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JAMA Oct 2023Overt hyperthyroidism, defined as suppressed thyrotropin (previously thyroid-stimulating hormone) and high concentration of triiodothyronine (T3) and/or free thyroxine... (Review)
Review
IMPORTANCE
Overt hyperthyroidism, defined as suppressed thyrotropin (previously thyroid-stimulating hormone) and high concentration of triiodothyronine (T3) and/or free thyroxine (FT4), affects approximately 0.2% to 1.4% of people worldwide. Subclinical hyperthyroidism, defined as low concentrations of thyrotropin and normal concentrations of T3 and FT4, affects approximately 0.7% to 1.4% of people worldwide. Untreated hyperthyroidism can cause cardiac arrhythmias, heart failure, osteoporosis, and adverse pregnancy outcomes. It may lead to unintentional weight loss and is associated with increased mortality.
OBSERVATIONS
The most common cause of hyperthyroidism is Graves disease, with a global prevalence of 2% in women and 0.5% in men. Other causes of hyperthyroidism and thyrotoxicosis include toxic nodules and the thyrotoxic phase of thyroiditis. Common symptoms of thyrotoxicosis include anxiety, insomnia, palpitations, unintentional weight loss, diarrhea, and heat intolerance. Patients with Graves disease may have a diffusely enlarged thyroid gland, stare, or exophthalmos on examination. Patients with toxic nodules (ie, in which thyroid nodules develop autonomous function) may have symptoms from local compression of structures in the neck by the thyroid gland, such as dysphagia, orthopnea, or voice changes. Etiology can typically be established based on clinical presentation, thyroid function tests, and thyrotropin-receptor antibody status. Thyroid scintigraphy is recommended if thyroid nodules are present or the etiology is unclear. Thyrotoxicosis from thyroiditis may be observed if symptomatic or treated with supportive care. Treatment options for overt hyperthyroidism from autonomous thyroid nodules or Graves disease include antithyroid drugs, radioactive iodine ablation, and surgery. Treatment for subclinical hyperthyroidism is recommended for patients at highest risk of osteoporosis and cardiovascular disease, such as those older than 65 years or with persistent serum thyrotropin level less than 0.1 mIU/L.
CONCLUSIONS AND RELEVANCE
Hyperthyroidism affects 2.5% of adults worldwide and is associated with osteoporosis, heart disease, and increased mortality. First-line treatments are antithyroid drugs, thyroid surgery, and radioactive iodine treatment. Treatment choices should be individualized and patient centered.
Topics: Adult; Female; Humans; Male; Pregnancy; Antithyroid Agents; Graves Disease; Hyperthyroidism; Iodine; Iodine Radioisotopes; Osteoporosis; Thyroid Neoplasms; Thyroid Nodule; Thyroiditis; Thyrotoxicosis; Thyrotropin; Thyroxine; Weight Loss
PubMed: 37847271
DOI: 10.1001/jama.2023.19052 -
Annals of Internal Medicine Apr 2020Thyrotoxicosis is a general term for excess circulating and tissue thyroid hormone levels, whereas hyperthyroidism specifically denotes disorders involving a hyperactive...
Thyrotoxicosis is a general term for excess circulating and tissue thyroid hormone levels, whereas hyperthyroidism specifically denotes disorders involving a hyperactive thyroid gland (Graves disease, toxic multinodular goiter, toxic adenoma). Diagnosis and determination of the cause rely on clinical evaluation, laboratory tests, and imaging studies. Hyperthyroidism is treated with antithyroid drugs, radioactive iodine ablation, or thyroidectomy. Other types of thyrotoxicosis are monitored and treated with β-blockers to control symptoms given that most of these conditions resolve spontaneously.
Topics: Adrenergic beta-Antagonists; Antithyroid Agents; Biomarkers; Diagnosis, Differential; Humans; Hyperthyroidism; Iodine Radioisotopes; Mass Screening; Risk Factors; Thyroid Hormones; Thyroidectomy; Thyrotoxicosis
PubMed: 32252086
DOI: 10.7326/AITC202004070 -
Emergency Medicine Clinics of North... Nov 2023Hyperthyroidism is a diagnosis existing along a spectrum of severity. Patients present with a variety of signs and symptoms: tachycardia, elevated heart rate, anxiety,... (Review)
Review
Hyperthyroidism is a diagnosis existing along a spectrum of severity. Patients present with a variety of signs and symptoms: tachycardia, elevated heart rate, anxiety, changes in mental status, gastrointestinal disturbances, and hyperthermia. Management of subclinical hyperthyroidism and thyrotoxicosis without thyroid storm is heavily dependent on outpatient evaluation. Thyroid storm is the most severe form of hyperthyroidism with the highest mortality. Management of thyroid storm follows a stepwise approach, with resuscitation and detection of the precipitating cause being paramount. Special attention should be paid to cardiac function in patients with thyroid storm before treatment, as these patients may develop cardiac collapse.
