Thyroid hormones, antithyroid drugs

Published on 02/03/2015 by admin

Filed under Basic Science

Last modified 22/04/2025

Print this page

rate 1 star rate 2 star rate 3 star rate 4 star rate 5 star
Your rating: none, Average: 0 (0 votes)

This article have been viewed 4770 times

Chapter 37 Thyroid hormones, antithyroid drugs

Thyroid hormones

L-Thyroxine (T4 or tetra-iodo-l-thyronine) and lio-l-thyronine (T3 or tri-iodo-l-thyronine) are the natural hormones of the thyroid gland. T4 is a less active precursor of T3, which is the major mediator of physiological effect. In this chapter, T4 for therapeutic use is referred to as levothyroxine (the rINN; see p. 69).

For convenience, the term ‘thyroid hormone’ is used to comprise T4 plus T3. Both forms are available for oral use as therapy.

Physiology and pharmacokinetics

Thyroid hormone synthesis requires oxidation of dietary iodine, followed by iodination of tyrosine to mono- and di-iodotyrosine; coupling of iodotyrosines leads to formation of the active molecules, tetra-iodothyronine (T4 or L-thyroxine) and tri-iodothyronine (T3 or l-thyronine).

These active thyroid hormones are stored in the gland within the molecule of thyroglobulin, a major component of the intrafollicular colloid. They are released into the circulation following reuptake of the colloid by the apical cells and proteolysis. The main circulating thyroid hormone is T4. About 80% of the released T4 is de-iodinated in the peripheral tissues to the biologically active T3 (30–35%) and biologically inactive ‘reverse’ T3 (45–50%); thus most circulating T3 is derived from T4. Further de-iodination, largely in the liver, leads to loss of activity.

In the blood both T4 and T3 are extensively (99.9%) bound to plasma proteins (thyroxine binding globulin (TBG) and transthyretin (TTR), albumin and lipoproteins). The concentration of TBG is raised by oestrogens (physiological or pharmacological) and prolonged use of neuroleptics. The concentration of TBG is lowered by adrenocortical and androgen (including anabolic steroid) therapy and by urinary protein loss in the nephrotic syndrome. Phenytoin and salicylates compete with thyroid hormone for TBG binding sites. Effects such as these would interfere with the assessment of the clinical significance of measurements of total thyroid hormone concentration but the availability of free thyroid hormone assay largely avoids such complicating factors. Normal values are: free T4 9–25 picomol/L, free T3 3–9 picomol/L.

T4 and T3 are well absorbed from the gut, except in myxoedema coma when parenteral therapy is required.

Levothyroxine for hypothyroidism

The main indication for levothyroxine is treatment of thyroxine deficiency (cretinism, adult hypothyroidism) from any cause. The adult requirement of hormone is remarkably constant, and dosage does not usually have to be altered once the optimum has been found. Patients should be monitored annually. Monitoring needs to be more frequent in children, who may need more as they grow. Similarly, pregnant women should be monitored monthly, and require a 50–100% increase in their normal dose of levothyroxine.

Early treatment of neonatal hypothyroidism (cretinism) (1 in 5000 births) is important if permanent mental defect is to be avoided. It must be lifelong.

Hypothyroidism due to panhypopituitarism requires replacement with glucocorticoids as well as with thyroid hormone. Use of levothyroxine alone can cause acute adrenal insufficiency.

Small doses of levothyroxine in normal subjects merely depress pituitary thyroid-stimulating hormone (TSH) production and consequently reduce the output of thyroid hormone by an equivalent amount.

Levothyroxine is used in some countries for the treatment of non-toxic nodular goitre, on the assumption that nodular thyroid tissue growth is dependent on TSH. The treatment is not curative. Levothyroxine should not be used to treat obesity (see Obesity, p. 602).

Treatment of hypothyroidism

Levothyroxine tablets

contain pure L-thyroxine sodium and should be used.

The initial oral dose in healthy patients under the age of 60, without cardiac disease, is 50–100 micrograms/day. In the old and patients with heart disease or multiple coronary risk factors, this level should be achieved gradually (to minimise cardiovascular risk due to a sudden increase in metabolic demand), starting with 12.5–25 micrograms daily for the first 2–4 weeks, and then increasing by 12.5 micrograms monthly until normal TSH levels are achieved.

