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Hypothyroidism

(Myxedema)

by Jerome M. Hershman, MD

Hypothyroidism is thyroid hormone deficiency. It is diagnosed by clinical features such as a typical facial appearance, hoarse slow speech, and dry skin and by low levels of thyroid hormones. Management includes treatment of the cause and administration of thyroxine.

Hypothyroidism occurs at any age but is particularly common among the elderly. It occurs in close to 10% of women and 6% of men > 65. Although typically easy to diagnose in younger adults, it may be subtle and manifest atypically in the elderly. Hypothyroidism may be

  • Primary: Caused by disease in the thyroid

  • Secondary: Caused by disease in the hypothalamus or pituitary

Primary hypothyroidism

Primary hypothyroidism is due to disease in the thyroid; thyroid-stimulating hormone (TSH) is increased. The most common cause is autoimmune. It usually results from Hashimoto thyroiditis and is often associated with a firm goiter or, later in the disease process, with a shrunken fibrotic thyroid with little or no function. The 2nd most common cause is post-therapeutic hypothyroidism, especially after radioactive iodine therapy or surgery for hyperthyroidism or goiter. Hypothyroidism during overtreatment with propylthiouracil, methimazole, and iodide abates after therapy is stopped.

Most patients with non-Hashimoto goiters are euthyroid or have hyperthyroidism, but goitrous hypothyroidism may occur in endemic goiter. Iodine deficiency decreases thyroid hormonogenesis. In response, TSH is released, which causes the thyroid to enlarge and trap iodine avidly; thus, goiter results. If iodine deficiency is severe, the patient becomes hypothyroid, a rare occurrence in the US since the advent of iodized salt.

Iodine deficiency can cause congenital hypothyroidism. In severely iodine-deficient regions worldwide, congenital hypothyroidism (previously termed endemic cretinism) is a major cause of intellectual disability.

Rare inherited enzymatic defects can alter the synthesis of thyroid hormone and cause goitrous hypothyroidism (see Congenital Goiter).

Hypothyroidism may occur in patients taking lithium, perhaps because lithium inhibits hormone release by the thyroid. Hypothyroidism may also occur in patients taking amiodarone or other iodine-containing drugs, and in patients taking interferon-alfa. Hypothyroidism can result from radiation therapy for cancer of the larynx or Hodgkin lymphoma (Hodgkin disease). The incidence of permanent hypothyroidism after radiation therapy is high, and thyroid function (through measurement of serum TSH) should be evaluated at 6- to 12-mo intervals.

Secondary hypothyroidism

Secondary hypothyroidism occurs when the hypothalamus produces insufficient thyrotropin -releasing hormone (TRH) or the pituitary produces insufficient TSH. Sometimes, deficient TSH secretion due to deficient TRH secretion is termed tertiary hypothyroidism.

Symptoms and Signs

Symptoms and signs of primary hypothyroidism are often subtle and insidious. Symptoms may include cold intolerance, constipation, forgetfulness, and personality changes. Modest weight gain is largely the result of fluid retention and decreased metabolism. Paresthesias of the hands and feet are common, often due to carpal-tarsal tunnel syndrome caused by deposition of proteinaceous ground substance in the ligaments around the wrist and ankle. Women with hypothyroidism may develop menorrhagia or secondary amenorrhea.

The facial expression is dull; the voice is hoarse and speech is slow; facial puffiness and periorbital swelling occur due to infiltration with the mucopolysaccharides hyaluronic acid and chondroitin sulfate; eyelids droop because of decreased adrenergic drive; hair is sparse, coarse, and dry; and the skin is coarse, dry, scaly, and thick. The relaxation phase of deep tendon reflexes is slowed. Hypothermia is common. Dementia or frank psychosis (myxedema madness) may occur.

Carotenemia is common, particularly notable on the palms and soles, caused by deposition of carotene in the lipid-rich epidermal layers Deposition of proteinaceous ground substance in the tongue may cause macroglossia. A decrease in both thyroid hormone and adrenergic stimulation causes bradycardia. The heart may appear to be enlarged on examination and imaging, partly because of dilation but chiefly because of pericardial effusion. Pleural or abdominal effusions also may be noted. The pericardial and pleural effusions develop slowly and only rarely cause respiratory or hemodynamic distress.