Topics: Humans; Thyroid Crisis; Thyrotoxicosis
PubMed: 37758422
DOI: 10.1016/j.emc.2023.06.005 -
Missouri Medicine 2022Thyroid storm is a severe manifestation of thyrotoxicosis. Thyroid storm is diagnosed as a combination of thyroid function studies showing low to undetectable thyroid... (Review)
Review
Thyroid storm is a severe manifestation of thyrotoxicosis. Thyroid storm is diagnosed as a combination of thyroid function studies showing low to undetectable thyroid stimulating hormone (TSH) (<0.01mU/L) with elevated free thyroxine (T4) and/or triiodothyronine (T3), positive thyroid receptor antibody (TRab) (if Graves' disease is the underlying etiology), and with clinical signs and symptoms of end organ damage. Treatment involves bridging to a euthyroid state prior to total thyroidectomy or radioactive iodine ablation to limit surgical complications such as excessive bleeding from highly vascular hyperthyroid tissue or exacerbation of thyrotoxicosis. The purpose of this article is a clinical review of the various treatments and methodologies to achieve a euthyroid state in patients with thyroid storm prior to definitive therapy.
Topics: Graves Disease; Humans; Iodine; Iodine Radioisotopes; Thyroid Crisis; Thyroid Neoplasms; Thyrotoxicosis; Thyrotropin; Thyroxine; Triiodothyronine
PubMed: 36118802
DOI: No ID Found -
Lancet (London, England) Feb 2024Thyrotoxicosis causes a variety of symptoms and adverse health outcomes. Hyperthyroidism refers to increased thyroid hormone synthesis and secretion, most commonly from... (Review)
Review
Thyrotoxicosis causes a variety of symptoms and adverse health outcomes. Hyperthyroidism refers to increased thyroid hormone synthesis and secretion, most commonly from Graves' disease or toxic nodular goitre, whereas thyroiditis (typically autoimmune, viral, or drug induced) causes thyrotoxicosis without hyperthyroidism. The diagnosis is based on suppressed serum concentrations of thyroid-stimulating hormone (TSH), accompanied by free thyroxine and total or free tri-iodothyronine concentrations, which are raised (overt hyperthyroidism) or within range (subclinical hyperthyroidism). The underlying cause is determined by clinical assessment, detection of TSH-receptor antibodies and, if necessary, radionuclide thyroid scintigraphy. Treatment options for hyperthyroidism include antithyroid drugs, radioactive iodine, and thyroidectomy, whereas thyroiditis is managed symptomatically or with glucocorticoid therapy. In Graves' disease, first-line treatment is a 12-18-month course of antithyroid drugs, whereas for goitre, radioactive iodine or surgery are preferred for toxic nodules or goitres. Evidence also supports long-term treatment with antithyroid drugs as an option for patients with Graves' disease and toxic nodular goitre.
Topics: Humans; Antithyroid Agents; Goiter, Nodular; Iodine Radioisotopes; Thyroid Neoplasms; Hyperthyroidism; Graves Disease; Thyrotoxicosis; Thyroiditis
PubMed: 38278171
DOI: 10.1016/S0140-6736(23)02016-0 -
Polish Archives of Internal Medicine Aug 2019Myxedema coma and thyroid storm are among the most common endocrine emergencies presenting to general hospitals. Myxedema coma represents the most extreme,... (Review)
Review
Myxedema coma and thyroid storm are among the most common endocrine emergencies presenting to general hospitals. Myxedema coma represents the most extreme, life‑threatening expression of severe hypothyroidism, with patients showing deteriorating mental status, hypothermia, and multiple organ system abnormalities. It typically appears in patients with preexisting hypothyroidism via a common pathway of respiratory decompensation with carbon dioxide narcosis leading to coma. Without early and appropriate therapy, the outcome is often fatal. The diagnosis is based on history and physical findings at presentation and not on any objective thyroid laboratory test. Clinically based scoring systems have been proposed to aid in the diagnosis. While it is a relatively rare syndrome, the typical patient is an elderly woman (thyroid hypofunction being much more common in women) who may or may not have a history of previously diagnosed or treated thyroid dysfunction. Thyrotoxic storm or thyroid crisis is also a rare condition, established on the basis of a clinical diagnosis. The diagnosis is based on the presence of severe hyperthyroidism accompanied by elements of systemic decompensation. Considering that mortality is high without aggressive treatment, therapy must be initiated as early as possible in a critical care setting. The diagnosis cannot be established based on laboratory tests alone, but several scoring systems are available. The usual clinical signs and symptoms of hyperthyroidism are present along with more exaggerated clinical manifestations affecting the cardiovascular, gastrointestinal, and central nervous systems. A multipronged approach has been recommended and has been associated with improved outcomes.
