by West Medical Ward King Edward Medical University , Lahore, Pakistan.

1. Prof. Tariq Waseem
Dr. Hina Latif

2. Prof. Tariq Waseem
Progress
A” Wireless” pole alongside
an abandoned British Era
railway track
Pind Dadan Khan
Salt Range Punjab Pakistan

3. A 32 year old female executive in a multinational
organization started having low mood, lethargy
and lack of initiative and drive. She had been
receiving excellent performance awards for three
consecutive years but was not even considered for
regular annual promotion this year. She got
frustrated over this neglect and started using anti-
depressants on advice of her GP. She was
repeatedly found somnolent in her office and the
pile of files in need of her comments swelled up on
her desk. Her boss arranged a psychiatrist
consultation.
laboratory screening was ordered and a medical
consultation was advised.
Prof. Tariq Waseem

4.  A lady with depressed mood who is slow to
respond to questions reports being lethargic,
somnolent and feels that winters are becoming
increasingly cold over past three years. Her
appetite has reduced, she feels constipated and
her periods have been unusually heavy for past 9
months. Her hemoglobin was low so she started
taking iron supplements on advice of her GP. She
also c/o pain and numbness in lateral half of her
hands particularly when she rise up from her
desk placing them on table for support.
Prof. Tariq Waseem

5. A lady with cold, rough and coarse skin. She
has a slightly hoarse and croaky voice. A mild
diffuse goitre was noted.
Pulse: 56 beats/min
BP 150/95
Non pitting edema feet
Hypoaesthesia over lateral 3 fingers of both
hands and delayed relaxation of ankle jerks
was noted.
Prof. Tariq Waseem

6.  Hb 11.5 g/dl , MCV 104
 CPK 550 ng/l
 Serum Cholestrol 230mg/dl
 ALT 55 iu/L
 TSH > 100 ng/L
Prof. Tariq Waseem

7. Prof. Tariq Waseem

8. Chest X-Ray
Prof. Tariq Waseem

9. Prof. Tariq Waseem

10. The most common endocrine disease
Yet Grossly under diagnosed
Females > Males – 8 : 1
90 % patients have Primary Hypothyroidism
Menstrual irregularities, miscarriages,
growth retard. Vague pains, anemia,
constipation, lethargy, cold intolerance,
gain in weight, carpel tunnel syndrome are
frequent complaints.
Prof. Tariq Waseem

11. How Common is Hypothyroidism?
1. 5% of the general population are Sub-
clinically Hypothyroid
2. 15 % of all women > 65 yrs are hypothyroid
3. Detecting sub-clinical hypothyroidism in
pregnancy is highly essential – order for
TSH and FT4 routinely in all pregnant
women at the beginning of each trimester
4. All persons aged above 60 years – Order
for TSH
Prof. Tariq Waseem

12.  Hypothyroidism is common in people of every
age.
 It is most frequent in elderly
 Most common in females
 1 in every 10 people have a thyroid disorder
 1 in every 5000 infant has hypothyroid
disorder
Prof. Tariq Waseem

13.  IODINE DEFICENCY is the most common
cause of hypothyroidism worldwide.
 In Iodine sufficient areas, Autoimmune
disease (HASHIMOTO’S THYROIDITIS) is most
common.
Prof. Tariq Waseem

14. With Goiter
Hashimoto’s Thyroiditis
I2 deficiency goiter
Drug induced goiter
(Li, Amiodarone, PAS,
ethionamide, Rifampicin)
Due to goitrogens
Riedel’s thyroiditis
Without Goiter
 Hashimoto’s Thyroiditis
 Post ablative(radioactive I 2)
 After thyroidectomy
 Congenital hypothyroidism
 Secondary hypothyroidism
(Sheehan syndrome)
Prof. Tariq Waseem

15.  Autoimmune
hypothyroidism
(Hashimoto’s, atrophic
thyroiditis)
 Iatrogenic
(I123treatment,
thyroidectomy,
external irradiation of
the neck)
 Drugs: iodine excess,
lithium, antithyroid
drugs, etc
 Iodine deficiency
 Infiltrative disorders of
the thyroid:
amyloidosis,
sarcoidosis,haemochro
matosis, scleroderma
Prof. Tariq Waseem

16.  Primary
◦ Thyroid dysfunction…
 Secondary
◦ Hypopituitarism
 Tertiary
◦ Hypothalamic dysfunction
Others
Post partum
Drugs
Prof. Tariq Waseem

