1. Insufficient awareness of the diversity of hyperthyroidism symptoms
Zhang Daniang has a cheerful personality, treats people very warmly, speaks quickly, and her neighbors can always see her busy figure inside and outside every day. However, in the last month or so, Zhang Danyang like a new person, expression mute, few words, the whole day lethargic, food and drink, weight loss of more than 20 pounds. The family suspected that the old man had grown a digestive tumor, so they took her to the hospital, and after a thorough examination, the final diagnosis was “hyperthyroidism. The family was puzzled: hyperthyroidism is a very good eater, fear of heat, sweating, irritability, protruding eyes and thick neck, but these symptoms are not present in the elderly, what is going on?
Expert comment: The typical symptoms of hyperthyroidism are usually overeating, weight loss, diarrhea, fear of heat, excessive sweating, palpitations, easily agitated, protruding eyes, enlarged thyroid gland and so on. However, there are many hyperthyroid patients who do not have typical symptoms, especially among elderly patients. For example, some elderly patients with hyperthyroidism have prominent cardiovascular symptoms, such as panic attacks, premature beats, atrial fibrillation, cardiac insufficiency, etc., without obvious protrusion and goiter, which are often misdiagnosed as coronary heart disease; some elderly patients with hyperthyroidism have symptoms completely opposite to typical symptoms of hyperthyroidism, such as anorexia, indifference, depression, lethargy, and progressive wasting, which are often misdiagnosed as gastrointestinal tumors. In addition, there are a few male hyperthyroid patients who show periodic episodes of muscle weakness with heavy symptoms in the lower limbs, which may be accompanied by hypokalemia. Therefore, we must have sufficient understanding of the diversity of hyperthyroidism symptoms so as to reduce and avoid misdiagnosis and underdiagnosis.
2. Diagnosis of hyperthyroidism is based on the results of thyroid function tests
Xiao Li is a female college student. She had a cold half a month ago, and has been feeling “sore throat”, panic, sweating and continuous low fever since then. She was diagnosed as “hyperthyroidism” and given anti-thyroid medication. Soon after, the patient developed hypothyroidism symptoms such as coldness, general weakness and slow heartbeat. After further tests (iodine 131 uptake rate, thyroid fine needle aspiration cytology, etc.), the patient was finally diagnosed with “subacute thyroiditis”. The anti-thyroid medication was discontinued and small doses of glucocorticoids and non-steroidal anti-inflammatory drugs were given as symptomatic treatment, and the patient recovered quickly.
Expert comment: Many non-professional doctors diagnose hyperthyroidism based on the results of laboratory tests. As long as the T3 (or FT3) and T4 (or FT4) are elevated on the laboratory test, it is easily diagnosed as hyperthyroidism, which is obviously wrong. There are many reasons for elevated levels of thyroid hormones (T3 and T4), except for Graves’ disease (also known as “diffuse goiter with hyperthyroidism”), which is the most common cause of increased synthesis and secretion of thyroid hormones, but there are also other diseases that can cause elevated thyroid function, such as “For example, in patients with subacute thyroiditis, the thyroid tissue is damaged by inflammation, resulting in a transient increase in thyroid hormone release; in hypothyroidism replacement therapy, for example, exogenous thyroid hormone supplementation can also lead to elevated T3 and T4. Therefore, to confirm the diagnosis of hyperthyroidism (i.e., what we usually call Graves’ disease), it is not enough to rely only on the results of thyroid function tests, but also to combine clinical symptoms, iodine 131 absorption rate, thyroid ultrasound and nuclear scan.
3. Inappropriate choice of treatment for hyperthyroidism
Xiao Mei is a senior student in college. Near graduation, she is overwhelmed by the pressure from all sides and often suffers from insomnia. After this year’s Spring Festival, her roommates in the same dormitory found that she had changed her temper and was anxious at every turn, and although she was wearing glasses, she could clearly see her eyes protruding. When she went to the hospital for a checkup, the result was hyperthyroidism. The doctor advised Xiao Mei to take anti-thyroid medication, which would take at least 1.5 to 2 years. Xiao Mei’s graduation was imminent and she wanted to get well soon and find a good job. So she went to another hospital and had iodine 131 treatment. 2-3 months later, her thyroid function was completely normal, but her protruding eyes were significantly aggravated and her eyelids could not close completely, so she could not even sleep with her eyes.
Expert comment: There are three methods of treatment for hyperthyroidism: medication, radioactive iodine treatment and surgery, each of which has its own specific indications, and the correct choice of treatment is crucial to the patient’s prognosis. The choice of treatment method depends not only on whether the method is simple and fast, but also on whether the method is suitable for the patient’s specific condition. For patients with mild hyperthyroidism and mild enlargement of the thyroid gland (especially for young patients under 20 years of age), drug therapy is generally preferred; surgery is preferred for patients with severe diffuse goiter or hyperthyroidism with thyroid cancer (or nodules) that has produced pressure symptoms. All hyperthyroid patients with iodine allergy, obvious proptosis, and those who are pregnant or breastfeeding should not undergo this treatment, because this method not only has a higher risk of permanent hypothyroidism in the future, but also aggravates proptosis.
