Hyperthyroidism in Adults

Clinical Description

• Metabolic disorder resulting from excessive circulating thyroid hormones

Causes

• Graves’ disease, toxic multinodular goitre, toxic solitary nodule

Signs and Symptoms

• Fatigue, nervousness or anxiety, weight loss, palpitations, heat intolerance, irregular menses/sub infertility.
• Tachycardia (may be irregular if atrial fibrillation), warm moist hands.
• Goitre (smooth if Grave’s disease) and tremor.
• Diarrhoea, jaundice or heart failure symptoms and signs (if in thyroid storm).
• If Graves’ disease: thyroid eye signs: lid retraction, proptosis, lid lag, chemosis, ophthalmoplegia.

Investigations

• Thyroid function tests
• Full blood count
• Thyroid antibodies (TSH-receptor antibody, Thyroperoxidase antibody)
• Thyroid gland ultrasound
• Random blood sugar
• ECG and echocardiogram

Treatment

• Treatment objectives are to reduce thyroid hormone levels in the blood to normal, reduce symptoms associated with thyrotoxicosis, and prevent or treat complications e.g., heart failure, atrial fibrillation and ophthalmopathy.

Pharmacological

• Management should be supervised by a doctor
• Refer to tertiary level

Treatment

• Give Propranolol 40-120mg q8h to control symptoms, especially tachycardia
• Give Carbimazole 40mg od or in divided doses for approximately 2 months then reduce dose according to symptoms improvement and improved thyroid function tests. Monitor side effects of carbimazole (neutropenia with infection, hepatitis)
• In Graves’ disease continue for 12 to 18 months then stop and monitor TSH every 3 months for a year, then once a year (In large percentage, hyperthyroidism will be resolved)
• If patient pregnant or breast-feeding, use Propylthiouracil instead of carbimazole
• For persistent hyperthyroidism on treatment in Grave’s disease, and relapsed hyperthyroidism after remission following treatment, consider total thyroidectomy (or radioactive iodine once it becomes available in the country)
• In other causes continue Carbimazole and refer for surgery or radioactive iodine once it becomes available in the country which might be soon; these patients should be considered for radioiodine first before surgery unless it not suitable in their case)