17.  Fatigue
 Weight Gain
 Depression
 Dry skin
 Bradycardia
 Constipation
 Intolerant to cold
Prof. Tariq Waseem

18.  Dry skin, cool extremities
 Puffy face, hands and feet
 Delayed tendon reflex
relaxation
 Carpal tunnel syndrome
 Bradycardia
 Diffuse alopecia
 Serous cavity effusions
Prof. Tariq Waseem

19. Symptoms
Dry & coarse skin- 76%
Cold intolerance – 64%
Puffiness of face- 60%
Sweating- 54%
Wt gain-54%
Paresthesia - 52 %
Constipation- 50%
Aches & pains non specific
Signs
Ankle reflex delayed
relaxation- 77%
Bradycardia - 58%
Somnolence
Diastolic hypertension
Depression
Anemia
Menorrhagia
 Infertility
Prof. Tariq Waseem

20. Hoarseness of voice
Deafness
Ascites
Pericardial & pleural effusion
Carpel tunnel syndrome
Impotence
Galactorrhoea & Amenorrhoea
Cardiac failure
Psychosis
Prof. Tariq Waseem

21. HYPOTHYRODISM
Prof. Tariq Waseem

22. Prof. Tariq Waseem

23.  Depression
 Dementia
 Parkinsonism
 Proximal Myopathies
Prof. Tariq Waseem

24.  Hypercholesterolemia
 Infertility – Menstrual
Irregularities
 Diabetes mellitus
Prof. Tariq Waseem

25. Primary Test
TSH
Additional Test
Free T4
Prof. Tariq Waseem

26. TSH raised (>3.5-5.5 according to the lab)
Free T4 decreased
Total T4 decreased
Prof. Tariq Waseem

27.  TSH , free T4 , free T3 ,
 Ultrasound of thyroid – little value
 Thyroid scintigraphy – little value
 Anti thyroid antibodies – anti-TPO
Prof. Tariq Waseem

28.  CPK ,
 AST
 LDH
 Cholestrol ,
 Triglycerides 
 Anemia:
Normochromic normocytic/macrocytic /
microcytic
 Increased serum prolactin
 Hyponatremia
Prof. Tariq Waseem

29. Sinus Bradycardia
Low voltage
Prolongation of the PR interval
Bundle branch blocks
Flattening or inversion of the T wave
Ventricular premature contractions (VPS)
Sustained or non-sustained attacks of ventricular
tachycardia (VT)
Prolongation of the QT interval
Prof. Tariq Waseem

30. Primary hypothyroidism
Transient
Recovery from NTIS
Pituitary adenoma
Primary adrenal insufficiency
T4 resistance
TSH resistance at receptor level
Prof. Tariq Waseem

31. Central hypothyroidism
Imaging indicated to distinguish
hypothalamic from pituitary disease
Evaluate for 2dary adrenal insufficiency
Prof. Tariq Waseem

32.  Improvement of symptoms
 Normalization of TSH
 Reduction of goiter
 Avoid over supplementation :
 risk of A-fib in elderly
 risk of bone loss
Prof. Tariq Waseem

33. Algorithm for Hypothyroidism
Measure TSH
Elevated TSH Normal TSH
Measure FT4 Considering Pituitary
Normal Low No Yes
Sub-clinical hypo
TPO + TPO -
T4 repl Annual FU
Primary hypothyroid
TPO + TPO -
No tests Measure FT4
Low Normal
No tests
Evaluate Pituitary
Sick Euthyroid
Drugs effect
Hashimoto
Others
Prof. Tariq Waseem

34.  Adverse Effects
◦ Angina in patients having occult IHD
◦ Osteopenia
 Contraindicated
◦ Acute MI
◦ Treatment of obesity
◦ Uncontrolled HTN
Prof. Tariq Waseem

35.  Goal : Normalize TSH level regardless of
cause of hypothyroidism
 Treatment : Once daily dosing with
Levothyroxine sodium (1.6µg/kg/day-
1.8ug/kg/day)
 Monitor TSH levels at 6 to 8 weeks, after
initiation of therapy or dosage change
Prof. Tariq Waseem

36.  Dose of Levothyroxine depends on the degree
of Hypothyroidism, Age & General health
condition of the patient
 Usually daily replacement dose is 1.6µgm/Kg
body weight
 Start with Low Dose
Prof. Tariq Waseem

37.  Levothyroxine
◦ If no residual thyroid function 1.5
μg/kg/day
◦ Patients under age 60, without cardiac
disease can be started on 50 – 100 μg/day.
Dose adjusted according to TSH levels
◦ In elderly especially those with CAD the
starting dose should be much less (12.5 –
25 μg/day)
Prof. Tariq Waseem

