What are the key learning points for morning report on hyperthyroidism (excessive thyroid hormone production)?

From the Guidelines

Hyperthyroidism management should focus on efficient diagnosis and treatment strategies, prioritizing patient outcomes and quality of life. When presenting hyperthyroidism cases, emphasize the importance of recognizing common symptoms (tachycardia, heat intolerance, weight loss, anxiety, tremor) and physical findings (goiter, exophthalmos, hyperreflexia) 1. Laboratory diagnosis relies on low TSH and elevated free T4/T3 levels. For treatment discussions, highlight that methimazole is the preferred antithyroid medication (starting at 10-30mg daily based on severity) over propylthiouracil (reserved for first trimester pregnancy or thyroid storm) 1.

Key points to consider:

• Beta-blockers like propranolol (10-40mg every 6 hours) effectively manage sympathetic symptoms while awaiting definitive treatment 1.
• For Graves' disease cases, discuss the treatment triad: antithyroid drugs (12-18 months), radioactive iodine ablation, or thyroidectomy, with their respective advantages and limitations 1.
• Emphasize monitoring for methimazole side effects, particularly agranulocytosis (check CBC if fever/sore throat develop), and the importance of checking TFTs every 4-6 weeks during initial treatment 1.
• For thyroid storm presentations, stress the urgency of treatment with high-dose propylthiouracil (200mg every 4 hours), saturated solution of potassium iodide (SSKI) drops, glucocorticoids, and aggressive supportive care 1.

It is essential to prioritize treatment for patients with a TSH level that is undetectable or less than 0.1 mIU/L, particularly those with overt Graves disease or nodular thyroid disease, as this approach is generally recommended despite lacking definitive data 1. Additionally, consider the presence of thyroid autoantibodies (antithyroid peroxidase [TPO] and antithyroglobulin [TG]) to identify patients at increased risk for thyroid autoimmunity 1.

From the FDA Drug Label

Patients who receive propylthiouracil should be under close surveillance and should be counseled regarding the necessity of immediately reporting any evidence of illness, particularly sore throat, skin eruptions, fever, headache, or general malaise. Thyroid function tests should be monitored periodically during therapy Once clinical evidence of hyperthyroidism has resolved, the finding of an elevated serum TSH indicates that a lower maintenance dose of propylthiouracil should be employed. Patients who receive methimazole should be under close surveillance and should be cautioned to report immediately any evidence of illness, particularly sore throat, skin eruptions, fever, headache, or general malaise. Thyroid function tests should be monitored periodically during therapy Once clinical evidence of hyperthyroidism has resolved, the finding of a rising serum TSH indicates that a lower maintenance dose of methimazole should be employed.

The key learning points for morning report on hyperthyroidism are:

• Monitoring: Patients with hyperthyroidism should be under close surveillance and monitored periodically for thyroid function tests.
• Dose adjustment: Once clinical evidence of hyperthyroidism has resolved, the dose of antithyroid medication (such as propylthiouracil or methimazole) should be adjusted based on serum TSH levels.
• Adverse effects: Patients should be cautioned to report immediately any evidence of illness, particularly sore throat, skin eruptions, fever, headache, or general malaise, as these may be signs of adverse effects such as agranulocytosis or vasculitis 2 3.
• Pregnancy: Hyperthyroidism should be closely monitored in pregnant women, and treatment adjusted to ensure a sufficient but not excessive dose is given during pregnancy 2 3.

From the Research

Key Learning Points for Morning Report on Hyperthyroidism

• Hyperthyroidism is a condition where the thyroid gland produces and secretes inappropriately high amounts of thyroid hormone, which can lead to thyrotoxicosis 4.
• The prevalence of hyperthyroidism in the United States is approximately 1.2% 4, with a global prevalence of 0·2-1·3% 5.
• Common causes of hyperthyroidism include:
  • Graves' disease (GD) 4, 5
  • Toxic multinodular goiter 4, 5
  • Toxic adenoma 4, 5
  • Subacute granulomatous thyroiditis 5
  • Drugs such as amiodarone, tyrosine kinase inhibitors, and immune checkpoint inhibitors 5
• Diagnosis can be made based on clinical findings and confirmed with biochemical tests and imaging techniques, including:
  • Low TSH, high free thyroxine (FT4), or high free tri-iodothyonine (FT3) 5
  • Ultrasound 4
  • Radioactive iodine uptake scans 4
• Management options for hyperthyroidism include:
  • Anti-thyroid medications (e.g., propylthiouracil, methimazole) 4, 5, 6, 7
  • Radioactive iodine ablation of the thyroid gland 4, 5, 7
  • Surgical thyroidectomy (e.g., total thyroidectomy for GD and toxic multinodular goiters, thyroid lobectomy for toxic adenomas) 4, 7
• Treatment should be individualized, taking into consideration the underlying pathology, age, sex, patient preference, and availability of expert thyroid surgical care 8.
• Long-term management of patients with hyperthyroidism requires careful consideration of the likely outcomes of treatment, including the risk of hypothyroidism 8.
• Cardiovascular manifestations, such as hypertension and tachycardia, should be recognized and treated with beta blockers 4.
• Thyroid storm is a rare but life-threatening condition that can occur with thyrotoxicosis and must be treated with a multidisciplinary approach and ultimately, definitive treatment of the hyperthyroidism 4, 6.