<<forEachTiddler  where 'tiddler.tags.contains(context.inTiddler.title)'
sortBy 
        tiddler.title
    ascending 
write '"*[["+tiddler.title+"]]\n"'>>
<<tiddler AutoRefresh with: force>>

2-3% F 0.2-0.3% M - Caucasians
 
T4 / T3 - increases metabolic rate and sensitivity to sympathetic NS so causes ....
weight loss
heat intolerance, sweating
tremor, palpitations (?AF)
Irritable, poor concentration, sleep disturbance
Diarrhoea
Oligo / amenorrhoea
 
Causes ....
''Graves (autoimmune)'' 70-90% - IgG to TSH receptor keeping it switched on - peaks 20-50yrs
relapse and remit (wks to years) - esp if male, large goitre, more severe disease at presentation
give initial Rx for over 1year - best chance for remission
Abs present in 70% (antithyroid peroxidase (TPO) and anti-thyroglobulin (TG))
''Toxic Adenoma'' - 3-5% - single follicular adenoma - solitary mobile neck lump
''Toxic Multinodular goitre'' - 15-20% - develops slowly, elderly, not resolve without surgery or I131
''De Quervain's thyroiditis'' - ? response to acute viral illness, painful thyroid, Rx NSAID or steroid (30mg 2/52) takes 2-4/52 to resolve
note ''thyrotoxicosis factitia'' (xs use thyroxine ?desire to loose weight)
other rare causes - ''Pituitary adenoma, molar pregnancy, carcinoma''

''Sx only with Graves''
Proptosis - enlarged extraocular muscles
Thyroid dermopathy - esp pretibial - thickened skin with peau d'orange
Thyroid acropachy - clubbing - soft tissue swelling and periosteal changes - fingers and toes
 
''Sx with all hyperthyroid''
eyelid retraction - overstimulation of Mullers muscle in eyelid
AF - also with subclinical hyperthyroid - 15% - may need control thyroid, rate control AF and warfarin 
tremor - fine with hands outstretched - restlessness - helped with thyroid Rx and BB
 
Also get ...
hypercalcaemia
normochromic normocytic anaemia
abnormal LFT
 
Some need Isotope scanning (functional test) but not all - 2ndary care request
USS useful for nodules
 
''Medical Mx''
''Carbimazole'' - can titrate dose to T4 level (risk hypothyroid) or block with high dose and replace with thyroxine (more SE, not good for fetus)
takes - 2-3/52 to get response - recheck bloods 4-6/52
SE - headache, nausea, arthralgia, skin rash (change drug), agranulocytosis - rare but serious - sore throat, mouth ulcers, fever - stop drug if sore throat, usually recover in 1-2/52 - never give again
''Propylthiouracil'' - bd, more SE
BB - help control Sx while thyroid drug works, then stop, not if asthma or heart failure
 
''Radioactive I131''
Destroys functioning follicular cells
capsule or liquid - tasteless - stop antithyroid drugs week before and after giving I131 (so it can act) and need to be euthyroid pre I131 else risk thyroid storm
half life 8 days, takes 6-8/52 to see effect, 60-80% resolve with one dose, can repeat at 4-6/12, no change in cancer risk with use
avoid in pregnancy (not for 6/12 after I131) and if active thyroid eye disease, 
for 2-3/52 avoid kids and public transport (may trigger alarm at airport) - carry card to show recent admin
TFT 3/12 for 1yr then annually - 80% Graves and 30% toxic adenoma will be hypothyroid by 20yrs after I131
inc risk of CVS disease and fracture (?hyper or hypothyroid or from Rx ??)
 
''Surgery''
Control medically first
98% cure rate with total / sub-total thyroidectomy
indications - pt choice, medication untolerated, CI to I131, large goitre (cosmesis)
1% - haemorrhage, vocal cord paralysis, hypoparathyroidism
hypothyroidism is expected
 
AF - 5% in under 60 >20% in over 70 in sub-clinical hyperthyroidism too
VTE risk is higher than AF alone - needs anticoagulation
 
usually new hyperthyroid needs referral to 2ndary care for diagnosis and initial Mx after Ix bloods and imaging
urgently if unwell, or to ophthalmology if severe eye Sx
if starting meds in GP - discuss with hospital team