Hyperthyroidism -- Overview and Analysis Term Paper

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Once a patient is being treated for hyperthyroidism, his or her health professional will usually test TSH and thyroid hormones several times each year to evaluate how well the patient is responding to treatment and to check for a worsening of the condition. ("Hyperthyroidism: Topic Overview -- Exams and Tests," WebMD, Last updated 6 Aug 2003) Other tests include an anti-thyroid antibody test, which may help specifically diagnose Graves' disease and autoimmune thyroiditis, if the patient is known to have a genetic history of Graves in particular. ("Hyperthyroidism: Topic Overview -- Exams and Tests," WebMD, Last updated 6 Aug 2003) radioactive thyroid scan and radioactive iodine uptake tests are also often performed to evaluate why the thyroid gland is overactive. "Radionuclide uptake and scan" can also easily distinguish the high uptake of Graves' disease from the low uptake of thyroiditis" and provide other useful anatomic information about failures in the patient's endocrine system due to iodine exposure. "Nonspecific laboratory findings can occur in hyperthyroidism, including anemia, granulocytosis, lymphocytosis, hypercalcemia, transaminase elevations, and alkaline phosphatase elevation," which may also show up in lab results. This is one reason why a full-lab workup is usually necessary in a patient with a thyroid complaint, or even in a patient with a suspected thyroid complaint. (Reid & Wheeler, 2005)

Treatment plan

Treatment options for hyperthyroidism include antithyroid medication, radioactive iodine, and surgery. The treatment course will depend upon the severity of the disorder, its cause, and also previous treatments that have been performed for complaints relating to the thyroid. "Antithyroid drugs act principally by interfering with the organification of iodine, thereby suppressing thyroid hormone levels. Methimazole usually is the drug of choice in nonpregnant patients because of its lower cost, longer half-life, and lower incidence of hematologic side effects." (Reid & Wheeler, 2002, p.2) In patients that initially used drugs, a randomized study indicated that "relapse can occur in up to fifty percent of patients who respond initially, regardless of the regimen used," and relapse was more likely in patients who smoked, had large goiters, or had elevated thyroid-stimulating antibody levels at the end of therapy." (Reid & Wheeler, 2002, p.2)

Surgery to remove the thyroid is usually only a last result, and even the use of radioactive iodine is avoided unless necessary, as this requires the patient to become dependant upon synthetic hormones for his or her life. "After obtaining baseline thyroid function tests, complete blood count and liver function tests," periodic reassessment must always be performed while "antithyroid agents are administered," and especially in older patients without support services, sustained compliance with the treatment plan must be monitored closely. (Shrier & Burman, 2002)

In most cases, one or more of these treatments cane reduce or eliminate the symptoms of hyperthyroidism. Because hyperthyroidism may return after successful treatment of drug therapy, it is important that patients undergoing such drug therapy to balance their hormones have their thyroid hormone levels be prepared for more invasive treatment if need be. Left untreated, a relapse of hyperthyroidism can lead to "atrial fibrillation, osteoporosis, and a life-threatening condition called thyroid storm." ("Hyperthyroidism: Topic Overview -- Symptoms?" WebMD, Last updated 11 Nov 2003

Beta blockers offer prompt relief of the adrenergic symptoms of hyperthyroidism such as tremor, palpitations, heat intolerance, and nervousness. (Reid & Wheeler, 2005) Currently, most endocrinologists in the United States recommend definitive treatment of patients with overt hyperthyroidism by ablating thyroid function first with drug treatment, then with radioactive iodine after the short-term use of antithyroid agents, then only last with surgery, and in the final stages of radioactive and surgical treatment then maintaining the patient on life-long thyroid hormone replacement therapy if all else fails, but in Japan, the preferred initial mode of treatment of patients with overt hyperthyroidism is the use of long-term antithyroid medications alone.

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(Shrier & Burman, 2002)

Thus there is no absolute consensus as to the best treatment or to the cause of hyperthyroidism -- it depends on the patient and the etiology of the ailment. The field of treatment is evolving. "Newer treatment options under investigation include endoscopic subtotal thyroidectomy, (incomplete removal) embolization of the thyroid arteries, plasmapheresis, and percutaneous ethanol injection of toxic thyroid nodules. (Reid & Wheeler 2005) "Autotransplantation of cryopreserved [frozen] thyroid tissue may become a treatment option for postoperative hypothyroidism. Nutritional supplementation with L-carnitine has been shown to have a beneficial effect on the symptoms of hyperthyroidism, and L-carnitine may help prevent bone demineralization caused by the disease." (Reid & Wheeler, 2005)

Further research

In addition to further exploration as to how to treat hyperthyroidism and its different causes, further research as to why women, particularly older women, seem more susceptible to thyroid complaints in general is necessary. The differences between Graves and other thyroid complaints, as well as the genetic tendency to exhibit or not exhibit Graves are all potential areas of further research.

Another area of interest to physicians is known as subclinical hyperthyroidism, an "increasingly recognized entity that is defined as a normal serum free thyroxine and free triodothyronine levels with a thyroid-stimulating hormone level suppressed below the normal range and usually undetectable." (Shrier & Burman, 2002) In other words, the distinguishing feature of this aspect of hyperthyroidism is that the lab work-up is ambiguous until thyroid-stimulating hormone value "is typically measured in a third-generation assay capable of detecting approximately 0.01 µU per mL (0.01 mU per L)," or above normal. (Shrier & Burman, 2002)

Subclinical hyperthyroidism may be a distinct clinical entity, related only in part to Graves' disease or multinodular goiter," not related at all, or may relate to unknown causal factors that protect the aforementioned individual. "Persons with subclinical hyperthyroidism usually do not present with the specific signs or symptoms associated with overt hyperthyroidism." (Shrier & Burman, 2002) It is assumed that most elderly patients with subclinical hyperthyroidism have a multinodular goiter, but several other conditions should be considered in the differential diagnosis.

As per usual a detailed clinical history should be obtained of any patient with abnormal endocrine levels that indicate hyperthyroidism, including a physical examination performed and other thyroid function tests to evaluate the possible deleterious effects of excess thyroid hormone on end organs such as the heart and the bones. (Shrier & Burman, 2002) "A reasonable treatment option for many patients is a therapeutic trial of low-dose antithyroid agents for approximately six to twelve months in an effort to induce a remission," but this is yet another reason that "further research regarding the etiology, natural history, pathophysiology, and treatment of subclinical hyperthyroidism is warranted." (Shrier & Burman, 2002) By doing such research as well it is hoped that clues as to the still-mysterious machinations of the human endocrine system as it relates to the development of hyperthyroidism can be discovered.

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