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Thyroid Disease And Osteoporosis PowerPoint Presentation

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Description : This medical presentation on cancer titled "Thyroid Disease And Osteoporosis" contains information on signs and symptoms of hyperthyroidism, diagnostic studies for hyperthyroidism, causes and treatments of hyperthyroidism, general overview of hypothyroidism, evaluation of thyroid nodules, and overview of osteoporosis.

Tags : Cancer, Thyroid Cancer, Disease, Osteoporosis, signs, symptoms, hyperthyroidism, diagnostic studies, causes, treatments, overview, evaluation, thyroid nodules, Osteoporosis

Published on : May 03, 2021 | Views : 3036 | Downloads : 14

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Slide 1-

Thyroid Disease And Osteoporosis Lisa Hays, MD Endocrinology Fellow
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Outline Signs and symptoms of hyperthyroidism Diagnostic studies for hyperthyroidism Causes and treatments of hyperthyroidism General overview of hypothyroidism Evaluation of thyroid nodules Overview of osteoporosis
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Cellular effects of thyroid
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Hyperthyroidism Symptoms Anxiety/irritability Weakness Tremors Difficulty sleeping Palpitations Increased bowel movements Fatigue Weight loss Hyperkinetic movements Heat intolerance
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Case Presentation 37 yo male presented to PCP w/ complaint of feeling poorly for past month Also complained of weakness, difficulty sleeping, increased heart rate. 10 stools per day. What else do we need to know before examining?
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Case Presentation T 99.1, HR 92 irregular, RR 20, BP 153/75 Physical examination Mild proptosis Nontender goiter with thyroid bruit present CV: Irregularly irregular rhythm Ext: Brisk DTR’s, mild resting tremor What labs or studies do we need?
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Laboratory Studies TSH <0.010 uIU/ml (nl 0.47-5.0) Free T4 >6 ng/dl (nl 0.71-1.85) Total T3 >600 ng/dl (nl 72-170) Thyroid Stimulating Antibody 130% (nl 0-125%) Negative Thyroid peroxidase and thyroglobulin antibodies
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Case Presentation Patient was diagnosed with Graves’ Disease Started on Methimazole 10 mg TID Propranolol for symptom management Anticoagulation for atrial fibrillation
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Thyroid Antibodies TSH receptor antibodies Can be stimulating or inhibitory Thyroglobulin antibodies Thyroid peroxidase antibodies (formerly known as microsomal)
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Anything else? Radioactive Iodine Uptake Measures the amount of iodine taken up by the thyroid in 24 hours Normal 15-30% Thyroid Scan Gives an anatomic view of the thyroid Technetium used to image
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Differential Diagnosis High uptake Graves’ Disease Multinodular Goiter Toxic solitary Nodule TRH secreting Pituitary Tumor HCG secreting tumor Low uptake Subacute Thyroiditis Silent Thyroiditis Iodine induced Exogenous L-Thyroxine Struma ovarii Amiodarone
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Graves’ Disease Most common cause of hyperthyroidism 60-80% of cases Autoimmune disease Caused by thyroid stimulating immunoglobulins Bind to TSH receptors on thyroid Cause hypersecrection of thyroid hormone Cause hypertrophy & hyperplasia of thyroid follicles
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Weetman, A. P. N Engl J Med 2000;343:1236-1248 Pathogenesis of Graves' Disease
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Clinical Manifestations Symptoms and signs of hyperthyroidism Ophthalmopathy Present in 50% of patients Eyelid retraction Periorbital edema Proptosis (exopthalmos) Diploplia Dermopathy (myxedema)
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Weetman, A. P. N Engl J Med 2000;343:1236-1248 Clinical Manifestations of Graves' Disease
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Graves’ Disease Associated Conditions Type I Diabetes Mellitus Addison’s Disease Vitiligo Pernicious anemia Alopecia Areata Myasthenia Gravis Celiac Disease
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Graves Treatment Antithyroid drugs (Thionamides) Proplythiouracil (PTU) 300-400 mg daily Methimazole 30-40 mg daily Decrease synthesis of hormone, PTU also decreases conversion of T4 to T3 Permanent remission in 40-50% of treated patients Risk of agranulocytosis PTU used in pregnancy Beta-Blockers for symptoms
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Graves Treatment Thyroidectomy Rapid cure but requires thyroid replacement Radioactive Iodine Iodine (131I) is given Effect is typically seen in 3-6 months Hypothyroidism often develops
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Multinodular Goiter Less common than Graves and effects older individuals Discrete nodules become autonomous and hyperfunction Treatment with thyroidectomy (often poor surgical candidates) or iodine, thionamides
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Subacute Thyroiditis Etiology is typically viral Known as De Quervain’s thyroiditis or granulomatous thyroiditis Thyroid is often enlarged, tender, painful Very low radioactive iodine uptake Self-resolving within weeks to months Treatment with NSAIDS, steroids, Beta-blockers
