1. Prof. M.ABD ELAZIZ Department of Clinical Pharmacy College of Pharmacy Salman Bin Abdulaziz University Mohammad Ruhal Ain Department of Clinical Pharmacy College of Pharmacy Salman Bin Abdulaziz University

2.  Hypothyroidism is a disorder with multiple causes in which the thyroid fails to secrete an adequate amount of thyroid hormone. Common causes of hypothyroidism are autoimmune disease, surgical removal of the thyroid, and radiation treatment.

3. CAUSES AUTOIMMUNE DISEASE Immune system Against bacterial and viral "invaders." protects In autoimmune diseases, immune system Normal part of the body Attacks In autoimmune hypothyroidism, Attacks Thyroid cells Cells inflamed and damaged interfering with their ability to make thyroid hormone

4. The most common form of autoimmune hypothyroidism is called Hashimoto’s disease. SURGICAL REMOVAL OF PART OR ALL OF THE THYROID Part or the entire thyroid removed Thyroid nodules, Thyroid cancer, or Graves' disease Hypothyroidism results when the entire thyroid is removed or when the remaining thyroid tissue no longer works properly.

5. RADIATION TREATMENT Graves' disease, nodular goiter, or thyroid cancer Treated with radioactive iodine ( 131 I) destroys the thyroid Hypothyroidism

6. Causes Cont………………….. CONGENITAL (FROM BIRTH) HYPOTHYROIDISM MEDICINES Lithium (most common) Amiodarone (Antiarrythmic), interferon alpha, and interleukin-2 TOO LITTLE OR TOO MUCH IODINE DAMAGE TO THE PITUITARY GLAND The pituitary gland tells the thyroid how much hormone to make.

7. TSHT 4 T 3 Hypothyroidism HighLow Low Hyperthyroidism LowHigh High Typical Thyroid Hormone Levels in Thyroid Disease

8. Case 1: M.W., a 70-kg, 23-year-old voice student, thinks that her neck has become “fatter” over the past 3 to 4 months. She has gained 10 kg, feels mentally sluggish, tires easily, and finds that she can no longer hit high notes. Physical examination reveals puffy facies, yellowish skin, delayed DTRs, and a firm, enlarged thyroid gland. Laboratory data include FT4, 0.6 ng/dL (normal, 0.7– 1.9); TSH, 60 μunits/mL (normal, 0.5–4.7); and TPO antibodies, 136 IU/L (normal,<1). Free thyroxine ( FT4), Thyroid-stimulating hormone ( TSH), Thyroid peroxidase (TPO) DTR = deep tendon reflexes

9. Assess M.W.’s thyroid status based on her clinical and laboratory findings. According to the patient results ! He has low T4 and high TSH Hypothyroidism

10. Classify hypothyroid disorders ? (hypothyroidism disorders ) A. Hashimoto’s disease: Most common hypothyroid disorder i. Autoimmune-induced thyroid injury resulting in decreased thyroid secretion ii. Disproportionately affects women more than men B. Surgery or radioiodine induced (iatrogenic) C. Iodine deficiency or excessive intake D. Secondary causes i. Pituitary insufficiency (lack of TSH secretion) ii. Drug induced (e.g., amiodarone, lithium) This patient has hashimoto’s disease

11. Sings and symptoms consistent with hypothyroidism ? Subjective Thinks that her neck has become “fatter” over the past 3 to 4 months. She has gained 10 kg, feels mentally sluggish, tires easily, and finds that she can no longer hit high notes. Objective ? reveals puffy facies, yellowish skin, delayed DTRs, and a firm, enlarged thyroid gland. FT4, 0.6 ng/dL (normal, 0.7– 1.9); TSH, 60 μunits/mL (normal, 0.5–4.7); and TPO antibodies, 136 IU/L (normal,<1).

12. Signs and symptoms HypothyroidismHyperthyroidism a. Cold intolerance b. Dry skin c. Fatigue, lethargy, weakness d. Weight gain e. Bradycardia f. Slow reflexes g. Coarse skin and hair h. Periorbital swelling i. Menstrual disturbances (more frequent or longer menstruation, painful menstruation, menorrhagia) a.Weight loss/increased appetite b. Lid lag c. Heat intolerance d. Goiter e. Fine hair f. Heart palpitations/tachycardia g. Nervousness, anxiety, insomnia h. Menstrual disturbances (lighter or more infrequent menstruation, amenorrhea) i. Sweating or warm, moist skin j. Exophthalmos, pretibial myxedema in Graves disease

13. Write a note on signs and symptoms regarding hypothyroidism and hyperthyroidism ?

14. Goal of therapy ? 1. Minimize or eliminate symptoms, 2. Improve quality of life 3. Minimize long-term damage to organs. 4. Normalize free T4 and TSH concentrations. Goal of therapy for hypothyroidism including hyperthyroidism

15. Hyperthyroidism

16. Hyperthyroidism refers to excess synthesis and secretion of thyroid hormones by the thyroid gland, which results in accelerated metabolism in peripheral tissues Hyperthyroidism

17. Case 2: S.K., a 48-year-old woman, is admitted to the hospital for a possible MI. Her complaints include chest pain that is unrelieved by NTG, increasing SOB with exercise, nervousness, palpitations, muscle weakness, weight loss despite an increased appetite, and epistaxis; she also bruises easily. She has a history of deep venous thrombosis treated with warfarin (Coumadin) 5 mg/day; her last prothrombin time (PT) was 18 seconds (normal, 10.5–12.1), and an international normalized ratio (INR) was 1.8 (normal, 1; therapeutic, 2–3). She has angina, treated withNTG0.4 mg, and CHF, treated with digoxin (Lanoxin) 0.25 mg/day.

