

Silent thyroiditis 0-10%

Peroxidase Graves’ disease 70-80%

Silent thyroiditis 90-95%

Thyroglobulin Graves’ disease 20-40%

Silent thyroiditis 30-50%

THYROID AUTOANTIBODIES

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SLIDE 5 Vaidya & al., Clin Endocrinol 2008; 68: 814
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SLIDE 6

Cooper, N Engl J Med 2005

Methimazole Propylthiouracil

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SLIDE 7

Pharmacology

MMI PTU

  • Absorption

rapid rapid

  • Bioavailability

~ 100% ~ 100%

  • Peak serum level

60-120 min 60 min

  • Serum half life

6-8h 90 min

  • Duration of action > 24h 8-12h
  • Thyroidal concentration 5x10-5 mol/L unknown
  • Thyroidal turnover slow

moderate

Cooper, NEJM 2005; Brent, NEJM 2008
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SLIDE 8

Pharmacokinetics

Cooper, NEJM 2005; Brent, NEJM 2008

MMI PTU

  • Serum protein binding nil

85 %

  • Crosses placenta

++ +

  • Levels in breast milk ++

+

  • Volume of distribution

40 L 20 L

  • Excretion

renal renal

  • Metabolism during illness
  • renal

nil nil

  • liver

prolonged nil

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SLIDE 9

Antithyroid Drugs DOSE (mg /day)

Starting Maintenance

Methimazole 10-30 2.5-5 Propylthiouracil 100-300 25-50 Perchlorate 600-1200 100-400 Lithium 450-900 300

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SLIDE 10

SIDE EFFECTS

  • f

ANTI - THYROID DRUGS

Cooper, NEJM 2005

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SLIDE 11

„BLOCK and REPLACE“

McIver & al. NEJM 1996

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SLIDE 12

Occurence of Ophthalmopathy after treatment for Graves‘ hyperthyroidism

Tallstedt & al., N Engl J Med 1992; 326: 1733

Relative Risk 4.1

95% CI 1.7 – 10.0 P = 0.002

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SLIDE 13

ß-Adrenergic Blocking Drugs

(mg/day) Starting dose

  • Propranolol

80 - 160

  • Atenolol / Metoprolol

50 - 200

  • Nadolol 40 - 80
  • Bisoprolol

2.5 - 5 ► Relief from palpitations, tremor, anxiety ! Caution: Asthma, bradyarrhythmia

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SLIDE 14

Comparison between intravenous and oral

glucocorticoids for Graves’ orbitopathy

%

Kahaly & al., JCEM 2005

10 20 30 40 50 60 70 80

Response rate Side Effects

IV

P < 0.001

Oral