1. Management of
hyperthyroidism
In ksa

2. Content
1
2
3
4
5
introduction
Epidemiology
Management and treatment
Conclusion and recommendation
Literature review

3. Introduction

4. thyroid disease is common affecting approximately 5% to 15
% of the general population.
Women are three to four times more likely than men to experi
ence any type of thyroid disease.
Triiodothyronine (T3) and thyroxine (T4) are the two biologica
lly active thyroid hormones produced by the thyroid gland in r
esponse to hormones released by the pituitary and hypothala
mus
The hypothalamic thyrotrophic-releasing hormone (TRH) stim
ulates release of thyrotropin .
Introduction

5. Cont,
TSH in turn promotes hormone synthesis and release by increasing
thyroid activity.
The intrapitutary DE iodination of T4 to T3 play critical role in the in
hibition of TSH section .
The serum concentration thyroid hormone decrease , the hypothala
mic-pituitary centers again become responsive by releasing TRH a
nd TSH .
T3 four times more potent than T4 but serum concentration is lower
.
T4 is the major circulating hormone secreted by the thyroid.
Hypothyroidism is a clinical syndrome that results from a deficiency
of thyroid hormone.
The incidence increases in persons older than 60 years , can cause
by either primary.

6. Epidemiology
 Background
Aim Methods
Total 71 Saudi adults’ m
ales and females were T
ested for Thyrotropin (TS
H) level using direct anti
gen EIA by fully automat
ed DS2 ELISA system
most prevalent of
medical conditions
determined principal by th
e availability of iodine in the
diet
To determine
the prevalence
of thyroid dysfunction
Results: We found that prevalence of thyroid dysfunction in overall males and females is 43.6%
, 40.8% hypothyrodisms and 2.8 hyperthyroidisms, th
e prevalence in females separately is 46.03% 29 /6 3 cases, 42.8 % of them hypothyroidisms a
nd 3.17 hyperthyroidism case and in males is 25% 2/8 hypothyroidisms and no case of hyperthyroidisms observed .
Conclusion: Thyroid dysfunction is highly prevalent in albaha city in females more prevalent than males
we recommend more researches in this area with high sample size especially in females.

7. cause and symptoms
•caused by polymorphisms in the TSH receptor Toxic uninodul
ar goiter
• (Plummer disease) Toxic multinodular goiter Nodular goiter
•hyperthyroidism caused by exogenous iodine (Jod-Basedow)
•Exogenous thyroid Tumors (thyroid adenoma, follicular carcin
oma
•thyrotrophic-secreting tumor of the pituitary
•hydatidiform mole with secretion of a thyroid-stimulating subst
ance)
•Drug-induced

8. Common symptoms include:
1) Heat intolerance
2) Excessive sweating
3) Increased bowel movements
4) Tremor (usually fine shaking)
5) Nervousness, agitation, anxiety
6) Rapid heart rate, palpitations, irregular heart rate
7) Weight loss
8) Fatigue, weakness
9) Decreased concentration
10)Irregular and scant menstrual flow
11)Fine or brittle hair
12)Thinning skin
13)Sleep disturbances

9. Complications;-
involve the heart. These include a rapid heart rate
a heart rhythm disorder called atrial fibrillation and congestive heart failure
(osteoporosis).
Eye problems. People with Graves'
Thyrotoxic crisis;- leading to a fever

10. Management
and treatment

11. There is many type of treatments for :hyperthyroidism
Radioactive iodine
It effectively destroys the cells that produce hormones.
Common side effects include dry mouth, dry eyes, sore throat, and ch
anges in taste. Precautions may need to be taken for a short time afte
r treatment to prevent radiation spread to others.

12. Surgery
A section or all of your thyroid gland may be surgically removed. You will then h
ave to take thyroid hormone supplements to prevent hypothyroidism, which occ
urs when you have an underactive thyroid that secretes too little hormone. Also,
beta-blockers such as propranolol can help control your rapid pulse, sweating, a
nxiety, and high blood pressure. Most people respond well to this treatment.