38.  Age (in elderly start with half dose)
 Severity and duration of hypothyroidism (↑
dose)
 Weight (0.5µg/kg/day ↑ upto 3.0µg/kg/day)
 Malabsorption (requires ↑ dose)
 Concomitant drug therapy (only on empty
stomach)
 Pregnancy ( 25% -50%↑ in dose), safe in
lactating mother
 Presence of cardiac disease (start alt. day Rx)
Dosage Adjustments
Prof. Tariq Waseem

39. How the patient improves
 Feels better in 2 – 3 weeks
 Reduction in weight is the first improvement
 Facial puffiness then starts coming down
 Skin changes, hair changes take long time to
regress
 TSH starts showing decrements from the high
values
 TSH returns to normal eventually
 Decrease in cholesterol level
Prof. Tariq Waseem

40. Serum TSH levels should be measured after
6-8 weeks of therapy and dosages should be
adjusted accordingly
Target TSH levels should be between 1-2
mU/l
Once a stable TSH is achieved, it should be
estimated every year
Prof. Tariq Waseem

41.  Obtain baseline FT4, TSH, LFT, CBCs before
initiation of therapy
 Repeat FT4 and TSH after 4-6 weeks on
therapy and 4-6 weeks after adjustments
 Once euthyroid state obtain thyroid function
test after 3-6 months
Prof. Tariq Waseem

42. During pregnancy requirement of thyroxin
increases by 25-50µg/d during pregnancy
Even on mild Thyroxin hormone deficiency
there are chances of low IQ and
developmental delay of the child
Hypothyroid And pregnancy
Prof. Tariq Waseem

43. Thyroid Hormone exists in two forms :
Free (Active) & Bound (with thyroxine
binding globuline).
In Pregnancy increased Estrogen, increases
TBG which in turn increases Total T4 & T3
level
However Free T4, Free T4 REMAINS
NORMAL.
SO Free T4 should be used in the treatment
and follow up during pregnancy & not total
T4
Prof. Tariq Waseem

44.  Same for the non-pregnant pt
 Goal is to normalize TSH
 Adjust dose at 4 week intervals
 Should check TSH levels every trimester in pts
with hypothyroidism
Prof. Tariq Waseem

45. Prof. Tariq Waseem

46. Prof. Tariq Waseem

47.  Occurs in previously:
undiagnosed hypothyroidism
inadequately treated hypothyroidism
elderly patients more susceptible
MEDICAL EMERGENCY
Prof. Tariq Waseem

48.  Infection/sepsis
 Drugs…(sedatives, antidepressants, anesthetic
drugs)
 Cardiac failure/ MI
 Respiratory failure/ pneumonia
 CVA
 GI bleed
 Hypoglycemia
 Dilutional hyponatremia
 Hypoxia/ hypercapnia
Prof. Tariq Waseem

49. Signs and Symptoms :
 Hypothermia
 Coma
 Seizures
 Other features of hypothyroidism
 Usually older age
 Bradycardia, ↓ Na,↓ glucose, ↑ CO2, ↓ WBC, ↓
Hct, ↑ CPK
 ↓ EKG voltage
Prof. Tariq Waseem

50.  Treatment
ICU transfer,
IV levothyroxine 500 µg bolus followed by
50-100µg/d (same dose can be given
through NG tube),
antibiotics, ventilation, hydrocortisone IV,
passive warming, careful volume
management,
correction of hypoglycemia and
hyponatremia
Prof. Tariq Waseem

51. When being crazy is not in your head BUT IN
THYROID
Delirium With Auditory Hallucinations &
Paranoid Delusions
Takes The Form Of Psychotic Depression Or
Pure Psychosis.
No Cognitive Impairment
Treatment- Thyroxine
Prof. Tariq Waseem

52. Sick Euthyroid Syndrome
 Total T3 reduced
 FT3 reduced
 Total T4 reduced
 FT4 Normal
 TSH Normal
 Clinically Euthyroid
Prof. Tariq Waseem

53.  Women > 60
 women with a family history of thyroid
disease,
 prior thyroid dysfunction,
 symptoms suggestive of hyperthyroidism or
hypothyroidism, abnormal thyroid gland on
examination,
 type 1 diabetes
 personal history of autoimmune disorder
Prof. Tariq Waseem

54. Prof. Tariq Waseem
Abandoned British Era
Railway Track
Pind Dadan Khan
Salt Range Punjab Pakistan
Mudat se koyi ayaa naa gaya
Wiran paree hai Ghar Ki Fiza