Hypothyroidism is a complex of symptoms of changes on the part of various organs and systems, caused by a decrease in the level of thyroid hormones.
The quality of life of patients with hypothyroidism who are constantly receiving replacement therapy with levothyroxine does not differ significantly from that of those without hypothyroidism. Hypothyroidism itself becomes a lifestyle for the patient, not a disease.
However, in the absence of timely adequate treatment for hypothyroidism, the risk of complications increases. Hypothyroid coma (HA) is a rare, life-threatening complication of hypothyroidism. First of all, it develops in elderly patients who have not been or poorly treated for a long time. Patients with HA die mainly from respiratory and heart failure, in some cases from cardiac tamponade. Even with promptly initiated vigorous therapy, 40% of patients die.
Clinical symptoms of hypothyroidism
Clinical symptoms of hypothyroidism develop in a patient with a gradual increase. Most often, hypothyroidism is characteristic of patients undergoing surgery on the thyroid gland (primary postoperative hypothyroidism).
The doctor should suspect the presence of hypothyroidism in an elderly patient and determine the level of thyroid-stimulating hormone (TSH) in the blood serum if the patient had a history of thyroid disease or received medications that can provoke the development of hypothyroidism. In addition, the presence of constipation resistant to conventional treatment, cardiomyopathy, anemia of unknown origin, dementia should be the reason for the exclusion of hypothyroidism in an elderly patient.
The laboratory parameters for the diagnosis of hypothyroidism are the determination of the basal (non-stimulated) TSH and the indices of free T 4 and T 3 . Normal basal TSH levels rule out hypothyroidism. With an increased basal TSH, the diagnosis is confirmed by the detection of reduced concentrations of free T 4 and T 3 .
Hypothyroidism diagnosis errors
The diagnosis of hypothyroidism is often untimely, since in its initial stage, the symptoms detected are extremely nonspecific. In addition, hypothyroidism syndrome can mimic various non-thyroid diseases, which is associated with the multiple organ lesions found in conditions of thyroid hormone deficiency. Very often, the manifestations of hypothyroidism in the elderly are considered by the doctor and the patient as signs of normal aging. Indeed, symptoms such as dry skin, alopecia, decreased appetite, weakness, dementia, etc., are similar to the manifestations of the aging process. Typical symptoms of hypothyroidism are detected only in 25-50% of elderly people, while the rest have either extremely blurred symptoms, or hypothyroidism is clinically realized in the form of some kind of monosymptom.
Clinical symptoms of hypothyroidism
Common symptoms of
fatigue, fatigue, weakness,
weight gain, chilliness
Cardiovascular symptoms of
or paradoxical hypertension,
Skin and its derivatives
Dry skin, loss of hair
loss of the lateral parts of eyebrows
Coloring of skin pale
with a yellowish tinge
Apathy, drowsiness, impaired
concentration of attention
Stupor and coma
Violation skeletoobrazovaniya in children
Constipation, megacolon, ileus
in women: violation of the cycle according to the type of amenorrhea or menorrhagia
in men: lack of libido, reduced
Reducing primary exchange
Weight gain, obesity
High cholesterol, hypoglycemia
Fluid retention with an increase in
tongue volume , swelling of the face, especially the eyelids
Increased creatine kinase levels
Goiter or its absence
The resolving factors are severe concomitant diseases, operations, trauma, sedation and drug use, and hypothermia.
The basis of the pathogenesis of HA is alveolar hypoventilation followed by hypoxia of vital organs, resulting in a decrease in body temperature, bradycardia and hypoglycemia. If assistance is not provided in a timely manner, a lethal outcome is possible. Mortality with GC is 60 to 90%.
The patient has all the symptoms of hypothyroidism worse. Drowsiness, disorientation, coma are expressed. The body temperature is reduced to 34-35 C, bradycardia occurs. The skin is cold, pasty.
The main symptom of HA is a decrease in body temperature. Coma is accompanied by progressive changes in the central nervous system, inhibition of all types of reflexes. Changes in the central nervous system lead to an increase in bradycardia, a decrease in blood pressure and hypoglycemia.
Disturbances from the cardiovascular system that develop in a patient with HA are often the cause of death. Peripheral hemodynamic parameters are among the first to respond to changes in the concentration of thyroid hormones. Hypothyroidism is accompanied by a decrease in heart rate (HR). Bradycardia that occurs with hypothyroidism is reversible when euthyroidism is achieved.
Another effect in hypothyroidism is a change in total peripheral vascular resistance (OPSR). Hypothyroidism causes an increase in systemic vascular resistance, which is to some extent associated with the development of diastolic arterial hypertension (AH). Diastolic hypertension with hypothyroidism is common. In patients with hypothyroidism and the presence of hypertension, the content of aldosterone and renin in the blood plasma is reduced, i.e. diastolic hypertension in hypothyroidism is hyporenin in nature.
The alleged causes of impaired vasodilating function in hypothyroidism are: a decrease in the generation of vasodilating substances and / or resistance to them of vascular smooth muscle cells; decrease in the concentration of atrial Na-uretic peptide.
The state of hypothyroidism is characterized by a decrease in the number of -adrenergic receptors, which is associated with a lower likelihood of developing arrhythmias. However, it was found that in persons with hypothyroidism, the secretion of norepinephrine and its content in the blood plasma is increased. Norepinephrine, being mainly a stimulant of adrenergic receptors, can contribute to spasm of the coronary arteries.