13. Management and treatment
• high potassium
Common side effects may include:
• swollen glands
• nausea, vomiting, diarrhea
• stomach pain
• confusion, tired feeling, numbness
• mild skin rash
• weakness or heavy feeling in your hands or feet

14. Adverse effect :
THIOAMIDE RASH
may be experiencing a drug rash from PTU, or the dermopathy of Graves' diseas
e may also be Possibilities because of the location of the pruritic area , Pruritus or
pain May be present.
Treatment includes topical corticosteroids, control Of the Graves' disease, and re
assurance.
Thiazides can produce a maculopapular pruritic rash can occur at any time but Is
more common early in therapy. If the rash is mild, drug therapy Can be continued
while the patient’s symptoms are treated With an antihistamine and a topical ster
oid; such rashes generally Subside spontaneously.
Thioamides should be stopped if the rash is urticarial in Nature or associated with
systemic manifestations (e.g., fever, Arthralgias).

15. HEPATITIS
symptoms of nausea, vomiting, diarrhea, fatigue, and Abdominal tenderness re
quire further evaluation. Her symptoms Could be consistent with mild GI side ef
fects from her PTU therapy, impending thyroid storm from no adherence , or m
ore seriously, PTU-induced Hepatitis.
PTU has been associated with severe hepatotoxicity, Leading to liver transplant
s and fatalities primarily in children.
In patients With thioamide-induced hepatitis, changing to the alternative Thioa
mide is not recommended because fatalities have been reported on rechalleng
e. In such patients, either RAI therapy or surgery should be used.
all patients receiving thioamide therapy should be well educated about the sign
s and symptoms of agranulocytosis.

16. Adverse effect :
Thioamide
( PTU - methimazole )
THIOAMIDE RASH
Nausea, vomiting, diarrhea, fatigue, and abdominal tenderness
Infiltrative exophthalmos
Infiltration and accentuation of hair follicles.
Leucopenia
maculopapular pruritic rash
PTU associated with Hepatotoxicity , hepatocellular , Cholestasis
hepatic necrosis , hepatic failures .
PTU induce Agranulocytosis (<500/μL of neutrophils)
• methimazole rarely produces a Cholestasis jaundice picture,
which might be more common in older patients
and in Those receiving higher dosages (i.e., >40 mg/day).

17. Literature
review

18. surgical management of Graves' hyperthyroidism in Saudi Arabia
retrospective hospital study
introduction :
- surgical management of Graves' disease has been successful moday
in treating patient with hyperthyroidism worldwide with variable
indication and post surgical course.
- yet data the central region of Saudi Arabia is lacking .
- the aims of the study were to determine indication and complication
of thyroidectomies for adult patient with Graves' disease at out
center .

19. material and method :
we conducted retrospective chart review of 194 consecutive patient who
presented or referred with Graves' disease to the endocrine clinic at
a king khalid university hospital.
- Graves' disease was defined as the presence of biochemical
hyperthyroidism together with elevated diffuse thyroid uptake seen in
scan
- if an uptake scan not available the presence of biochemical
hyperthyroidism with two of following was required diffuse goiter ,
significant titre of thyroid peroxidase and thyroglobulin
autoantibodies and presence of thyroid ophthalamopathy
-data were also collected from achieved laboratory data and when
needed from discussion with the patient endocrinologist .
- T4 and T3 and TSH were measured by ELISA
- thyroid autoantibodies were measured by antibody agglutination test
- the presence or absence of goiter was assessed clinically by staff
endocrinologist during the patient frist visit to endocrine clinic .

20. Diagnosis and Management of Thyroid Disease in
Pregnancy
*The American College of Obstetrics and Gynecology (ACOG)
does not recommend routine screening in patients
without history or symptoms consistent with hyroid disease
the median TSH is lowest in the first trimter
, with wider variation than in later trimers
HYPERTHYROIDISM IN PREGNANCY :
result of an excess of thyroid hormones that complicates less than 1% of pregnancies
symptoms such as nausea and vomiting, increased appetite,
heat intolerance, insomnia, changes in bowel habits, fatigue,
and irritable or anxious mood

21. The prevalence of thyroid cancer in patients with hyperthyroidism
ABSTRACT
Objectives: To determine the prevalence of thyroid cancer in patients with hyperthy
roidism.
Methods: This is a retrospective observational study using the data of 71 Omani p
atients with a diagnosis of hyperthyroidism due to Grave’s disease, toxic multinodu
lar goiter, and solitary toxic adenoma. These patients underwent thyroidectomy at t
he Royal Hospital (RH), Muscat, Oman, and were followed up at the National Diab
etes and Endocrine Center (NDEC) between 2007 and 2013. The details were coll
ected from the medical records of both the RH and the NDEC. Patients who under
went thyroidectomy for other reasons like non-toxic goiter and hypothyroidism with
cancer were excluded from the study.