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Silent Thyroiditis Also called painless or lymphocytic thyroiditis Not painful like subacute Transient Low iodine uptake
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Hypothyroidism Weakness Fatigue Lethargy, sleepiness Slowness of speech and thought “Puffy” appearance Dry skin, coarse hair Cold intolerance Constipation
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Physical Findings Puffy features Dry skin Nonpitting edema Hypothermia Bradycardia Slow return of deep tendon reflexes Loss of lateral portion of eyebrows
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Causes of Hypothyroidism Primary Hypothyroidism Iodine deficiency Iatrogenic-surgery, radioablation Autoimmune thyroid destruction Drugs interfering with hormone synthesis Infiltrative disease hemochromotosis, sarcoidosis, neoplastic disease Congenital thyroid agensis or defects in hormone synthesis
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Hashimotos Thyroiditis Most common type of thyroid disease Autoimmune damage Lymphocytic infiltrate, fibrosis, decreased thyroid hormone production Autoantibodies (thyroglobulin and peroxidase) Can also be associated with polyglandular autoimmune disease Adrenal insufficiency, ovarian failure, vitiligo, diabetes
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Thyroid Replacement Synthetic levothyroxine (T4) Converted to T3 in the body Studies vary on utility of using T3 Typical replacement dose is 1.6 micrograms/kg (100-150 mcg typical) Start with reduced dose in elderly and patients with history of heart disease
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Myxedema Coma Severe untreated hypothyroidism Hypothermia, hypoglycemia, shock, hypoventilation, ileus 50% mortality Treat with IV levothyroxine, steroids
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Thyroid Nodule 21 yo male w/ no past medical history presents to his PCP complaining of gradually enlarging “knot” in his neck What questions do you have? Examination reveals a firm 3 cm nodule in right lobe of thyroid What is the next step?
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Thyroid Nodules Lifetime risk of palpable nodule 5-10% 50% of the population has a nodule on autopsy or ultrasound Only 1 in 20 is malignant
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Differential Diagnosis Malignancy Papillary Follicular Medullary Anaplastic Metastasis Benign follicular adenoma Cyst Colloid Nodule
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Hegedus, L. N Engl J Med 2004;351:1764-1771 Algorithm for the Cost-Effective Evaluation and Treatment of a Clinically Detectable Solitary Thyroid Nodule
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Hegedus, L. N Engl J Med 2004;351:1764-1771 Clinical Findings Suggesting the Diagnosis of Thyroid Carcinoma in a Euthyroid Patient with a Solitary Nodule, According to the Degree of Suspicion
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Evaluation of Nodule Measure TSH If Hyperthyroid (low TSH), do uptake and scan Treat with surgery or I-131 ablation If normal thyroid function, next step is fine needle aspiration (FNA) Check Calcitonin level if family history of MEN2 or medullary carcinoma exists.
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Hegedus, L. N Engl J Med 2004;351:1764-1771 Algorithm for the Cost-Effective Evaluation and Treatment of a Clinically Detectable Solitary Thyroid Nodule
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Fine Needle Aspiration FNA is most effective way to distinguish between benign and malignant nodules Inexpensive, performed as outpatient Ultrasound guided FNA if not palpable or less than 1.5 cm in diameter What results will I see? Benign-75% of the time Malignant-4% of cases Suspicious or inadequate-22%
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Hegedus, L. N Engl J Med 2004;351:1764-1771 Algorithm for the Cost-Effective Evaluation and Treatment of a Clinically Detectable Solitary Thyroid Nodule
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Management of Nodules Malignant Total thyroidectomy Suspicious Thyroidectomy Benign Discuss with the patient Ultrasound surveillance Surgery Consider levothyroxine suppression (varying results)
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Case Presentation FNA revealed papillary thyroid carcinoma Patient underwent total thyroidectomy Treatment with I-131 ablation after surgery
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Osteoporosis
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Case Presentation 70 year old female asks her PCP if she should have a bone density done. What questions should her PCP ask? No history of fractures Menopause was surgical at age of 55 Mother fractured her hip at 74
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Osteoporosis Definition Microarchitectural deterioration of bone tissue leading to decreased bone mass Bone fragility Susceptibility to fracture A problem of decreased peak bone mass and accelerated bone loss Affects 10 million in the United States
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1. Consensus Development Conference. Am J Med. 1993;94:646-650. 2. Riggs BL, Melton LJ III. Bone. 1995;17:505S–511S. 3. Ray NF et al. J Bone Miner Res. 1997;12(1):24–35. 4. Cummings SR et al. Arch Intern Med. 1989;149:2445–2448. Hip Fractures Can Lead to Disability, Loss of Independence, and Even Death Hip fracture is associated with increased risk of: Disability: 50% never fully recover1,2 Long-term nursing home care required: 25%2 Increased mortality within 1 year due to complications: up to 24%3 Lifetime risk of death: comparable to that of breast cancer4
