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Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_2899_Библиотеки_им_академика_М_И_Перельмана

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Fig.18.1Exampletreatmentalgorithm.
VTE,venousthromboembolism.
Treatmentafterstabilization
Checkserumosmolality2-hourlyforthefirst6hours,andthen4-hourly(ifimproving)forthenext 12hours.Afterthefirst24hours,bloodscanbecheckeddailyifimproving Bloodglucoselevelshouldbecheckedhourlyforthefirst24hours.Target:10–15mmol/L inthe first24hours DiscontinueIVinsulinwhenthepatientiseatinganddrinking Continuetoassessfluidbalance—aimfor3–6Lpositiveby12hoursbutcheckforsignsoffluid overloadorcerebraloedema Dailyfootchecksduetohighriskofpressureulceration.Considerusingheelprotectors Itmaytakeupto72hoursforelectrolytesandosmolalitytoreturntowithinnormalrange Continueanticoagulationwhilepatientisrecovering Refertospecialistteam.
Furtherreading
1. ‘Hyperglycaemic Emergencies’—online lecture material by Dr S Nag for the Royal College of
Physicians.Availableat:https://www.rcplondon.ac.uk/file/6424/download?token=D9VhtcgX
1 Pasquel FJ, Umpierrez GE. Hyperosmolar hyperglycemic state: a historic review of the clinical
presentation,diagnosis,andtreatment.DiabetesCare.2014;37:3124–31.
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Chapter19
Hyperthyroidism
Guideline: NICE NG145 (Thyroid disease: assessment and management):
https://www.nice.org.uk/guidance/ng145
OUPdisclaimer:OxfordUniversity Press makesno representation, express or implied, that the drugdosagesarecorrectand thatthe recommendations are an exclusive or mandatory course of care. All health professionals readingthistexthavearesponsibilitytoevaluateitsappropriatenessandtake theindividualneedsofthepatientintoaccount.
Localtrustguidelines:pleaserefertoyourlocalguidelinesasnecessary.
Overview
Hyperthyroidismisacommonconditionwhichaffectsapproximately2%ofwomenand
0.2% of men in the UK and occurs due to an overproduction of thyroid hormones. Initially, symptoms may develop insidiously which can make diagnosis challenging. Untreated, symptoms become more severe and can become disabling and even life­threatening.Inthelong-term,untreatedhyperthyroidismleadstoincreasedcardiovascular morbidityandmortalityandpatientsareatanincreasedriskofdevelopingosteoporosis. Itisthereforevitaltorecognisesymptomsearlyinordertomakeatimelydiagnosisand initiatemanagement.
Diagnosis
Causes
Hyperthyroidismmaybecausedby:
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Graves’disease(75%) Toxicnodularhyperthyroidism—toxicadenomaandtoxicmultinodulargoitre(15%) Thyroiditis(10%);silent,postpartum,subacute(viral) Druginduced(amiodarone,checkpointinhibitors,interferon) Pituitaryadenoma Otherrarecauses.
Itisessentialtoestablishthecausesothatappropriatemanagementcanbecommenced.
History
Cardiovascular
Palpitations ↑perspiration Light-headedness.
Gastrointestinal
↑appetite Diarrhoea Weightloss.
Neurological
Difficultysleeping Tremor Anxiety Irritability Hyperactivity Fatigue Heatintolerance.
Other
Oligomenorrhea Thyroid eye disease (TED) in Graves’ disease (Box 19.1)—red, gritty, bulging eyes, light sensitivity,doublevision,lossofvision()—seekurgentexpertadvice Thyroiditis—fever,thyroidpain,malaise,recentviralillness,postpartum.
Box19.1Thyroideyedisease
TED is an autoimmune condition, most commonly associated with Graves’ disease,
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which can leadto blindness.Itcan develop beforeor afterthyroidsymptomsdevelop andsmokingincreasestherisk.
Examination
RedflagsforpossiblethyroidmalignancyarelistedinBox19.2.
Cardiovascular
Warm,sweatytotouch Irregularpulse Tachycardia.
Thyroid
Goitre—diffuseornodular Tenderness(suggeststhyroiditis) Thyroidbruit.
Neurological
Tremor Proximalmyopathy Hyperreflexia.
Other
TED—exophthalmos,diplopia,lidlag Pretibialmyxoedema Thyroidacropachy Thyrotoxicperiodicparalysis.