The usual replacement dose at steady state in patients with complete thyroid failure, is 1.6 micrograms/kg/day, 100–200 micrograms per day given as a single dose. This is usually sufficient to reduce plasma TSH to normal (0.3–3.5 mU/L), which is the best indicator of adequate treatment. Patients who appear to need increasing doses with fluctuating TSH levels, are probably not taking their tablets consistently; the possibility of malabsortion or other drug interaction should be excluded. The maximum effect of a dose is reached after about 10 days and passes off over about 2–3 weeks. Absorption is more complete and less variable if levothyroxine is taken at the same time every day, one hour before breakfast.

Tablets containing physiological mixtures of levothyroxine and liothyronine are not sufficiently evaluated to recommend in preference to levothyroxine alone.

Hypothyroid patients tend to be intolerant of drugs in general owing to slow metabolism.

Antithyroid drugs and hyperthyroidism

Drugs used for the treatment of hyperthyroidism include:

Thionamides (thiourea derivatives) carbimazole, methimazole, propylthiouracil

Mode of action (Fig. 37.1)

The major action of thionamides is to reduce the formation of thyroid hormone by inhibiting oxidation and organification (incorporation into organic form) of iodine (iodotyrosines) and coupling of iodotyrosines. Maximum effect is delayed until existing hormone stores are exhausted (weeks, see below). With high dose, reduced hormone synthesis leads to hypothyroidism.

Adverse reactions

The thionamide drugs are all liable to cause adverse effects. Minor reactions include maculopapular or urticarial rash, pruritus, arthralgia, fever, anorexia, nausea, abnormalities of taste and smell. Major effects include agranulocytosis, aplastic anaemia, thrombocytopenia, acute hepatic necrosis, cholestatic hepatitis, lupus-like syndrome, vasculitis.

Blood disorders (< 3 per 10 000 patient-years) are most common in the first 2 months of treatment. Routine leucocyte counts to detect blood dyscrasia before symptoms develop are unlikely to protect, as agranulocytosis may be so acute that blood counts give no warning. Patients must be given written warning to stop the drug and have a leucocyte count performed if symptoms of a sore throat, fever, bruising or mouth ulcers develop. Any suggestion of anaemia should be investigated.

Cross-allergy between the drugs sometimes occurs, but is not to be assumed for agranulocytosis. Treatment of agranulocytosis consists of drug withdrawal, admission to hospital, and administration of broad-spectrum antibimicrobials plus granulocyte colony-stimulating factor.

Control of antithyroid drug therapy

The aim of drug therapy is to control the hyperthyroidism until a natural remission takes place. The recommended duration of therapy is 12–18 months. Longer treatment is usual for young patients with large, vascular goitres, because of the higher risk of recurrence (2–3 years). A shorter course (6–9 months) is recommended for the block–replace regimen. Most patients enter remission, but some will relapse – usually during the first 3 months after withdrawal from treatment. Approximately 30–40% of patients remain euthyroid 10 years later. If hyperthyroidism recurs, there is little chance of a second course of thionamide achieving long-term remission. In such patients, indefinite low-dose antithyroid treatment is an alternative option to radioiodine or surgery.

The use of levothyroxine concurrently with an antithyroid drug (‘block and replace regimen’) facilitates maintenance of a euthyroid state and reduces the frequency of clinic visits. There is a higher risk of the dose-related adverse effects of carbimazole, and no compensatory reduction in the incidence of relapse. Therefore, the ‘titration’ (see above) regimen is regarded as first-line treatment.

Iodine (iodide and radioactive iodine)

Iodide is well absorbed from the intestine, distributed like chloride in the body, and rapidly excreted by the kidney. It is selectively taken up and concentrated (about × 25) by the thyroid gland, more in hyperthyroidism and less in hypothyroidism. A deficiency of iodide reduces the amount of thyroid hormone produced; this stimulates the pituitary to secrete TSH. The result is hyperplasia and increased vascularity of the gland, with eventual goitre formation.2

Uses

Iodide (large dose) is used for thyroid storm (crisis) and in preparation for thyroidectomy because it rapidly benefits the patient by reducing hormone release and renders surgery easier and safer (above).

