Hyperthyroidism E05.9

Hyperthyroidism (hyperthyroidism) is a condition caused by excess thyroid hormones and their effect on peripheral body cells.

Hyperthyroidism has several underlying causes. Common causes are:

• Graves' disease (immunohyperthyroidism)
• functional autonomy (non-immunogenic thyroid autonomy)
• unifocal autonomy (autonomous adenoma)
• multifocal autonomy
• disseminated autonomy

Rare causes are:

• hormone-active thyroid carcinoma and metastases
• Thyroiditis (passager): Hashimoto's T., Postpartum T., Silent de Quervain Radiation T., Amiodarone-induced Thyroidopathy II
• exogenous hormone supply (Hyperthyreosisfactitia)
• Jode excess in existing thyroid disease, contrast medium, medication, amiodarone-induced thyroidopathy I
• TSH (-like) activities, pituitary adenoma (TSHom), paraneoplastic, HSG stimulation (bladder mole, chorionic carcinoma, pregnancy).
  

The following clinical symptoms should be taken into account in the patient's medical history:

• Weight loss despite normal or increased food intake
• inner and motor restlessness, fine tremor
• Nervousness, quick excitability, unsteadiness, lack of concentration, sleep disorders, anxiety, depressive symptoms
• general tendency to weld, heat intolerance
• Performance kink, rapid exhaustion, adynamics, stress dyspnoea
• increased stool frequency; mostly (mushy) bowel movement
• neagtive calcium balance with osteopathy
• Women: cycle disorders
• Men: erectile dysfunction
• Opthalmological complaints: photophobia, eyelid edema, increased tearing of the eyes, foreign body sensation; possible double vision
  

Depending on the problem, the following laboratory values are examined:

exclusion of hyperthyroidism: normal TSH value

Detection of hyperthyroidism:

• Subclinical latent hyperthyroidism: TSH low, fT4 and fT3 are normal:
• Manifest hyperthyroidism: TSH low, fT4 and fT3 are elevated
• Autoimmune hyperthyroidism (Graves ' disease): TRAK, TPO-AK, TG-AK increased. No antibody detection in case of functional autonomy.
• Autoimmune thyroiditis Hashimoto: TG-AK, TPO-AK are elevated: TRAK negative.
• Thyroid hormone resistance (RTH): fT3 and fT4 are elevated, TSH normal; a differential diagnosis is necessary

In many cases, hyperthyroidism can be distinguished from psychosomatic complaints. The following speak against hyperthyroidism
: damp-cold hands, heat tolerance, tendency to freeze, normal
blood pressure and pulse, tendency to orthostasis
,fear of space
, psychogenic globe, multiple cardiac
disorders, hypertension intoxications
(drugs, alcohol).

Thiamazole (agent of choice): initially 20 to maximum 30 mg/day, within 2 to 4 weeks reduction to a maintenance dose of 2.5 to 10 mg/day.

Carbimazole: no advantages compared to thiamazole, because carbimazole is converted hepatic into thiamazole. 10 mg carbimazole corresponds to about 7 mg thiamazole. Dosage: initial 15 to 50 mg/day, then a maintenance dose of 5 to 15 mg/day.

Propylthiouracil: alternative preparation for side effects of thionamides. Initial 150 to 300 mg/day in 2 to 3 doses. Maintenance dose: 50 to 150 mg/day.

Sodium perchlorate: initial 1200 to 2000 mg/day, then a maintenance dose of 100 to 400 mg/day. Perchlorate should not be used during a planned radioiodine therapy, because the iodine uptake is blocked.

The duration of treatment varies according to the manifestation:

Autoimmune hyperthyroidism: The duration of treatment is 8 to 12 months, followed by an attempt to cure. Four weeks later, the laboratory values fT3, fT4, TSH, TRAK and a sonography are checked. In case of persistence or recurrence of hyperthyroidism, treatment with thyrostatic drugs may be repeated for 6 to 12 months. The treatment of choice here is surgery or radioiodine therapy.

There is a case for persistence of hyperthyroidism:

• the TRAK value is > 10 IU/I after 6 months of thyrostatic therapy and > 7.5 IU/I after 12 months
• despite high-dose therapy with thyrostatic drugs, a satisfactory euthyroid metabolism is not achieved
• progressive therapy-resistant endocrine orbitopathy
• great goiter
• Autonomy

Therapy with thyrostatic drugs is carried out until euthyroidism is reached, followed by ablative therapy in the form of radioiodine therapy or surgery.

Long-term therapy with thyrostatics is possible for old patients who are inoperable or refuse surgery. In these cases, patients must be informed about possible hematological side effects such as sore throat and fever. In female patients, advice on contraception must be given.

Hyperthyroidism and pregnancyManifestations of
hyperthyroidism in pregnancy: low-dose thyrostatic monotherapy is used:

in the 1st trimester of pregnancy Propylthiouracil is the drug of choice. Initially, 100 to 150 mg per day are administered, a maximum of 200 mg in three single doses. Initially for 2 to 4 weeks, followed by a rapid reduction to a low maintenance dose of 25-50-150 mg.

In the 2nd trimenon, a switch to thiamazole with a maintenance dose of 2.5-5-10 mg per day takes place. If thiamazole is administered initially: 5 to 15 mg per day.
Important: close controls (at intervals of 2 to 6 weeks). Hypothyrotic phases should be avoided in any case, do not aim at normalizing the TSH value, fT3 and fT4 are in the upper normal range.
Symptomatic and low-dose therapy with beta blockers is possible temporarily and as a supplement.
If there is a very high requirement for thyrostatic drugs or an intolerance, surgery is possible (in the 2nd trimester), if necessary also in the case of large goiter with mechanical problems.
High placental maternal TRAK titres can stimulate a foetal thyroid gland. If the TRAK value is more than 3 times higher, close sonographic monitoring in the 2nd trimester is necessary.

Postpartum pediatric monitoring of the child
:Exclusion of goiter or hyperthyroidism as an iatrogenic therapy consequence

Exclusion of fetal or neonatal TRAK-induced hyperthyroidism

Breastfeeding during thyrostatic therapy: doses up to 20 mg thiamazole or 150 to 300 mg prophylthiouracil

Gestational hyperthyroidism: Therapy is only carried out in exceptional cases and for a short period of time with minimally dosed beta blockers.

Hyperthyroidism in thyroiditis De Quervain or Hashimoto
: It is recommended to initially wait and see during therapy. Thyrostatic drugs should not be administered. If hypothyroidism develops, an L-thyroxine substitution takes place.

Postpartum thyroiditis: In this case a wait-and-see attitude is recommended because the spontaneous healing rate is very high. In the case of drug therapy beta blockers should be used, not thyrostatic drugs.

Iodine-induced hyperthyroidism Therapy may result in an increased initial requirement of thiamazole in combination with sodium perchlorate. The initial dose is 1200 to 2000 mg per day, the maintenance dose is 100 to 400 mg per day.

For prevention in case of unavoidable use of iodine-containing contrast media (in patients with functional autonomy): sodium perchlorate: 500 mg orally 2 to 4 hours before and after the administration of contrast media, and 3 times 300 mg per day for the following 7 to 14 days. In addition, thiamazole can be taken before and after the administration of contrast medium.

Before starting therapy, it is important to distinguish between autoimmunological and autonomous hyperthyroidism. Furthermore, hyperthyreosis factitia must be excluded.

Patients with autoimmune hyperthyroidism tend to dissimulate.