Box19.2Redflagsforthyroidmalignancy
Rapidnodulargrowth Shortnessofbreath Hoarsevoice Swallowingdifficulties.
Source:datafromNICENG145.
Investigations
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The main aim of the investigations is to determine the aetiology as this determines the long-term management. It is important to differentiate between thyroiditis (usually transient and self-limiting) and other causes of hyperthyroidism that require definitive treatment.InterpretationofinvestigationfindingsarelistedinTable19.1.
Bedside
ECG—AForsinustachycardia.
Bloods
TSH(suppressedinprimaryandelevatedinsecondaryhyperthyroidism) Freethyroxine(FT4)/triiodothyronine(FT3) FBC/U&E/LFT/CRP—toexcludeothercauses TSH-receptorantibodies(Graves’disease) ESR—raisedinthyroiditis.
If a patientis acutely unwell with a non-thyroidal illness, do not routinely use TFT as the resultsmaybeunreliable.
Imaging
Radioisotopescanning Ultrasoundifpalpablethyroidnodule.
Table19.1Investigationfindingsindifferentcausesofhyperthyroidism
Investigation Graves’disease Toxicnodular
hyperthyroidism
Thyroiditis
Bloods TSHundetectable
FT4andFT3raised OnlyFT3raisedinT3 toxicosis
TSHundetectable FT4andFT3raised OnlyFT3raisedinT3toxicosis
TSHundetectable FT4andFT3raised RaisedESR/CRP
Antibodies TSH-receptorantibodies
raised TPOantibodiesmayberaised
TPOantibodiesmaybe raised
Radioisotope scan
Diffuseuptake Focalpatternofuptake Minimaluptake
TPO,thyroidperoxidase.
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Management
Referallpatientstoanendocrinologistforfurtherassessment.
Patienteducation
Discuss the function of the thyroid gland and the risks of over- and undertreatment. Explaintheimportanceoftreatmentcomplianceevenwhenasymptomatictoavoidlong­term complications. Explain the need for routine monitoring. Risks of various managementoptionsarediscussedinTable19.2.
Lifestyleandsimpleinterventions
Smokingcessation(particularlyifTED) Seleniumsupplements(particularlyifTED).
Pharmacologicalmanagement
Thionamide:
Carbimazoleisfirstline(propylthiouracilifpregnant)
Monotherapy(titrateddoseofcarbimazole)OR
‘Blockandreplace’(higherdoseofcarbimazole,addlevothyroxinewhenneeded) Radioiodine Beta-blockersforadrenergicsymptoms.
Surgicalmanagement
Thyroidectomy/hemithyroidectomy.
Graves’disease
Radioiodineis usuallyrecommendedasfirstlinebutthionamides canbe offeredasfirstlinein mild,uncomplicateddiseaseorifradioiodineisunsuitable Thionamidesmaybegivenasa12–18-monthcourse Ifthereareconcernsaboutcompressionormalignancy,surgeryshouldbeofferedfirstline(once euthyroidismisachievedwiththionamidetreatment).
Toxicnodularhyperthyroidism
Radioiodineisfirstlineunlessunsuitable Surgicalorlong-termantithyroidmedicationsaresecondline Forcasesofasinglenodule,radioiodineorhemithyroidectomyarefirst-lineoptions.
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Thyroiditis
Supportivemanagement,e.g.simpleanalgesia.
Table19.2Risksofhyperthyroidismmanagementoptions
Radioiodine Surgery Antithyroiddrugs
Risks
Long-termhypothyroidismlikely Short-term radiation protection required Avoidance of pregnancy/fathering a childinnearfuture Newor worseningthyroideye disease particularly if untreated hypothyroidism
Invasive and requires general anaesthetic Long-term hypothyroidism Scarring Swallowing and breathingdifficulties Voicechange Hypoparathyroidism
Long-term cure rate 50% Graves’ disease (but lower for nodule/multinodulargoitre) Carbimazole: Agranulocytosis Pancreatitis Birthdefectsiftakeninpregnancy Propylthiouracil: Agranulocytosis Liverfailure Need for regular bloods and follow-up appointments
Source:datafromNICENG145.