Hypothyroidism is characterized by a decrease in myocardial contractility, a decrease in the ejection fraction, and the development of heart failure. The state of hypothyroidism is also accompanied by prolongation of diastole, an increase in the time of isovolumetric relaxation of the left ventricle.
Since GC is the result of either the lack of treatment for hypothyroidism, or inadequate therapy for this syndrome and is an extremely serious condition with high mortality, a doctor of any specialty should have an idea of the algorithms for treating hypothyroidism and the drugs used for this.
It is very important to recognize hypothyroidism in time, which can be diagnosed with just one indicator of hormonal analysis – TSH, and to prescribe replacement therapy with Eutirox. Its difference from other preparations of thyroid hormones is the ability to easily select the required dosage – 25,50,75,100, 125 or 150 mcg, which greatly facilitates the replacement therapy of hypothyroidism.
Dosage regimen of the drug
EUTYROX (levothyroxine sodium)
Set individually depending on the indications, the effect of treatment and laboratory data. The entire daily dose is taken 1 time / day in the morning, at least 30 minutes before breakfast and washed down with liquid.
In hypothyroidism, at the beginning of treatment, it is prescribed at a dose of 50 mcg / day. The dose is increased by 25-50 mcg every 2-4 weeks until signs of a euthyroid state are reached.
In patients with long-term hypothyroidism, myxedema and, especially, in cases where there are diseases of the cardiovascular system, the initial dose of the drug should be no more than 25 g / day. In most patients, the effective dose does not exceed 200 mcg / day. The lack of an adequate effect when prescribing 300 mcg / day indicates malabsorption or that the patient does not take the prescribed dose of Eutirox. Adequate therapy usually leads to a normalization of the level of thyroid-stimulating hormone and thyroxine (T 4 ) in plasma after 2-3 weeks of treatment.
Provides a summary of the manufacturer’s information on dosage of medicinal products in adults. Read the instructions carefully before prescribing the drug.
The main goal of HA treatment is to restore the normal physiological functions of all organs and systems impaired as a result of hypothyroidism. The criterion for the adequacy of treatment is the disappearance of clinical and laboratory manifestations of hypothyroidism.
The severity and duration of hypothyroidism are the main criteria that determine the doctor’s tactics at the time of initiation of treatment.
The more severe the hypothyroidism and the longer it has not been compensated for, the higher the overall susceptibility of the body to thyroid hormones will be, especially for cardiomyocytes.
The main therapeutic measures for HA:
- Substitution therapy with thyroid hormone drugs (levothyroxine).
- The use of glucocorticoids.
- Fight against hypoventilation and hypercapnia, oxygen therapy.
- Elimination of hypoglycemia.
- Normalization of the activity of the cardiovascular system.
- Elimination of severe anemia.
- Elimination of hypothermia.
- Treatment of concomitant infectious and inflammatory diseases and elimination of other causes that led to the development of coma.
HA treatment is carried out in a specialized intensive care unit and is aimed at increasing the level of thyroid hormones, combating hypothermia, and eliminating cardiovascular and neuro-vegetative disorders.
The principle of HA treatment is based on the principle of maximum administration of thyroid hormones, primarily levothyroxine, through a tube either by drip or by intramuscular injections.
The goal of the treatment of hypothyroidism is a stable normalization of the TSH level within the normal range (0.4-4.0 U / L). In adults, euthyroidism is usually achieved by administering levothyroxine at a dose of 1.6–1.8 g / kg of body weight per day. The initial dose of the drug and the time to reach the full replacement dose is determined individually, depending on age, body weight and the presence of concomitant cardiac pathology. A variant of the gradual achievement of the full replacement dose of levothyroxine is possible – an increase of 25 g every 8-10 weeks. The need for levothyroxine decreases with age. Some older people may receive less than 1 mcg / kg of the drug per day.
The need for levothyroxine increases during pregnancy. Assessment of thyroid function in pregnant women, implying a study of the level of TSH and free T 4 , is advisable in each trimester of pregnancy. The dose of the drug should ensure the maintenance of a low-normal level of TSH.
In postmenopausal hypothyroid women on estrogen replacement therapy, levothyroxine may need to be increased to maintain normal TSH levels.
The TSH level, after changing the dose of levothyroxine, is examined no earlier than after 8-10 weeks. Patients receiving a selected dose of the hormonal drug are advised to test the TSH level annually. The TSH level is not affected by the time of blood sampling and the interval after taking levothyroxine. If, in addition to this, the determination of the level of free T 4 is used to assess the adequacy of therapy , the drug should not be taken in the morning before blood sampling, since for about 9 hours after taking levothyroxine, the level of free T 4 in the blood is increased by 15-20%. Ideally, the drug should be taken on an empty stomach at the same time of day and at least 4 hours apart before or after taking other drugs or vitamins. Taking drugs and compounds such as cholestyramine, iron sulfate, soy proteins, sucralfate and antacids containing aluminum hydroxide reduces the absorption of levothyroxine, which may require an increase in its dose. An increase in the dose of this drug may be necessary when taking rifampin and anticonvulsants that alter hormone metabolism.