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Osteoporosis Primary osteoporosis Unrelated to chronic illness Related to aging and decreased gonadal function Secondary osteoporosis Secondary to chronic illnesses that cause accelerated bone loss Examples: Glucocorticoid use, celiac sprue, hyperthyroidism
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Risk Factors for Osteoporotic Fracture Nonmodifiable Potentially Modifiable Personal history of fracture as an adult History of fracture in first-degree relative Caucasian race Advanced age Female sex Dementia Poor health/frailty Current cigarette smoking Low body weight (<127 lbs) Estrogen deficiency, including menopause onset
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Diagnosis of Osteoporosis History and physical examination to exclude secondary osteoporosis Laboratory studies if suspect secondary osteoporosis Measurement of Bone Mineral Density (BMD) Dual X-ray Absorptiometry (DEXA scan) Provides most reproducible values of bone density g/cm2
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60 70 80 90 100 30 40 50 60 70 80 90 Age Relative BMD (%) Forearm Spine Hip and Heel 0 1000 2000 3000 4000 35- 39 85+ Colles' Vertebrae Hip Age Annual Fracture Incidence Cooper C. Baillières Clin Rheumatol. 1993;7:459–477. Faulkner KG. J Clin Densitom. 1998;1:279–285. BMD and Fracture Risk Are Inversely Related
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Central DXA Measurement Measures multiple skeletal sites Spine Proximal femur Forearm Total body Office based Considered the clinical standard
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National Osteoporosis Foundation, Physician’s Guide to Prevention and Treatment of Osteoporosis. Belle Mead, NJ: Excerpta Medica, Inc.; 1998. National Osteoporosis Foundation Guidelines Who Should Be Considered for BMD Testing? Women 65 years of age regardless of additional risk factors Postmenopausal women <65 years of age with at least one risk factor for osteoporosis (in addition to menopause) Postmenopausal women 65 years of age with fractures (to confirm diagnosis and determine disease severity) Women considering therapy for osteoporosis, if BMD testing would facilitate the decision Women who have been on HRT for prolonged periods
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Other Populations To Consider for Assessment of Osteoporosis Men Patients on long-term high-dose glucocorticoids
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T-Score Is Key Interpreting BMD Measurement Reports A clinically relevant value on the BMD report Describes bone mass compared with the mean peak bone mass of healthy young adult women in terms of Standard Deviation (SD) Can help confirm the diagnosis of low bone mass or osteoporosis For every SD below the young adult normal, the risk of fracture approximately doubles 1. National Osteoporosis Foundation, Physician’s Guide to Prevention and Treatment of Osteoporosis. Belle Mead, NJ: Excerpta Medica, Inc.; 1998. 2. Marshall D. Johnell O, Wedel H. Meta-analysis of how well measures of bone mineral density predict occurrence of osteoporotic fractures. BMJ. 1996;312:1254–1259.
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SD Age (years) 2 1 0 –1 –2 –3 –4 –5 –6 20 30 40 50 60 70 80 90 T-score = –3.0 Peak Bone Mass Visualizing a Patient’s T-Score T-score = Number of standard deviations (SDs) by which the patient’s bone mass falls above or below the mean peak bone mass for normal young adult women = T-score for patient, a 60-year-old woman; here, T = –3.0 Light line: Change in mean bone mass over time in women Heavy line: Mean peak bone mass for young normal adult women National Osteoporosis Foundation, Physician’s Guide to Prevention and Treatment of Osteoporosis. Belle Mead, NJ: Excerpta Medica, Inc.; 1998.
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National Osteoporosis Foundation, Physician’s Guide to Prevention and Treatment of Osteoporosis. Belle Mead, NJ: Excerpta Medica, Inc.; 1998. T-SCORE ACTION < –2.0 Initiate therapy < –1.5 Initiate therapy (with at least 1 additional risk factor) National Osteoporosis Foundation Guidelines for postmenopausal Women Recommendations for Treatment Based on BMD Testing Results
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Treatment of Osteoporosis Adequate Calcium (1200 mg elemental) Adequate Vitamin D (at least 400 IU) Weight-bearing exercise
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Pharmacologic Agents Bisphosphonates Inhibit osteoclastic bone resorption Increased BMD and decreased fractures Ex: alendronate, risedronate Calcitonin Nasal spray or injection Decreased vertebral fractures No hip fracture data Raloxifen SERM Decreased vertebral fracture
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Osteoporosis Summary Osteoporosis is a disease with serious consequences. Bone loss associated with osteoporosis increases fracture risk, which may lead to disability, loss of independence, and death. Patients at risk for osteoporotic fracture should be considered for BMD testing. T-score is the most clinically relevant measure of fracture risk. According to NOF guidelines, consider therapy in patients with a T-score of <–2.0 and those with a T-score of <–1.5 with at least one risk factor.