The patient with acute endocrine problems
Peate Ian, Dutton Helen in Acute Nursing Care, 2020
Hyperthyroidism results from an excess of thyroid hormones (T3 and T4), with an exaggerated form being a thyroid crisis. A thyroid crisis (or storm) can be triggered by infection, surgery, trauma or any other acute episode (e.g., myocardial infarction, stroke and eclampsia), but fortunately, is very rare. An over-secretion of thyroid hormones will lead to a hypermetabolic state, resulting in hyperpyrexia, tachycardia, hypertension, agitation and tremors. The management is aimed essentially at reducing the effects of these hormones until the patient is stable. Drug therapy will include the use of: Beta-blockers such as metoprolol, to reduce sympathetic activity.Sedatives, such as chlorpromazine or haloperidol.Corticosteroids such as hydrocortisone, to inhibit the conversion of T3 to T4.Carbimazole, a specific anti-thyroid drug, inhibits enzymes that play a role in T3 and T4 production.Iodine is a specific antithyroid therapy used to inhibit thyroxine release and treat some forms of hyperthyroidism.
Endocrine and Growth
Timothy G Barrett, Anthony D Lander, Vin Diwakar in A Paediatric Vade-Mecum, 2002
Again this may be idiopathic or associated with other autoimmune disorders (e.g. type 1 diabetes) or Down’s syndrome. Usually there is a gradual onset, and this may present with worsening performance at school or worsening glycaemic control in a diabetic. Occasionally, an acute onset or thyroid storm is an endocrine emergency, with behaviour disturbance, tachycardia and arrhythmias. T4 levels are grossly elevated (>70 pmol/l), with TSH < 1 mU/l. TSH-receptor-stimulating antibodies are present in high titre. Treatment with potassium iodide reduces release by the thyroid gland of T4 and T3, and in thyroid storm it is used in conjunction with a benzodiazepine, carbimazole and propranolol. For chronic hyperthyroidism, carbimazole and propranolol alone are sufficient. Propranolol is contraindicated if the child has asthma. Carbimazole has several side-effects, including rashes and transient leucopenia. A rare but severe side-effect is agranulocytosis, so it is sensible to check a baseline FBC, and then repeat it 2 weeks after commencement of treatment.
Amiodarone: a candidate for the title ‘riskiest drug’
Hugh Mcgavock in Pitfalls in Prescribing and How to Avoid Them, 2017
Amiodarone contains iodine and can cause disorders of thyroid function; both hypothyroidism and hyperthyroidism may occur. Clinical assess ment alone is unreliable and laboratory tests should be performed before treatment and every 6 months. Thyroxine (T4) may be raised in the absence of hyperthyroidism; therefore tri-iodothyronine (T3), T4 and thyroid-stimulating hormone (thyrotrophin, TSH) should all be measured. A raised T3 and T4 with a very low or undetectable TSH concentration suggests the development of thyrotoxicosis. The thyrotoxicosis may be very refractory, and amiodarone should usually be withdrawn at least temporarily to help achieve control. Treatment with carbimazole may be required. Hypothyroidism can be treated with replacement therapy without withdrawing amiodarone if it is essential; careful supervision is required.
Reactivation of Graves’ Disease and Thyroid Eye Disease following COVID-19 Vaccination – A Case Report
Published in Ocular Immunology and Inflammation, 2023
Chien-Wei Hung, Chih-Heng Hung
A 51-year-old Asian male had a history of well-controlled GD under regular follow-up, treated with carbimazole (10 mg per day) for 10 years, and TED with post bilateral (OU) orbital decompression 7 years ago. Recent thyroid function tests showed stable results. However, two weeks after the administration of the second dose of the BNT162B2 messenger ribonucleic acid (mRNA) (Pfizer-BioNTech) COVID-19 vaccine, he presented symptoms of anxiety, persistent tiredness and weakness. Five weeks after the injection, thyroid function tests showed elevated levels of thyroxine (free T4) (2.30 ng/dL; normal range, 0.93–1.70 ng/dL) and low levels of thyroid-stimulating hormone (TSH) (< 0.01 uIU/mL; normal range, 0.27–4.20 uIU/mL). During the follow-up period, the antithyroid drug was as previously prescribed with carbimazole (10 mg per day). Five months after the second dose of the Pfizer-BioNTech COVID-19 vaccine, he received the booster shot of the mRNA-1273 (Moderna) COVID-19 vaccine. Follow-up thyroid function tests showed worsened free T4 (7.77 ng/dL) and TSH (< 0.01 uIU/mL), and carbimazole (30 mg per day) was prescribed for another 3 months. The patient subsequently experienced hypothyroidism, and the antithyroid drug was halted for one month. After that, thyroid function tests showed elevated free T4 (6.31 ng/dL) and low levels of TSH (< 0.01 uIU/mL). Since then, the patient received carbimazole (10 mg per day), and recent thyroid function tests showed stable results for 2 months. Reactivation of GD lasted for a total duration of 11 months.
A retrospective study of pediatric thyroid eye disease: the Asian experience
Published in Orbit, 2022
Bryan Sim, Chiaw Ling Chng, Chia Audrey, Lay Leng Seah
Patient A (Figure 1) was a 13 year old Chinese girl, with Graves’ hyperthyroidism (diagnosed in January 2018) on carbimazole treatment, who had inactive mild TED. She had no surgical thyroidectomy or radioactive iodine treatment performed. Ophthalmic examination showed bilateral superior epiblepharon worse on the left with occasional lash corneal touch. Exophthalmometry revealed minimal proptosis with 18 mm in the right eye and 17 mm in the left eye. She also had preexisting myopia with a refractive error of −5DS in the right eye and −2.50DS in the left eye. Extraocular movements were full except for mild abduction deficits bilaterally with a mild elevation deficit in her right eye but she did not experience diplopia (Figure 2). Systemic clinical examination also revealed a diffuse soft non-tender enlarged goiter (Figure 3).
Current and future immunotherapies for thyroid cancer
Published in Expert Review of Anticancer Therapy, 2018
Alessandro Antonelli, Silvia Martina Ferrari, Poupak Fallahi
Thyroid function tests are to be checked at baseline and then every 2 months while on treatment with immune checkpoint inhibitors [53]. Immune checkpoint therapy can be continued for grade 1–2 hyperthyroidism, and treatment is initiated for symptoms of hyperthyroidism [54,55]. In case of symptomatic hyperthyroidism (grade 3), immune checkpoint inhibitor therapy should be withheld and corticosteroids commenced (oral prednisolone 1–2 mg/kg/day) [54]. If necessary, anti-thyroid medications (methimazole, propilthyouracil, or carbimazole) may be indicated. In case of severe hyperthyroidism (grade 4), immune checkpoint inhibitor therapy should be permanently stopped, and methylprednisolone (1–2 mg/kg/day; IV) should be administered for 3 days, followed by oral prednisolone (1–2 mg/kg/day), which is tapered over at least 1 month [54].
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