Elderly patients have significantly fewer symptoms than do younger adults, and complaints are often subtle and vague. Many elderly patients with hypothyroidism present with nonspecific geriatric syndromes—confusion, anorexia, weight loss, falling, incontinence, and decreased mobility. Musculoskeletal symptoms (especially arthralgias) occur often, but arthritis is rare. Muscular aches and weakness, often mimicking polymyalgia rheumatica or polymyositis, and an elevated CK level may occur. In the elderly, hypothyroidism may mimic dementia or parkinsonism.

Although secondary hypothyroidism is uncommon, its causes often affect other endocrine organs controlled by the hypothalamic-pituitary axis. In a woman with hypothyroidism, indications of secondary hypothyroidism are a history of amenorrhea rather than menorrhagia and some suggestive differences on physical examination. Secondary hypothyroidism is characterized by skin and hair that are dry but not very coarse, skin depigmentation, only minimal macroglossia, atrophic breasts, and low BP. Also, the heart is small, and serous pericardial effusions do not occur. Hypoglycemia is common because of concomitant adrenal insufficiency or growth hormone deficiency.

Myxedema coma

Myxedema coma is a life-threatening complication of hypothyroidism, usually occurring in patients with a long history of hypothyroidism. Its characteristics include coma with extreme hypothermia (temperature 24° to 32.2° C), areflexia, seizures, and respiratory depression with CO 2 retention. Severe hypothermia may be missed unless low-reading thermometers are used. Rapid diagnosis based on clinical judgment, history, and physical examination is imperative, because death is likely without rapid treatment. Precipitating factors include illness, infection, trauma, drugs that suppress the CNS, and exposure to cold.

Diagnosis

  • TSH

  • Free thyroxine (T 4 )

Serum TSH is the most sensitive test, and screening of selected populations is warranted (see Overview of Thyroid Function : Laboratory Testing of Thyroid Function). In primary hypothyroidism, there is no feedback inhibition of the intact pituitary, and serum TSH is always elevated, whereas serum free T 4 is low. In secondary hypothyroidism, free T 4 and serum TSH are low (sometimes TSH is normal but with decreased bioactivity).

Many patients with primary hypothyroidism have normal circulating levels of triiodothyronine (T 3 ), probably caused by sustained TSH stimulation of the failing thyroid, resulting in preferential synthesis and secretion of biologically active T 3 . Therefore, serum T 3 is not sensitive for hypothyroidism.

Anemia is often present, usually normocytic-normochromic and of unknown etiology, but it may be hypochromic because of menorrhagia and sometimes macrocytic because of associated pernicious anemia or decreased absorption of folate. Anemia is rarely severe (Hb usually > 9 g/dL). As the hypometabolic state is corrected, anemia subsides, sometimes requiring 6 to 9 mo.

Serum cholesterol is usually high in primary hypothyroidism but less so in secondary hypothyroidism.

In addition to primary and secondary hypothyroidism, other conditions may cause decreased levels of total T 4 , such as serum thyroxine-binding globulin (TBG) deficiency, some drugs (see Thyroid Disorders:Primary hypothyroidism), and euthyroid sick syndrome (see Hashimoto Thyroiditis).

Treatment

  • l -Thyroxine, adjusted until TSH levels are in midnormal range

Various thyroid hormone preparations are available for replacement therapy, including synthetic preparations of T 4 ( l -thyroxine), T 3 (liothyronine), combinations of the 2 synthetic hormones, and desiccated animal thyroid extract. L -Thyroxine is preferred; the usual maintenance dose is 75 to 150 mcg po once/day, depending on age, body mass index, and absorption (for pediatric doses, see Treatment regimens). The starting dose in young or middle-aged patients who are otherwise healthy can be 100 mcg or 1.7 mcg/kg po once/day.

However, in the elderly and in patients with heart disease, therapy is begun with low doses, usually 25 mcg once/day. The dose is adjusted every 6 wk until maintenance dose is achieved. The maintenance dose may need to be decreased in elderly patients and increased in pregnant women. Dose may also need to be increased if drugs that decrease T 4 absorption or increase its biliary excretion are administered concomitantly. The dose used should be the lowest that restores serum TSH levels to the midnormal range (though this criterion cannot be used in patients with secondary hypothyroidism). In secondary hypothyroidism the dose of L -thyroxine should achieve a free T 4 in the midnormal range.