4. The dosage of anti-thyroid drugs is always the same
Shortly after this year’s Spring Festival, Ms. Sun had unexplained panic attacks, weight loss, fatigue, insomnia, easily agitated, scanty and irregular menstruation, and thought it was “menopause syndrome”. The doctor prescribed Tabazol, 30mg once a day, and instructed her to follow up in half a month. After taking the medication, Ms. Sun’s symptoms improved significantly, plus she was very busy at work, so she forgot about the doctor’s advice and did not make any adjustment to the medication.
Expert comment: The drug treatment of hyperthyroidism is usually divided into three different phases: control phase, reduction phase and maintenance phase. The dosage and duration of application of anti-thyroid drugs are different for different stages. The “control phase” requires a larger dose of medication and aims to reduce the patient’s excessive thyroid hormone level to normal within a short period of time, which takes about 4-6 weeks; after the patient’s thyroid hormone level is reduced to normal level, the patient enters the “reduction phase”. After the patient’s thyroid hormone level is reduced to normal, the patient enters the “dose reduction phase”, at which time the dose of anti-thyroid drugs should be gradually reduced to prevent overkill and “drug hypothyroidism”, generally every two weeks, each time by 1~2 tablets, this process takes about 2~3 months; when the anti-thyroid drugs are reduced to about 1~2 tablets per day (Tabazol 5~10mg When the anti-thyroid medication is reduced to about 1~2 tablets per day (Tabazol 5~10mg/day or Propylthiouracil 50~100mg/day) and the thyroid function is still normal, the medication should not be stopped but should be maintained in small doses for a long period of time. However, some patients, including some non-specialist doctors, do not understand this, but continue to take the dose according to the initial control phase for a long time without reducing the dose at the right time, which leads to “drug hypothyroidism”.
5. Inadequate understanding of the pharmacological properties of different anti-thyroid drugs and inappropriate usage
About a month ago, Ms. Sun was diagnosed with hyperthyroidism by the hospital due to panic, sweating and an increase in the number of bowel movements. The treatment plan prescribed by the doctor was: propylthiouracil 10mg three times a day. After more than half a month of treatment, she felt that her symptoms were significantly improved. Not long ago, at a party, a woman at the same table with Ms. Sun also happens to suffer from hyperthyroidism, and during the conversation, we learned that this woman is taking tabazol, only once a day, the condition is also well controlled. After hearing this, Ms. Sun took the liberty to change the propylthiouracil from the first three times a day to a morning dose, more than a week later, Ms. Sun’s condition has recurred, and this is due to improper medication trouble.
Expert comment: Tabazol and propylthiouracil are two basic drugs for the treatment of hyperthyroidism, but the pharmacokinetic characteristics of the two are different, the half-life of tabazol is 4-6 hours, the effect can be maintained for 24 hours, so you can take a day’s dose in one oral dose, its efficacy and three times a day oral equivalent; and propylthiouracil half-life of only 2 hours, so you must take the drug three times a day, otherwise it will not play the proper Otherwise, it will not be effective.
It should be reminded that antithyroid drugs (tabazol or propylthiouracil) can only inhibit the synthesis of thyroid hormone, but they do not work on the synthesized thyroid hormone, nor can they block the release of thyroid hormone, so they do not work quickly after taking them. Therefore, you should not rashly think that the medicine is not effective and change the medicine or treatment method at will when the symptoms do not improve significantly after 2-3 days.
6.The course of treatment is not enough, stop the medicine at will
More than half a year ago, Mr. Li was found to be suffering from hyperthyroidism because of his ability to eat, thinness and thick neck. After a period of drug treatment, he felt his symptoms completely disappeared and his nail function tests returned to normal. 2 months ago, his doctor recommended that he switch to maintenance dosage, taking one tablet (50mg) of tabazol every day, and he felt all right, so he simply stopped taking all the drugs. Recently, Mr. Li had panic attacks and diarrhea again, and when he went to the hospital, he was found to have a relapse of hyperthyroidism.
Expert comment: Some hyperthyroidism patients’ symptoms disappear after taking medication, or they stop taking medication when their thyroid hormone levels are normal, which is very inappropriate and prone to relapse. Generally speaking, the course of medication for hyperthyroidism needs at least 1.5~2 years, and if there is a family history or treatment relapse, the medication time should be extended. Do not stop the medication too early, and do not use stop and go, otherwise it is very easy to lead to the relapse of hyperthyroidism. It is generally believed that medication can only be stopped if the following conditions are met simultaneously.