Monitoringandfollow-up
Thionamidetherapy
CheckFBCandLFTbeforestarting—onlyrecheckifunwell Warn patient regarding risks and give written advice (1. agranulocytosis, 2. pancreatitis, 3. teratogenic) Stoptherapyimmediatelyifthepatientdevelopsagranulocytosis() CheckTSH/FT4every6weeksuntilTSHiswithinthereferencerange,titratingasappropriateto thelowestdoserequiredtomaintainTSHinreferencerange,thencheckTSHevery3monthsuntil thetherapyisstopped(12–18monthsdependingonregimen) After stopping therapy—measure TSH within 8 weeks of stopping, 3-monthly for a year, then annuallythereafterorsoonerifsymptomsofrecurrenthyperthyroidism.
Ifreceivingthionamides,ariseinTSHorfallinFT4shouldleadtoareductionorwithdrawal inthionamidedose.
Radioiodinetherapy
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CheckTSH/FT4/FT3every6weeksforthefirst6monthsuntilTSHiswithinthereferencerange WarnandmonitorforevidenceofTED MeasureTSHat9and12monthsandthenevery6monthsthereafter Offerlevothyroxinetothosewhodevelophypothyroidism Ifhyperthyroidismpersists,offerantithyroiddrugsandfurtherradioiodine6monthsposttreatment.
Surgicaltherapy
Offerlevothyroxinetoallpatients:
<65 years and no history of cardiovascular disease: starting dose 1.6 micrograms/kg/day, roundedtothenearest25micrograms
≥65yearsorhistoryofcardiovasculardisease:startingdose25–50micrograms/day MeasureTSHpostoperativelyandthenannuallythereafter Measurecalciumpostoperativelyandreplaceasrequired(maybeshort-term).
Specialconsiderations
Subclinicalhyperthyroidism
OccurswhenTSHissuppressedbutT3/T4levelsarewithinthenormalrange(Box19.3).
Box19.3InterpretationofTSHlevelsinsubclinicalhyperthyroidism
A TSH level >0.1mIU/L is more likely to be related to non-thyroidal illness than hyperthyroidism ATSHlevel<0.1mIU/Lismorelikelytobeduetomildhyperthyroidism.
Management
SeekspecialistadviceifpatienthastwolowTSHreadingsatleast3monthsapartandevidenceof thyroiddisease IfuntreatedandTSHpersistentlyoutsidethereferencerange,considertestingTSH/FT4/FT3every 6months.
Amiodarone
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Amiodarone therapy may cause hyperthyroidism (amiodarone-induced thyrotoxicosis (AIT)) or hypothyroidismduetoitshighiodinecontent Inpatientswithunderlyinghyperthyroidism(includinglatentGraves’disease),theymaydevelop type1AITafterstartingamiodarone.Thisrequiresthionamidetherapy In previously euthyroid individuals whotakeamiodarone(often for several months/years), they maydeveloptype2AITcausedbythyroiditis.Oftenpatientsrecoverafterseveralmonthsandmay subsequentlyexperiencehypothyroidismbeforetheirthyroidhormonelevelsnormalize.Thistype sometimesrespondstosteroidtherapy.
Thyroidstorm
Thyroid storm manifests with signs of severe hyperthyroidism resulting in multisystem decompensation. This represents a life-threatening emergency and may be triggered in patients withhyperthyroidism(maybepreviouslyundiagnosed).Triggersincludeinfectionorsurgery.
Secondaryhyperthyroidism
Secondary hyperthyroidism causesanormalorraisedTSHlevel.Thismaybeduetoapituitary tumourthatproducesTSHorresistancetopituitaryhormones If secondary hyperthyroidism is suspected, it is important tocheck visual fields andrequest an MRIbrain.
Elderly
Often present with weight loss, depression, and cardiovascular features, such as AF and deteriorationofpre-existingcardiacdisease.
Pregnancy
All pregnantpatientswithhyperthyroidism should see a specialistas theymay needantithyroid drugdosereduction Patients on a ‘block and replace’ regimen should be switched to a maintenance regimen and patientsoncarbimazoleshouldbeswitchedtopropylthiouracil Duringpregnancy,targetFT4levelsshouldbeatupperendofthereferencerangeduetotherisk hypothyroidismposestothefetusand↑ratesofmiscarriageandprematuredelivery Hyperemesisgravidarummaybeassociatedwiththyrotoxicbiochemistrybutthisresolveswithout treatmentwhenhyperemesissettles.
Furtherreading
1.BoelaertK(2018).Thyroidhormonemetabolism.In:TurnerHE,EastellR,GrossmanA(eds)Oxford
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