• Grave's disease diagnosis:
  1. Presentation of new onset ophthalmopathy, large non-nodular thyroid, or other signs of hyperthyroidism
  2. Measure TSH, free T4 - TSH will be suppressed, free T4 will be elevated
  3. Radioactive iodine uptake scan - will have diffusely high radioiodine uptake
  4. Measurement of thyroidal blood flow on ultrasound - will see increased blood flow
  5. Measurement of thyrotropin receptor antibodies 
  
  

  Posted 06/29/16 10:50:36 AM by Anna Krigel

• Hyperthyroidism-unique physical exam signs
  • Brisk DTRs
  • Tachyarrhythmias
  • Means-Lerman Scratch - mid-systolic murmur heard in some hyperthyroid patients
  
  

  Posted 06/29/16 10:56:36 AM by Anna Krigel

• Management of Grave's disease
  
  Methimazole - primary drug used to treat Grave's disease
  • faster acting than PTU, better side effect profile
  • dosed once daily - inhibits thyroperoxidase for 24 horus
  • need to check baseline WBC count as 1/5000 people can have agranulocytosis (though hyperthyroid patients can have a leukopenic lymphocytosis at baseline)
  • first-line therapy EXCEPT during 1st trimester of pregnancy - use PTU instead
  Radioiodine ablation
  • used as definitive therapy for Grave's disease in non-pregnant patients
  • patients with significant symptoms or with underlying cardiovascular disease should be treated first with methimazole
  • thyroid storm can occur after ablation
  • ablation has the potential to cause or worsen Grave's ophthalmopathy
  • can take up to 6 months to be fully effective
  Surgery
  • preferred definitive therapy for Grave's patients with Grave's ophthalmopathy, those in the second trimester of pregnancy, or those who want immediate improvement (e.g. desire to become pregnant)
  
  

  Posted 06/29/16 11:13:19 AM by Anna Krigel

• Methimazole toxicity
  • teratogenicity in the first trimester of pregnancy
  • agranulocytosis - occurs in 0.1 to 0.5% of people, usually within the first 2-3 months of drug initiation
  • hepatotoxicity - typically secondary to cholestatic dysfunction, shown in case series to occur within 180 days of methimazole initiation, typically occurs at doses >13mg/day
  
  

  Posted 06/29/16 05:14:39 PM by Anna Krigel

• Hyperthyroidism Diagnosis and Treatment Review
  Methimazole toxicity case series
  
  

  Posted 06/29/16 05:15:37 PM by Anna Krigel

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