①The symptoms of hyperthyroidism completely disappear, the thyroid gland shrinks, the vascular murmur disappears, and the proptosis improves;
②Normalization of thyroid function (FT3, FT4, TSH) and negative thyroid stimulating antibody (TSAb);
③Small dose of drug maintenance (PTU25mg/day or MM2.5mg/day);
④The total course of treatment reached more than two years.
7, not enough attention to adverse drug reactions, ignore the regular review
Half a month ago, Ms. Li was found to have hyperthyroidism in the hospital and started taking anti-thyroid medication. The doctor repeatedly advised her to review her blood count and liver function at least once a week at the beginning of the treatment. However, Ms. Li did not follow the doctor’s advice. In the last two days, Ms. Li developed sore throat, chills, and high fever, and went to the hospital for laboratory tests. The patient was immediately taken off anti-thyroid medication and given anti-infective and leukocyte growth-promoting drugs.
Therefore, it is a must for all patients with hyperthyroidism to go to the hospital for regular checkups, including routine blood tests, liver function and thyroid function (FT3, FT4, TSH), which are the most basic and important tests. Through these tests, we can not only understand the control of hyperthyroidism, guide the adjustment of medication, and prevent “pharmacological hypothyroidism”, but also help to detect pharmacogenic leukopenia (especially granulocytopenia) and liver damage in time to ensure the safety of medication.
8. Blind iodine supplementation without differentiating the cause
Old Li is a hyperthyroid patient undergoing treatment. When he returned to his hometown this Spring Festival, he learned from his relatives that many local people had “thick neck disease” and their condition had improved significantly by eating more iodized salt and seafood (kelp, etc.). After hearing about this, Old Li went home and ate kelp and seaweed, but his condition was significantly worse than before. Old Li wondered why I had eaten iodine-rich food but the effect was not good.
Expert comment: Graves’ disease (also known as “diffuse goiter with hyperthyroidism”) and iodine-deficient goiter (also known as “endemic goiter”) can both lead to an enlarged thyroid gland, but the causes of the two are completely different. The former is related to genetics and autoimmunity, while the latter is due to compensatory hyperplasia of the thyroid tissue caused by insufficient iodine intake. In order to reduce the synthesis of thyroid hormone, hyperthyroidism patients should have a low iodine diet, use non-iodized salt for stir-fry, and eat as little or no iodine-rich seafood such as seaweed, kelp and seafood as possible.
9, do not pay attention to physical and mental conditioning and rest
Mr. Liu, who is in his third year, has a history of hyperthyroidism for more than 3 years, and although he has undergone regular medication, his condition has always been recurrent. It turns out that Mr. Liu works as a secretary in a bureau, so he often stays up late and works overtime in order to catch up on his writing, and his spirit is in a high state of tension for a long time, which leads to recurrence of the disease.
Expert comment: Hyperthyroidism makes the body in a high metabolic state and consumes a lot, therefore, hyperthyroidism patients must pay attention to rest and avoid overwork. In addition, long-term high mental tension, excessive stress, serious infections, drinking strong stimulating tea, coffee, tobacco and alcohol can trigger hyperthyroidism. Therefore, patients with hyperthyroidism must pay attention to physical and mental conditioning and maintain emotional stability, especially in the early stages of the disease, it is best to rest in bed or be hospitalized.
10.Pregnant women with hyperthyroidism, treatment with care
Li Li and Wang Gang have been married for almost two years and have not had children because Li Li was found to have hyperthyroidism soon after her marriage and has since been taking medication to treat the condition, which is well controlled and currently maintained with small doses. The first thing you need to do is to get a good idea of what you are getting into. Is it possible to have this child? If you can, what problems need to pay attention to during pregnancy? The two families are in a quandary.
The expert review: pregnancy generally does not lead to worsening hyperthyroidism, so hyperthyroidism is not an absolute contraindication to pregnancy. It is generally advisable for hyperthyroidism patients to get pregnant after their disease has been cured and their medication has been completely stopped. However, if the patient’s condition is well controlled at this stage and only requires small doses of medication for maintenance, pregnancy is also allowed and is generally considered to have no additional complications during pregnancy and a good prognosis for the mother and newborn. On the contrary, if the hyperthyroidism is poorly controlled, pregnancy is not advisable. Otherwise, miscarriage and preterm delivery will be easily caused. In addition, hyperthyroid pregnant women with hyper-metabolism cannot provide sufficient nutrition and oxygen to the fetus, which may lead to fetal growth restriction and intrauterine distress. In terms of medication, pregnant women with hyperthyroidism should choose propylthiouracil instead of tabazol, as the former has a larger molecular weight when combined with proteins in the pregnant woman’s body and passes through the placenta slowly, so the amount of blood entering the fetus is smaller and will not affect the fetus. In addition, during pregnancy, thyroid function should be closely monitored and the dose of propylthiouracil should be adjusted in time to maintain thyroid function at 1/3 of the upper limit of the normal value, and not to overdose, which may lead to hypothyroidism and affect fetal brain development.