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Hyperthyroidism

  1. Background/Cultural Points:

    Section titled “Background/Cultural Points:”

    Hyperthyroidism is a common condition in Cambodia, related to the high prevalence of Iodine Deficiency Disease (IDD) (adenomas later becoming toxic) and genetic factors (Grave’s Disease). Toxic MNG and Grave’s Disease, the latter characterized by smooth, symmetric goiter and exophthalmos, are both common. Medical management while awaiting definitive RAI131 (available in Bangkok, for Grave’s) or surgery by a visiting qualified surgeon (for Grave’s or Toxic MNG) is the preferred approach.

  2. Diagnosis & Lab:

    Section titled “Diagnosis & Lab:”
    1. Order TSH from Biomed or Calmette.
    2. Free T4 if new onset, or diagnosis unclear, or to clarify ongoing management. Avoid over-ordering and rely on clinical picture as able.
    3. Consider: EKG to r/o Atrial Fib, etc.
    4. Rule out: 1) dehydration and anemia as causes of tachycardia; 2) pregnancy – consider contraception; 3) toxic adenoma and thyroid cancer – confirm with U/S; 4) thyroiditis – consider ESR.

  3. Management/Education/Treatment:

    Section titled “Management/Education/Treatment:”

    1. Review with patient 3 approaches: medical, surgical, RAI131. Explain “auto-immune” disease to patient.

    2. Graves Disease/Toxic MNG:


      1. Option 1: Carbimazole (Prometabolite of Methimazole, which is not available) 20mg BID x 1month then 10-20mg QD for 18 month total course. Emphasize necessity of patient’s not missing any doses/days. Monitor for aplastic anemia
      2. Option 2 (safer in Pregnancy): PTU (BTU in Cambodia), lowest possible dose
      3. Consider: Atenolol (b1 specific) (50mg ½ - 1 tab QD) or Propranolol (b1b2) (if renal impairment) for symptomatic management until patient euthyroid. May Rx “PRN palpitations” dosing when initially discontinuing .

    3. If Thyroiditis, consider repeat TSH at 3 months and symptomatic treatment with B- Blocker and/or Ibuprofen 400mg TID or Prednisone 0.5mg/kg/d for pain (Consider GI Prophylaxis).

    4. Prognosis: Following 18 month course, recurrence common (50% in Graves / 80%+ in Toxic MNG).

  4. Follow-Up:

    Section titled “Follow-Up:”

    1. Initial follow-up at 1 month, then q3-6 months

    2. If recurrence after 18 month course, re-start course and enroll for RAI131 program (Bangkok) through MMC Patient Care Liaison. May consider subtotal thyroidectomy if experience head and neck surgeon available.