Graves’ Disease. The Case (1) 55 F Graves’ disease diagnosed at 彰基 one year ago Initial...

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Graves’ Disease

Transcript of Graves’ Disease. The Case (1) 55 F Graves’ disease diagnosed at 彰基 one year ago Initial...

Page 1: Graves’ Disease. The Case (1) 55 F Graves’ disease diagnosed at 彰基 one year ago Initial presentation: sweating, good appetite, easy nervousness Physical.

Graves’ Disease

Page 2: Graves’ Disease. The Case (1) 55 F Graves’ disease diagnosed at 彰基 one year ago Initial presentation: sweating, good appetite, easy nervousness Physical.

The Case (1)

55 F Graves’ disease diagnosed at 彰基

one year ago Initial presentation: sweating, good

appetite, easy nervousness Physical examination: enlarged thyr

oid gland about 5 cm in diameter at both lobes

PTU 1# bid

Page 3: Graves’ Disease. The Case (1) 55 F Graves’ disease diagnosed at 彰基 one year ago Initial presentation: sweating, good appetite, easy nervousness Physical.

The Case (2)

95/7/17: MVP, TVP 7/22: Af i RVR (HR 220) →Amiodarone 7/23: Bradycardia, conscious change

→ Pericardiocetesis, 580mL 7/24: Re-op PTU 1# qd during 7/19-7/24, then DC HR↑, free T4: 4.53, TSH<0.15 on 8/11 Newmazole 1# tid since 8/15

Page 4: Graves’ Disease. The Case (1) 55 F Graves’ disease diagnosed at 彰基 one year ago Initial presentation: sweating, good appetite, easy nervousness Physical.
Page 5: Graves’ Disease. The Case (1) 55 F Graves’ disease diagnosed at 彰基 one year ago Initial presentation: sweating, good appetite, easy nervousness Physical.

Graves’ disease

60 to 80% of hyperthyroidism Autoimmune disorder Common between 30 and 40

years Woman, 0.5 per 1000 Family history

Page 6: Graves’ Disease. The Case (1) 55 F Graves’ disease diagnosed at 彰基 one year ago Initial presentation: sweating, good appetite, easy nervousness Physical.

Clinical Presentation

Manifestations of hyperthyroidism: hypermetabolic state

Manifestations of Graves’ disease: Ophthalmopathy Localized dermopathy Thyroid acropachy

Page 7: Graves’ Disease. The Case (1) 55 F Graves’ disease diagnosed at 彰基 one year ago Initial presentation: sweating, good appetite, easy nervousness Physical.
Page 8: Graves’ Disease. The Case (1) 55 F Graves’ disease diagnosed at 彰基 one year ago Initial presentation: sweating, good appetite, easy nervousness Physical.

Diagnostic Modality

Decreased TSH Increased free T4 and incr

eased T3 TSHR-Ab Thyroid radioactive iodine

uptake and scan

Page 9: Graves’ Disease. The Case (1) 55 F Graves’ disease diagnosed at 彰基 one year ago Initial presentation: sweating, good appetite, easy nervousness Physical.

Treatment

Anti-thyroid drugs Radioactive iodine therapy (RAI) Surgery

Page 10: Graves’ Disease. The Case (1) 55 F Graves’ disease diagnosed at 彰基 one year ago Initial presentation: sweating, good appetite, easy nervousness Physical.

Anti-thyroid drugs

Propylthiouracil Carbimazole → Methimazole Both inhibit thyroid peroxidase PTU also inhibits T4 to T3 conversio

n Immunomodulatory action?

Page 11: Graves’ Disease. The Case (1) 55 F Graves’ disease diagnosed at 彰基 one year ago Initial presentation: sweating, good appetite, easy nervousness Physical.

Adverse effects

Rash Arthralgias Urticaria GI symptoms Agranulocytosis

Page 12: Graves’ Disease. The Case (1) 55 F Graves’ disease diagnosed at 彰基 one year ago Initial presentation: sweating, good appetite, easy nervousness Physical.

Drug Therapy

The Titration regimen is just as effective as the Block-Replace regimen with a significantly lower incidence of adverse effects.

The optimal duration of anti-thyroid drug therapy for the Titration regimen is 12–18 months.

There is no benefit from continued T4 replacement after a course of anti-thyroid treatment.

Page 13: Graves’ Disease. The Case (1) 55 F Graves’ disease diagnosed at 彰基 one year ago Initial presentation: sweating, good appetite, easy nervousness Physical.

Radioactive Iodine Therapy 131I Long latency period Contraindication: pregnancy, lactat

ion, ophthalmopathy? Only slight increased risk of mortali

ty from thyroid cancer but no other malignancies

Nausea, pain

Page 14: Graves’ Disease. The Case (1) 55 F Graves’ disease diagnosed at 彰基 one year ago Initial presentation: sweating, good appetite, easy nervousness Physical.

ATD vs. RAI (1)

Page 15: Graves’ Disease. The Case (1) 55 F Graves’ disease diagnosed at 彰基 one year ago Initial presentation: sweating, good appetite, easy nervousness Physical.

ATD vs. RAI (2)

Page 16: Graves’ Disease. The Case (1) 55 F Graves’ disease diagnosed at 彰基 one year ago Initial presentation: sweating, good appetite, easy nervousness Physical.

Surgery

Young age Male sex Pregnancy/lactation Patient preference Large or nodular goiter Inability to tolerate ATDs

Page 17: Graves’ Disease. The Case (1) 55 F Graves’ disease diagnosed at 彰基 one year ago Initial presentation: sweating, good appetite, easy nervousness Physical.

Complications

Thyroid storm or thyrotoxic crisis Hypothyroidism Recurrent hyperthyroidsim Recurrent laryngeal nerve injury Hypoparathyroidism

Page 18: Graves’ Disease. The Case (1) 55 F Graves’ disease diagnosed at 彰基 one year ago Initial presentation: sweating, good appetite, easy nervousness Physical.

Conclusions

Current treatment for Graves’ disease is effective, but the ideal treatment is still not available.

Further understanding about immunologic processes involved should allow better diagnostic methods and treatments.