Graves Disease (hyperthyroidism)
What are the ocular manifestations of Graves?
Upper eyelid retraction (Darymple sign) Staring appearance (Kocher sign) Lid lage with downward gaze (von Graefe sign) Exophthalmos (inc retro-orbital fat) Diplopia and blurred vision
Who needs prophylactic tx before radioactive iodine (Graves)? With what drug?
Smokers and patients with ophthalmopathy Prednisone
What should you watch for when using thiourea drugs to treat Graves?
Agranulocytosis in first 60-90 days of treatment: stop drug and seek med attention immediately with any infection or abnormal bleeding
What is the pathogenesis (timeline) of Graves?
Autoantibodies (TSHrAb) bind to TSH receptors Stimulate thyroid hormone synthesis and secretion Stimulates thyroid growth (causing diffuse goiter)
What is Graves disease?
Autoimmune disorder Autoantibodies (TSHrAb) to TSH receptors
Who is pharm treatment best for (Graves)?
Best in young adults, mild thyrotoxicosis, small goiters Prior to surgery or RAI treatment
What is used to treat/control symptoms of Graves?
Beta blocker: for symptomatic relief of tachy, tremor, diaphoresis, anxiety Atenolol 25-50 mg/day (200 max) Propranolol ER 60 mg once or twice daily (320 max)
What are consequences of radioactive iodine treatment for Graves?
D/C thiourea drugs, can cont propranolol Smokers/opthalmopathy need prophylactic tx with prednisone High incidence of hypothyroidism Lifelong thyroid hormone and calcium monitoring
What are possible complications of a thyroidectomy (Graves)?
Damage to recurrent laryngeal nerve Hypoparathyroidism: watch calcium levels
What are cardio manifestations of Graves?
Forceful heartbeat PACs Sinus tachy Exertional dyspnea Pulmonary HTN A fib, cardiomyopathy (less common)
What is the most common cause of hyperthyroidism?
Graves
What can cause hyperthyroidism?
Graves disease Excessive iodine intake Subacute thyroiditis Prenancy/post-partum Toxic multinodular goiter Exogenous LT4
What is the thyroidectomy surgical method?
Hartley-Dunhill: total resection of one lobe, subtotal resection of other lobe, leaving 4 g of tissue
What will serum TSH, FT4, and serum T3 labs be in hyperthyroidism?
Low High High
Which thiourea drug is teratogenic?
Methimazole Less hepatic necrosis
What is the most important diagnostic finding for Graves?
Positive ANA, TSHrAb
When is radioactive iodine C/I (Graves)?
Pregnancy, nursing, lack of childcare
When is thyroidectomy (Graves) indicated?
Pregnant women not controlled with low dose thiourea drugs Women who plan conception in near future
What is a unique clinical sign of Graves disease (presents in lower limbs)?
Pretibial myxedema Peau d'orange (orange skin) Deposits of hyaluronic acid
What is the thiourea drug of choice during pregnancy and nursing?
Propylthiouracil (PTU)
What is the treatment of choice in adult patients with Graves?
Radioactive Iodine: destroys overactive thyroid tissue
What labwork should be ordered for Graves?
TSH T4/FT4 T3/FT3 TSHrAb (TSI) - thyrotropin receptor antibodies
What are the possible pharmacologic treatments for Graves? (not first line)
Thiourea drugs (methimazole, PTU): can be used long-term, lower incidence of post-tx hypothyroidism
What imaging diagnostics are used for Graves?
Thyroid U/S Radioactive Iodine Uptake (RAIU) scan
What is another name for hyperthyroidism?
Thyrotoxicosis
Who is more affected by Graves?
Women 8:1 Family history of thyroid disease Assoc with increased risk of other auto diseases