Hyperthyroidism and Thyrotoxicosis

.: PREFACE
ÖN SÖZ
PREFACE
Prof. Dr. Refik TANAKOL
Amerikan Hastanesi, Endokrinoloji, Diyabet ve Metabolizma Hastalıkları Kliniği, İstanbul, Türkiye
Article Language: TR
Türkiye Klinikleri'nin bu kitabı klinik uygulamada sık rastlanan ve çok önemli bir konuya, yani tirotoksikoz ve hipertiroidiye ayrılmıştır. Bu durumlara yol açan pek çok hastalık vardır. Günümüzde özellikle onkoloji alanında yeni tedaviler, örneğin multikinaz inhibitörleri ve immun-check point inhibitörleri devreye girmekte ve bu ilaçlarla son derece başarılı sonuçlar elde edilmektedir. Ancak bu ilaçların yan etkisi olarak tiroid fonksiyon bozuklukları ve endokrin hastalıklar ortaya çıkmaktadır. Bu gelişmeler endokrinoloji uzmanları dışında birçok branşın da tiroid hastalıkları ve endokrin sistem bozuklukları konusunda farkındalıklarını artırmalarını gerekli kılmaktadır. Bu sebeplerle tirotoksikoz ve hipertiroidilere ayırdığımız bu kitabın büyük ilgi göreceği kanısındayız.

Tirotoksikoz ve hipertiroidinin aynı anlama gelmediğini bilmek gerekir. Tirotoksikoz denildiğinde serum serbest T4 ve serbest T3 konsantrasyonlarının arttığı ve buna bağlı olarak metabolizmanın hızlandığı bir sendromdan bahsedilmiş olur. Tirotoksikozda bizzat tiroid glandının aşırı fonksiyon göstermesi gerekmez. Buna karşılık hipertiroidi denildiğinde, tiroid glandının bizzat kendisinin tiroid hormon sentezi ve sekresyonu yaptığı ve bu durumun devamlılık arzettiği hastalıklar anlaşılmaktadır. Tirotoksikoza örnek olarak tiroiditler ve ekzojen aşırı tiroid hormon kullanımı verilebilir. Buna karşılık Basedow Graves hastalığı, toksik multinodüler guvatr, toksik adenom gibi durumlar hipertiroidiye yol açarlar. Tirotoksikozlarda klinik belirti ve bulgular genel olarak sebebe bağlı olmaksızın benzerdir. Hastalığın süresi, tiroid glandının şekli ve büyüklüğü, Basedow Graves hastalığında olduğu gibi ekstratiroidal bulgular hipertiroidinin sebebini ortaya koyabilir. Tiroiditlerde semptomlar birkaç haftadır mevcutken, Graves hastalığında bu süre aylarla ölçülebilir. Özellikle ağrılı subakut tiroiditte hastalar semptomların başladığı günü dahi net olarak söyleyebildiği hâlde, hipertiroidili hastalar çarpıntı, yorgunluk gibi semptomlarını başka nedenlere bağlayarak daha geç başvuruda bulunurlar. Bitkinliklerini ailevi problemlere, dispne ve çarpıntılarını düzenli egzersiz yapmamağa bağlayarak doktor başvurularını uzunca bir süre erteleyebilmektedirler. Karşılaştığımız her hastada tiroidhormon fazlalığının nedenini bulup ortaya çıkarmak zorundayız. Çünkü herbirinin prognozu ve tedavisi birbirinden çok farklıdır. Hipertiroidi ve tirotoksikozlar aşikar belirtiler verebileceği gibi, subklinik bir seyir de gösterebilirler. Özellikle hipertiroidiler zamanında tanınıp tedavi edilmediğinde hayatı tehdit eden ağır klinik tablolara yol açabilirler. Semptom ve belirtilerin ortaya çıkışı hastanın yaşı, birlikte bulunan hastalıklar ve hipertiroidinin süresi ile ilgili olabilmektedir. Özellikle yaşlı hastalarda semptomlar daha az ve daha silik olmaktadır. Gençlerde sempatik sistem aktivasyonu daha ön planda olduğu halde, yaşlı hastalarda kardiyovasküler semptomlar, atrial fibrilasyon, dispne, konjestif kalp yetmezliği gibi belirtiler daha belirgindir. Yaşlılarda apatetik tirotoksikoz denilen durumla karşılaşılmaktadır. Klinik olarak hipertiroidi ve tirotoksikozdan şüphelenilen durumlarda elimizdeki laboratuvar imkânları ile tanı ve ayırıcı tanıya gidebiliriz. Hipertiroidi-tirotoksikoz ayırımı yapmada bize ençok yardımcı olan yöntemin, tiroidin radyoaktif iyod tutma kapasitesini ölçmek olduğunu söylemek gerekir. Ancak bazen tiroid testleri çelişkili sonuçlar verebilmekte, klinisyen tecrübesini de kullanarak bunları doğru yorumlamak suretiyle gerçek tanıya ulaşabilmektedir. Hipertiroidinin tedavisinde elimizde etkin seçenekler bulunmakta; hastanın klinik durumuna göre antitiroid ilaçlar, radyoaktif iyot, cerrahi girişim gibi yöntemleri uygulamaktayız. Tirotoksikozların çoğunda ablatif tedavilerden kaçınmaktayız. Bu tedavi yöntemlerinin her birinin ayrı ayrı avantaj ve dezavantajlarını, etkinlik ve yan etki profilini bilmek zorundayız.