Radioiodine (131I)

131I is treated by the body just like the ordinary non-radioactive isotope, so that when swallowed it is concentrated in the thyroid gland. It emits mainly β radiation (90%), which penetrates only 0.5 mm of tissue and thus allows therapeutic effects on the thyroid without damage to the surrounding structures, particularly the parathyroids. It also emits some γ-rays, which are more penetrating and are detectable with a radiation counter.4 131I has a physical (radioactive) t½ of 8 days.

131I is the preferred initial treatment for hyperthyroidism caused by Graves’ disease in North America. It is contraindicated in children and pregnant or breast-feeding women, and can induce or worsen ophthalmopathy. It is used in combination with surgery in thyroid carcinoma.

In hyperthyroidism, the beneficial effects of a single dose may be felt in 1 month, and patients should be reviewed at 6 weeks to monitor for onset of hypothyroidism. The maximal effect of radioiodine may take 3 months to achieve. β-Adrenoceptor blockade and, in severe cases, an antithyroid drug (but see footnote 1) will be needed to render the patient comfortable while waiting; this is more likely when radioiodine is used for patients with relapsing thyrotoxicosis. Very rarely radiation thyroiditis causes excessive release of hormone and thyroid storm. Repeated doses may be needed.

Adverse effects of radioiodine are as for iodism, above. In the event of inadvertent overdose, large doses of sodium or potassium iodate should be given to compete with the radioiodine for thyroid uptake and to hasten excretion by increasing iodide turnover (increased fluid intake and a diuretic are adjuvants).

Radioiodine offers the advantages that treatment is simple and carries no immediate mortality, but it is slow in acting and the dose that will render the patient euthyroid is difficult to judge. In the first year after treatment, 20% of patients will become hypothyroid. Thereafter, 5% of patients become hypothyroid annually, perhaps because the capacity of thyroid cells to divide is permanently abolished so that cell renewal ceases. There is therefore an obligation to monitor patients indefinitely after radioiodine treatment, for most are likely to need treatment for hypothyroidism eventually.

Preparation for surgery

Routine preparation of hyperthyroid patients for surgery can be achieved satisfactorily by making them euthyroid with one of the above drugs plus a β-adrenoceptor blocker for comfort (see below) and safety,5 and adding iodate for 7–10 days before operation (not sooner) to reduce the surgically inconvenient vascularity of the gland.

In an emergency, the patient is prepared with a β-adrenoceptor blocker (e.g. propranolol 6-hourly, with dose titration to eliminate tachycardia) for 4 days, continued through the operation and for 7–10 days afterwards. Iodide is also given (see p. 591). The important differences with this second technique are that the gland is smaller and less friable but the patient’s tissues are still hyperthyroid and, to avoid a hyperthyroid crisis or storm, it is essential that the adrenoceptor blocker continue as above without the omission of even a single 6-hourly dose of propranolol.

Drugs that cause hypothyroidism

In addition to drugs used for their antithyroid effects, the following substances can cause hypothyroidism: lithium (for mania, bipolar disorder, recurrent depression), amiodarone (see below), β-interferon (hepatitis and multiple sclerosis), iodide (see above), resorcinol (leg ulcers). Effects may be reversible on withdrawal.

Amiodarone

bears a significant structural resemblance to thyroxine. Each molecule of amiodarone contains two iodine atoms, constituting 37.5% of its mass. Hence, a patient taking a 200-mg/day dose ingests 75 mg organic iodine each day. Subsequent de-iodination through drug metabolism results in the daily release of approximately 6 mg free iodine into the circulation, which is 20 to 40 times higher than usual daily iodine intake of 0.15–0.30 mg. Amiodarone has a very long t½ (54 days) on chronic dosing, mainly due to its storage in adipose tissue. Hence, the excess iodine clears slowly over months and the toxic effects of amiodarone can persist or can even occur well after its discontinuation.

Some 90% of patients receiving amiodarone remain euthyroid. Despite the exposure of the thyroid gland to an extraordinary load of iodine, important adjustments are made in thyroidal iodine handling and hormone metabolism; these are shown in Figure 37.2, and the consequences for thyroid function tests summarised in Table 37.1.

image

Fig. 37.2 Mechanisms by which amiodarone affects thyroid hormone metabolism. TSH, thyroid stimulating hormone.

(Adapted from Basaria S, Cooper D S 2005 Amiodarone and the thyroid. American Journal of Medicine 118:706–714.)