Topics: Critical Care; Emergencies; Humans; Myxedema; Thyroid Crisis; Thyroid Function Tests
PubMed: 31237256
DOI: 10.20452/pamw.14876 -
Journal of Clinical Pathology Jan 2023Thyroid-stimulating hormone (TSH) receptor antibody (TSH-R-Ab or TRAb) testing plays a pivotal role in arriving at the aetiological diagnosis in patients with... (Review)
Review
Thyroid-stimulating hormone (TSH) receptor antibody (TSH-R-Ab or TRAb) testing plays a pivotal role in arriving at the aetiological diagnosis in patients with thyrotoxicosis. A positive test establishes the diagnosis of Graves' disease (GD) while a negative result in conjunction with imaging studies supports other possible aetiologies. In patients with GD, TRAb levels at diagnosis and at the time of withdrawal of antithyroid drugs can identify patients who are unlikely to achieve remission and guide clinical management decisions. We provide an algorithm that incorporates TRAb in the decision-making process for the management of thyrotoxicosis. The utility of TRAb in predicting the risk of fetal and neonatal thyroid dysfunction is established and widely accepted in guidelines. TRAb may also help in the diagnosis of Graves' orbitopathy, especially in euthyroid or hypothyroid patients and its role in guiding its management is evolving as a useful adjunct to the clinical parameters used in making therapeutic decisions.Anti-thyroid peroxidase antibodies (TPOAb) and anti-thyroglobulin antibodies (TgAb) indicate thyroid autoimmunity. The most common use of TPOAb is to identify patients at a higher risk of progression to treatment-requiring hypothyroidism. They also aid the diagnosis of immune thyroiditis and Hashimoto's encephalopathy. Thyroglobulin measurement is used to help guide differentiated thyroid cancer treatment. TgAb is used as an accompanying test with thyroglobulin measurement as its presence can interfere with the thyroglobulin assay. A negative TgAb result reduces the likelihood of, but does not exclude, interference with thyroglobulin assay.
Topics: Infant, Newborn; Humans; Graves Ophthalmopathy; Autoantibodies; Graves Disease; Thyrotoxicosis; Receptors, Thyrotropin; Thyrotropin
PubMed: 36270794
DOI: 10.1136/jcp-2022-208290 -
The Journal of Clinical Endocrinology... Mar 2021Both hyperthyroidism and hypothyroidism can have adverse effects in pregnancy. The most common causes of thyrotoxicosis in pregnancy are gestational transient... (Review)
Review
Both hyperthyroidism and hypothyroidism can have adverse effects in pregnancy. The most common causes of thyrotoxicosis in pregnancy are gestational transient thyrotoxicosis and Graves' disease. It is important to distinguish between these entities as treatment options differ. Women of reproductive age who are diagnosed with Graves' disease should be counseled regarding the impact of treatment options on a potential pregnancy. Although the absolute risk is small, antithyroid medications can have teratogenic effects. Propylthiouracil appears to have less severe teratogenicity compared to methimazole and is therefore favored during the first trimester if a medication is needed. Women should be advised to delay pregnancy for at least 6 months following radioactive iodine to minimize potential adverse effects from radiation and ensure normal thyroid hormone levels prior to conception. As thyroid hormone is critical for normal fetal development, hypothyroidism is associated with adverse obstetric and child neurodevelopmental outcomes. Women with overt hypothyroidism should be treated with levothyroxine (LT4) to a thyrotropin (thyroid-stimulating hormone; TSH) goal of <2.5 mIU/L. There is mounting evidence for associations of maternal hypothyroxinemia and subclinical hypothyroidism with pregnancy loss, preterm labor, and lower scores on child cognitive assessment. Although there is minimal risk of LT4 treatment to keep TSH within the pregnancy-specific reference range, treatment of mild maternal thyroid hypofunction remains controversial, given the lack of clinical trials showing improved outcomes with LT4 treatment.
Topics: Adult; Embryo Loss; Female; Graves Disease; Humans; Infant, Newborn; Maternal Serum Screening Tests; Monitoring, Physiologic; Pregnancy; Pregnancy Complications; Prenatal Care; Tachycardia; Thyroid Diseases; Thyroid Function Tests; Thyrotoxicosis; Weight Loss
PubMed: 33349844
DOI: 10.1210/clinem/dgaa945 -
Anesthesiology Clinics Mar 2020Although endocrine emergencies are not common occurrences, their identification and careful perioperative management are of paramount importance for reduction of patient... (Review)
Review
Although endocrine emergencies are not common occurrences, their identification and careful perioperative management are of paramount importance for reduction of patient morbidity and mortality. The most common critical endocrine abnormalities are associated with functional tumors, such as pheochromocytomas, insulinomas, and carcinoid tumors, leading to carcinoid syndrome, abnormal thyroid function, or disturbances in the hypothalamus-pituitary-adrenal axis, causing adrenal insufficiency. This article aims to discuss the pathophysiology, diagnosis, and perioperative management of pheochromocytomas, hyperthyroidism, hypothyroidism, adrenal insufficiency, carcinoid disease, and insulinomas.
Topics: Adrenal Gland Neoplasms; Adrenal Insufficiency; Anesthesia; Emergencies; Endocrine System Diseases; Humans; Hypothyroidism; Insulinoma; Malignant Carcinoid Syndrome; Perioperative Care; Pheochromocytoma; Thyrotoxicosis
PubMed: 32008649
DOI: 10.1016/j.anclin.2019.10.006