18. Physical examination reveals a thin, flushed, hyperkinetic, nervous woman. Blood pressure (BP) is 180/90 mmHg; pulse is 130 beats/minute, irregularly irregular; respiratory rate is 30 breaths/min; and temperature is 37.5◦C. Other pertinent findings include a lid lag with stare, proptosis with tearing, a diffusely enlarged thyroid gland without nodules, a bruit in the left lobe of the thyroid, positive jugular venous distention (JVD), bibasilar rales, warm moist skin with multiple bruises, new-onset atrial fibrillation (AF), slight diarrhea, hepatomegaly, acropachy, 2+ pitting edema, a fine tremor, proximal muscle weakness, and irregular scant menses

19. Laboratory data FT4, 2.9 ng/dL (normal, 0.7–1.9); TSH,<0.5 μunits/mL (normal, 0.5–4.7); RAIU at 24 hours, 80% (normal, 5%–35%); PT, 40 seconds (normal, 10.5–12.1); INR, 4.8 (normal, 1; therapeutic, 2–3); TPO, 200 IU/mL (normal,<1); alkaline phosphatase, 200 units/L (normal, 41–133); total bilirubin, 1.1 mg/dL (normal, 0.1–1.2); AST, 60 units/L (normal, 7– 26); and alanine aminotransferase (ALT), 55 units/L (normal, 3–23). A scan shows a diffusely enlarged gland, three to four times normal size. Radioactive Iodine Uptake Test

20. Assess S.K.’s thyroid status based on her clinical and laboratory findings. According to the patient results ! FT4, 2.9 ng/dL (normal, 0.7–1.9); TSH,<0.5 μunits/mL (normal, 0.5–4.7); Hyperthyroidism

21. if thyroid gland is actively and excessively secreting T4 and/or T3 Elevated Radioactive iodine (Graves disease, TSH-secreting adenoma, toxic adenoma, multinodular goiter) Elevated in disorders caused by thyroiditis or hormone ingestion. Uptake is suppressed Uptake is suppressed RAIU at 24 hours, 80% (normal, 5%–35%)………..(Elevated ) Patient: Hyperthyroidism - Grave’s disease

22. Signs and symptoms support diagnosis of hyperthyroidism in this patient ? include chest pain that is unrelieved by NTG, increasing SOB with exercise, nervousness, palpitations, muscle weakness, weight loss despite an increased appetite, and epistaxis; she also bruises easily. Blood pressure (BP) is 180/90 mmHg; pulse is 130 beats/minute, irregularly irregular; respiratory rate is 30 breaths/min a lid lag with stare, proptosis with tearing, a diffusely enlarged thyroid gland without nodules, a bruit in the left lobe of the thyroid, positive jugular venous distention (JVD), bibasilar rales, warm moist skin with multiple bruises, new-onset atrial fibrillation (AF), slight diarrhea, hepatomegaly, acropachy, 2+ pitting edema, a fine tremor, proximal muscle weakness, and irregular scant menses FT4, 2.9 ng/dL (normal, 0.7–1.9); TSH,<0.5 μunits/mL (normal, 0.5– 4.7); RAIU at 24 hours, 80% (normal, 5%–35%); PT, 40 seconds (normal, 10.5–12.1); INR, 4.8

23. Signs and symptoms HypothyroidismHyperthyroidism a. Cold intolerance b. Dry skin c. Fatigue, lethargy, weakness d. Weight gain e. Bradycardia f. Slow reflexes g. Coarse skin and hair h. Periorbital swelling i. Menstrual disturbances (more frequent or longer menstruation, painful menstruation, menorrhagia) a.Weight loss/increased appetite b. Lid lag c. Heat intolerance d. Goiter e. Fine hair f. Heart palpitations/tachycardia g. Nervousness, anxiety, insomnia h. Menstrual disturbances (lighter or more infrequent menstruation, amenorrhea) i. Sweating or warm, moist skin j. Exophthalmos, pretibial myxedema in Graves disease

24. Goal of therapy ? 1. Minimize or eliminate symptoms, 2. Improve quality of life 3. Minimize long-term damage to organs. 4. Normalize free T4 and TSH concentrations. Goal of therapy for hyperthyroidism including hypothyroidism

25. differences between T 3 and T 4 ?

26. S. No. T3T3 T4T4 1.L-3,5,3'-triiodothyronineThyroxine/ L-3,5,3',5'- tetraiodothyronine 2.Active hormone T4 is produced by thyroid gland and is converted into T3 in the liver. 3.T3 is less common than T4 T4 is more common than T3 4.More potentLess potent

27. Question?