Table 37.1 Effects of amiodarone on thyroid function tests in euthyroid subjects

  Acute effects Chronic effects
Thyroid hormone (≤ 3 months) (> 3 months)
Total and free T4 ↑ 50% Remains ↑ 20–40% of baseline
T3 ↓ 15–20%, remains in low-normal range Remains ↓ 20%, remains in low-normal range
Reverse T3 ↑ > 200% Remains ↑ > 150%
TSH ↑ 20–50%, transient, generally remains < 20 mU/L Normal

Amiodarone-induced hypothyroidism is more prevalent in iodine-sufficient areas of the world, whereas thyrotoxicosis is more prevalent in iodine-deficient regions. Amiodarone-induced hypothyroidism typically occurs between 6 and 12 months of treatment with amiodarone. The main risk factor is underlying Hashimoto’s disease. In other patients, hypothyroidism resolves within 2–4 months of discontinuing amiodarone.

Thyrotoxicosis induced by amiodarone is of two types. Type 1 develops in individuals with underlying thyroid disease (nodular goitre or latent Graves’disease) and is due to increased synthesis and release of thyroid hormone. Type 2 is a destructive thyroiditis in individuals with no underlying thyroid disease, and the thyrotoxicosis is due to release of preformed thyroid hormone from damaged thyroid follicular epithelium. Mixed forms also occur. The two types are difficult to distinguish. Measurement of interleukin-6 or C-reactive protein has marginal diagnostic role in differentiating the two forms because of poor specificity. Thyroid ultrasonography, colour flow Doppler sonography and thyroid radioactive iodine uptake may help in the diagnosis. In type 1, amiodarone treatment should be discontinued, if possible. Large doses of thionamides and longer periods of therapy are required, because high intrathyroidal iodine stores antagonise their inhibitory effect on thyroidal iodine utilisation. In patients who fail to respond after 4–6 weeks of treatment, potassium perchlorate 200–1000 mg daily can be a useful adjunct. Radioiodine is rarely used because uptake is blocked by the high concentration of circulating iodine. In type 2, prednisolone 40–60 mg leads to rapid improvement in thyroid function in most patients, often within 1 week, and amiodarone discontinuation may not be necessary. Iopanoic acid (an oral cholecystographic agent) has also been used to reduce T4 to T3 conversion, but is generally inferior to prednisolone and currently unavailable in the market. In resistant cases, other therapies have been recommended, including lithium, plasmapheresis and ultimately thyroidectomy in patients with severe thyrotoxicosis, whose amiodarone cannot be discontinued.

1 Use of a thionamide during the week before and after radioiodine therapy may impair the response to radiation (Velkeniers B, Cytryn R, Vanhaelst L, Jonckheer M H 1988 Treatment of hyperthyroidism with radioiodine: adjunctive therapy with antithyroid drugs reconsidered. Lancet i: 1127–1129) (see Mode of action of thionamides, above).

2 Apparently from the beginning of time: Michelangelo’s image of the separation of light from darkness on the ceiling of the Sistine Chapel in the Vatican depicts the creator with a multinodular goitre (Bondeson L, Bondeson A-G 2003 Michelangelo’s divine goitre. Journal of the Royal Society of Medicine 96:609–611).

3 The newer preparations approximately triple the cost of diagnostic investigations requiring contrast media. With a fatality rate of about 1 per 50 000 in patients receiving the older agents, hospitals are faced with an interesting cost–benefit equation.

4 And emissions can be sufficient to activate airport radiation alarms. One victim was detained, strip-searched and interrogated, but released on producing his radionucleotide card (Gangopadhyay K K, Sundram F, De P 2006 Triggering radiation alarms after radioiodine treatment. British Medical Journal 333:293–294).

5 No patient should be operated on with a resting pulse of 90 beats/min or above, and no dose of β-adrenoceptor blocker, including the important postoperative dose, should be omitted (Toft A D, Irvine W J, Sinclair I et al 1978 Thyroid function after surgical treatment of thyrotoxicosis. A report of 100 cases treated with propranolol before operation. New England Journal of Medicine 298:643–647).

6 Consensus statement: Surks M I, Ortiz E, Daniels G H et al 2004 Subclinical thyroid disease: scientific review and guidelines for diagnosis and management. Journal of the American Medical Association 291:228–238.