22. Results: Thyroid cancer was identified in 32.8% (n=23) of patients with hyperthyroidi
sm. Half of these patients 52.1% (n=12) had papillary microcancer (intra-thyroidal), a
nd 3 patients with Grave’s disease (13%) had lymph nodes metastasis (locoregional i
nfiltration. The cancer preponderance was higher in young (n=21, 91.3%) and female
patients (n=18, 73.9%). Most patients with thyroid cancer had abnormal ultrasound n
eck findings and thyroid scintigraphy (99 mTc uptake).
Conclusion: Many patients with hyperthyroidism in Muscat, Oman, especially those
with Grave’s disease, show malignancy, and hence a proper initial evaluation of thes
e patients is required as part of long-term management

23. Diagnosis and Management of Thyroid Disease in
Pregnancy
Treatment of Hyperthyroidism in Pregnancy :
1 - antithyroid medication (first line of treatment of hyperthyroidism):
propylthiouracil (PTU), methimazole, and carbimazole .
2 - surgery
3 - Radioiodine ablation
Causes of Hyperthyroidism in Pregnancy :
is Graves disease, but the differential includes hyperemesis gravidarum/
gestational transient thyrotoxicosis
, solitary hyperfunctioning nodule, and thyroiditis. In addition,
there are some other causes to consider,
including toxic multinodular goiter, exogenous thyroid hormone (iatrogenic or factitious),
gestational trophoblastic disease
, metastatic thyroid cancer, struma ovarii, pituitary tumor, iodine induced, and medication associated

24. Infographic
: 2% to
15% of
women
in early
Hyperemesis gravid
arum/gestational
transient
thyrotoxicosis
90% to 95%
associated with
pregnancy
: nodules
occur in 1%
to 2% of
young
women
Thyroid Nodules in
Pregnancy
Graves disease

25. Management of hyperthyroidism during pregnancy in Asia
Subclinical hyperthyroidism is defined as an asymptomatic co
ndition in which a patient has a serum TSH level below the lo
wer threshold of a specified laboratory reference interval (usu
ally 0.4 mIU/L) but normal T4 and triiodothyronine (T3) levels.
Patients with subclinical hyperthyroidism are further classified
as having “low but detectable” (about 0.1 to 0.4 mIU/L) or “cle
arly low” or “undetectable” (< 0.1 mIU/L) TSH levels.3

26. Subclinical hyperthyroidism is defined as an asymptomatic condition in
which a patient has a serum TSH level below the lower threshold of a spe
cified laboratory reference interval (usually 0.4 mIU/L) but normal T4 and
triiodothyronine (T3) levels. Patients with subclinical hyperthyroidism are
further classified as having “low but detectable” (about 0.1 to 0.4 mIU/L)
or “clearly low” or “undetectable” (< 0.1 mIU/L) TSH levels.3
Early detection and treatment of asymptomatic persons with abnormal se
rum TSH levels with or without abnormal T4 levels may be beneficial bec
ause it may prevent longer-term morbidity and mortality from fractures, c
ancer, or cardiovascular disease. However, widespread screening and tre
atment of subclinical thyroid dysfunction can also result in harms due to
labeling, false-positive results, and overdiagnosis and overtreatment.
Screening for Thyroid Dysfunction: Recommendation

27. Treatment Guidelines:
Treatment A number of factors
anti-thyroid drugs, surgery and radioactive iodine
There is no general agreement as to the specific indications for each form of ther
apy, and none of them is ideal, all being associated with both short- and long-ter
m sequelae
Neither surgery nor radioactive iodine should be given until the patient has been rendere
d euthyroid due to the risk ofinducing a thyroid crisis
In pregnancy, radioiodine is not used due to the likelihood of producing a hypothyroid
neonate
hyroid surgery during pregnancy should be deferred until the second trimester
excessive treatment may produce goitre in the fetus

28. Treatment Guidelines:
Aplasia cutis is said to occur after carbimazole therapy,
so propylthiouracil (PTU) is usually used
in pregnancy. Pregnant patients with thyrotoxicosis
should be under the care of a specialist endocrine unit.