Liothyronine should not be used alone for long-term replacement because of its short half-life and the large peaks in serum T 3 levels it produces. The administration of standard replacement amounts (25 to 37.5 mcg bid) results in rapidly increasing serum T 3 to between 300 and 1000 ng/dL (4.62 to 15.4 nmol/L) within 4 h due to its almost complete absorption; these levels return to normal by 24 h. Additionally, patients receiving liothyronine are chemically hyperthyroid for at least several hours a day, potentially increasing cardiac risks.

Similar patterns of serum T 3 occur when mixtures of T 3 and T 4 are taken po, although peak T 3 is lower because less T 3 is given. Replacement regimens with synthetic T 4 preparations reflect a different pattern in serum T 3 response. Increases in serum T 3 occur gradually, and normal levels are maintained when adequate doses of T 4 are given. Desiccated animal thyroid preparations contain variable amounts of T 3 and T 4 and should not be prescribed unless the patient is already taking the preparation and has normal serum TSH.

In patients with secondary hypothyroidism, l -thyroxine should not be given until there is evidence of adequate cortisol secretion (or cortisol therapy is given), because l -thyroxine could precipitate adrenal crisis.

Myxedema coma

Myxedema coma is treated as follows:

  • T 4 given IV

  • Corticosteroids

  • Supportive care as needed

  • Conversion to oral T 4 when patient is stable

Patients require a large initial dose of T 4 (300 to 500 mcg IV) or T 3 (25 to 50 mcg IV). The IV maintenance dose of T 4 is 75 to 100 mcg once/day and of T 3 , 10 to 20 mcg bid until T 4 can be given orally. Corticosteroids are also given because the possibility of central hypothyroidism usually cannot be initially ruled out. The patient should not be rewarmed rapidly, which may precipitate hypotension or arrhythmias. Hypoxemia is common, so Pa o 2 should be monitored. If ventilation is compromised, immediate mechanical ventilatory assistance is required. The precipitating factor should be rapidly and appropriately treated and fluid replacement given carefully, because hypothyroid patients do not excrete water appropriately. Finally, all drugs should be given cautiously because they are metabolized more slowly than in healthy people.

Key Points

  • Primary hypothyroidism is most common; it is due to disease in the thyroid, and TSH levels are high.

  • Secondary hypothyroidism is less common; it is due to pituitary or hypothalamic disease, and TSH levels are low.

  • Symptoms develop insidiously and typically include cold intolerance, constipation, and cognitive and/or personality changes; later, the face becomes puffy and the facial expression dull.

  • Myxedema coma is a life-threatening complication that requires rapid diagnosis and treatment.

  • Free thyroxine (T 4 ) level is always low, but T 3 may remain normal early in some disorders.

  • Serum TSH is the best diagnostic test, and screening is warranted in select populations (eg, the elderly) because the disease is so subtle and insidious.

  • Oral T 4 ( L -thyroxine) is the preferred treatment and is given in the lowest dose that restores serum TSH levels to the midnormal range.

Subclinical Hypothyroidism

Subclinical hypothyroidism is elevated serum TSH in patients with absent or minimal symptoms of hypothyroidism and normal serum levels of free T 4 .

Subclinical thyroid dysfunction is relatively common; it occurs in more than 15% of elderly women and 10% of elderly men, particularly in those with underlying Hashimoto thyroiditis.

In patients with serum TSH > 10 mU/L, there is a high likelihood of progression to overt hypothyroidism with low serum levels of free T 4 in the next 10 yr. These patients are also more likely to have hypercholesterolemia and atherosclerosis. They should be treated with l -thyroxine, even if they are asymptomatic. For patients with TSH levels between 4.5 and 10 mU/L, a trial of l -thyroxine is reasonable if symptoms of early hypothyroidism (eg, fatigue, depression) are present. l -Thyroxine therapy is also indicated in pregnant women and in women who plan to become pregnant to avoid deleterious effects of hypothyroidism on the pregnancy and fetal development. Patients should have annual measurement of serum TSH and free T 4 to assess progress of the condition if untreated or to adjust the l -thyroxine dosage.

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Drugs Mentioned In This Article

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  • TAPAZOLE
  • CORDARONE
  • LITHOBID
  • CYTOMEL

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