Konularına son derece hâkim olan değerli endokrinologların katkıları ile hipertiroidi ve tirotoksikoza sebep olan durumlar, bu kitapta ayrı başlıklar altında gözden geçirilmiştir. Bu kitabın hazırlanmasında emekleri geçen değerli endokrinolog arkadaşlarıma ve bu önemli konuya yer verdikleri için Türkiye Klinikleri'nin değerli yöneticilerine teşekkürü bir borç bilirim. Bu vesileyle COVID-19 pandemisi döneminde canları pahasına bir karşılık beklemeksizin tüm güçleriyle hastalarını kurtarmaya çalışan meslektaşlarıma ve sağlık çalışanlarına sonsuz sevgi ve saygılarımızı sunuyor ve eğer onlara bir katkı verebilmişsek kendimizi mutlu hissedeceğimizi bildirmek istiyorum.

Prof. Dr. Refik TANAKOL
Editör
This book of Türkiye Klinikleri has been devoted to a very common and important subject, namely thyrotoxicosis and hyperthyroidism which have multiple causes. Today new therapeutic modalities have evolved in the area of oncology including multikinase inhibitors and immune check-point inhibitors which have opened a new era in the treatment of various cancers. On the other hand, these agents cause distinct thyroid and endocrine disorders , including hyperthyroidism and thyrotoxicosis. This necessitates awereness of thyroid diseases among the oncologists and many other branches of medicine other than endocrinologists. For these reasons this book of Türkiye Klinikleri will arouse much interest in many specialities practising in various areas of medicine.

The terms thyrotoxicosis and hyperthyroidism are generally used as synonyms, which should not be the case. Thyrotoxicosis is the clinical syndrome that results when tissues are exposed to high levels of free thyroxin or free triiodothyronine, or both, that cause generalized acceleration of metabolic processes. In most instances thyrotoxicosis is due to causes such as excessive ingestion of thyroid hormone or thyroiditis. On the other hand, hyperthyroidism means maintained hyperactivity of the thyroid gland, which synthesizes and secretes excessive amounts of thyroid hormones. Some examples of hyperthyroidism are Basedow Graves disease, toxic adenoma and toxic multinodular goiter. The clinical manifestations of thyrotoxicosis and hyperthyroidism are similar independent of the cause. However, some features of the clinical course and some clinical signs may provide clues to the diagnosis of the cause. For instance duration of the symptoms, findings in the physical examination such as shape of the thyroid or extrathyroidal manifestations like ophtalmopathy may lead to the final diagnosis. Patients with subacute thyroiditis may remember the date of onset of symptoms and they usually have had the symtoms not more than a few weeks. However, those with Graves disease have had symptoms for several months, and they relate their fatigue to psychological reasons and breathlessness to their sedantary lifestyle. An attempt should be made to determine the cause of thyrotoxicosis and hy perthyroidism in all patients, because every single patient will need individualized treatment and has different prognosis. While many patients have overt clinical and biochemical disease, some cases may have subclinical disease. When hyperthyroidism is not diagnosed in the early stages of the disease, life-threatening complications may occur. The onset of symptoms and signs may be related to the age of the patient, comorbidities and the duration of the disease. Older patients have fewer and diminished symptoms and signs of sympathetic activation, which are more common in younger patients. Old patients present more commonly with cardiovascular manifestations such as congestive heart failure, dyspnea, and atrial fibrillation. Apathetic thyrotoxicosis is more common in the elderly. It is easy to diagnose thyrotoxicosis in a patient by measuring TSH, free thyroxin and free T3 when thyroid disorder is suspected nowadays. The best method to differentiate between thyrotoxicosis and hyperthyroidism is radioiodine uptake of the thyroid. Sometimes thyroid function tests give conflicting results in certain clinical situations or due to interference with other substances present in the serum. In this case, the clinican is reponsible to approach the patient appropriately by using his or her knowledge and experience. Various antithyroid treatments are available, i.e., antithyroid drugs, radioactive iodine, and thyroidectomy which are indicated generally in the treatment of hyperthyroidism. Treatment in thyrotoxicosis depends on the cause but ablative therapies should be generally avoided. All methods of treatment have both advantages and disadvantages and the clinician should be able to choose the best treatment for the patient according to the clinical profile.

This book of Türkiye Klinikleri has been prepared by the distinguished endocrinologists of Turkey and we are thankful for their unsurmountable efforts. I also would like to thank the editorial board of Türkiye Klinikleri for bringing this very important subject forward to the attention of involved branches of medicine. I, and on behalf of my colleagues, would like to thank all the doctors and the healthcare workers who did not care for their lives while helping their patients during this COVID-19 pandemic. I send my best wishes and regards, and I hope this review on the topic of hyperthyroidism and thyrotoxicosis will be helpful to all.

Prof. Dr. Refik TANAKOL
Editor

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