29. Conclusion and
recommendation

30. Based on these conclusions, the Committee makes the following recommendation:
Based on these conclusions, the Committee makes the following recommendation:
The clinical practice of medicine suffers from the lack of a stronger evidence base. Mo
st decisions made by medical practitioners do not lead to results that clearly and prom
ptly demonstrate the wisdom of those decisions. In the case of screening for thyroid dy
sfunction, if their actions are repeated millions of times, the cumulative costs can
become enormous while the net health effects remain unknown. Because of the large
number of older persons who possess biochemical thyroid abnormalities, screening
and treating for these abnormalities could generate substantial benefit or harm at
considerable financial cost. Randomized, controlled trials of TSH screening
, pragmatic in
approach, could assess the effectiveness of screening and treatment obtained under u
sual community conditions and consider both health and economic outcomes.

31. Discussion
principal indication for surgical management of Graves' hyperthyroidism to
be failure of initial medico-radioiodine therapy with
or without severe eye disease, similar to recent observation by others
Another interesting finding of present study was the role of severe ophthalmopath
y as an indication for surgery. It was shown from our data that 52% of patients had
thyroidectomy after trial but failed radioiodine or antithyroid agents
epofted 23% of patients with Graves' disease had thyroidectomy due to severe eye
disease

32. Discussion
Maternal hyperthyroidism diagnosed during pregnancy should be corrected, beca
use hyperthyroidism
has detrimental effects on both mother and fetal health [3-7].
Based on current data, MMI and PTU have equal efficacy in the treatment of preg
nant women.
The use of PTU has been recommended by both organizations during the first
trimester, followed by MMI from second trimester onwards to the end of pregnanc
y.
The greatest concern in the use of MMI in the first trimester of pregnancy is related
to teratogenic effect called “methimazole embryopathy” that induces choanal or eso
phageal
atresia, and dysmorphic faces

33. Discussion
PTU and 40% MMI) and only 8% will ablate the thyroid (radiation or surgery) before
allowing the patient
clinicians advise women to postpone pregnancy for more than
6 month after ablation with
Differentiation of Graves’ disease and gestational thyrotoxicosis may be difficult
during the first half ofpregnancy. Severe nausea, vomiting, weight loss and palpitati
on, along with negative thyroid antibodies
on the accuracy of FT4 assays during pregnancy about 82% of physicians used
FT4 alone or incombination with other tests

34. Discussion
favor gestational thyrotoxicosis, a self limiting condition which is less severe than
Graves’ disease
Increased serum TRAb is a risk for fetal and neonatal hyperthyroidism
and can be detected in up to 95%of hyperthyroid pregnant women
with Graves’ disease.
Routine measurement of TRAb in a hyperthyroid pregnant woman under antithyroid
drug therapy isrecommended by major professional endocrine organizations.
The prevalence of fetal and neonatal hyperthyroidism ranges between 1-5% in
women with current or past history of Graves’ disease and lack of treatment wil
l increase morbidityand mortality in the fetus and infants

35. Discussion
Checking thyroid functions of breast-feeding infants of mothers taking antithyroid drugs is
recommended. Prescribing the treatment in divided doses
immediately after breast feeding is also suggested

36. Discussion
Conclusion #1: There is insufficient evidence to recommend periodic, routine
screening for thyroid dysfunction among asymptomatic persons using serum TSH
levels.
It is uncertain whether asymptomatic persons
with abnormal TSH levels but normal thyroid
hormone levels actually have some degree of physiologically meaningful abnormalities
that would benefit from early treatment in the absence of clinical manifestations.
While some individuals with unrecognized clinical or physiological abnormalities assoc
iated with thyroid dysfunction do progress to overt thyroid disease over several years,
the rates, timing, and risk factors for this progression are only partly understood.
Conclusion #2: Given insufficient evidence about the health benefits of a serum
TSH screening program, the cost implications for the Medicare pro gram are unc
ertain.

37. Thank you