3. HIPOTIROIDISMO.
• Deficiencia hormonal causada por una disfunción intrínseca de la
glándula tiroides que interrumpe la síntesis y secreción de T4 y TSH.
Canaris GJ, Manowitz NR, Mayor G, Ridgway EC. The Colorado thyroid disease prevalence study. Arch Intern Med 2010; 160: 526–34
4. Epidemiologia
• Prevalencia: 1 al 7% de la poblacion.
• Hereditario en un 25 a 65%.
• 10 > en Mujeres.
• Enfermedades autoinmunes.
Endocrinol Metab Clin N Am 36 (2017) 595– 615
5. Epidemiologia.
• Metaanalisis en 9 paises de europa estima la prevalencia media de
5%.
• Prevalencia mas comun en Mujeres.
• Personas > 65 años.
Garmendia Madariaga A, Santos Palacios S, Guillén-Grima F, Galofré JC. The incidence and prevalence of thyroid dysfunction in Europe: a
meta-analysis. J Clin Endocrinol Metab 2014; 99: 923–31.
6. Epidemiologia
• Diabetes tipo 1.
• Gastritis atrofica autoinmune.
• Enfermeda Celiaca
• Artritis Reumatoide.
• Sindrome de Down
• Lupus eritematoso sistemico.
McLeod DS, Caturegli P, Cooper DS, Matos PG, Hutfless S. Variation in rates of autoimmune thyroid disease by race/ethnicity in US military
personnel. JAMA 2014; 311: 1563–65.
7. Factores de riesgo:
1. Antecedentes familiares de enfermedad tiroidea.
2. Ser familiar o residente de zonas bocióigenas .
3. Presencia de otra enfermedad autoinmune: diabetes mellitus tipo 1 artritis
reumatoide o lupus,vasculitis etc.
4. Cirugía tiroidea
5. Terapia con radiación previa o actual.
6. Consumo de medicamentos: yodo, litio, amiodarona metimazole, interferon,
talidomida, rifampicina
Best Practice & Research Clinical Endocrinology & Metabolism 23 (2014) 793–800
8.
9. HIPOTIROIDISMO PRIMARIO.
• TSH (10mUI/I) con un nivel de T4 libre por debajo del limite inferior
del intervalo de referencia T4L <0.9ng/dl
• Tiroiditis Autoinmune Hashimoto.
• Elevadas concentraciones de Anticuerpos antitiroideos
• Anticuerpos antiperoxidasa en 11% poblacion.
Effraimidis G, Strieder TGA, Tijssen JGP, Wiersinga WM. Natural history of the transition from euthyroidism to overt autoimmune
hypo- or hyperthyroidism: a prospective study. Eur J Endocrinol 2017; 164: 107–13.
10. • 80% paciente con Enfermedad de Graves.
• 55% pacientes con nodulo toxico tiroideo.
• 20% Hemitiroidectomia.
• 14% pacientes con uso de amiodarona.
• 6% pacientes con uso de litio.
35. Zhong B, Wang Y, Zhang G, Wang Z. Environmental iodine content, female sex and age are associated with new-onset amiodarone-induced hypothyroidism: a systematic review
and meta-analysis of adverse reactions of amiodarone on the thyroid. Cardiology 2016; 134: 366–71.
35. Shine B, McKnight RF, Leaver L, Geddes JR. Long-term effects of lithium on renal, thyroid, and parathyroid function: a retrospective analysis of
laboratory data. Lancet 2015; 386: 461–68.
11. HIPOTIROIDISMO PRIMARIO.
• TSH (10mUI/I) - T4L <0.9ng/dl
• Hipotiroidismo primario
• Tiroiditis autoinmune crónica
• Tiroiditis postparto, subaguda, silente
• Deficiencia o exceso de yodo
• Cirugía de tiroides, tratamiento con yodo 131, radiación externa
• Enfermedades infiltrativas
• Medicamentos
• Agenesia o disgenesia de la tiroides
Endocrinol Metab Clin N Am 36 (2017) 595– 615
12. HIPOTIROIDISMO SUBCLINICO.
• TSH con moderado, aunque T4 libre, se encuentra en un intervalo
normal-bajo.
• TSH entre 4.5-10mUI/ml T4L normal 0.9-1.9ng/dl
Endocrinol Metab Clin N Am 36 (2017) 595– 615
13. Hipotiroidismo Secundario o central.
• Deficit en la en la glandula tiroides que de debe a estimulacion
inadecuada por hormona TSH secundaria a transtornos hipotalamicos
e hipofisiarios congenitos o adquiridos.
• TSH < 1mUI/ml T4L< 0.9ng/dl
Endocrinol Metab Clin N Am 36 (2017) 595– 615
14. • Adenomas.
• Trauma de craneo.
• Sindrome de Sheehan.
• Cirugia.
• Radioterapia.
• Enfermedades infiltrativas.
Persani L. Clinical review: Central hypothyroidism: pathogenic, diagnostic, and therapeutic challenges. J Clin
Endocrinol Metab 2012; 97: 3068–78.
15.
16. Coomorbilidades:
• Infarto agudo al miocardio.
• Derrame pericardico.
• Sindrome metabolico.
• Hipertension.
• Dislipidemias.
• Depresion.
• Demencia.
Tiller D, Ittermann T, Greiser KH, et al. Association of serum thyrotropin with
anthropometric markers of obesity in the general population. Thyroid 2016; 26: 1205–14.
17. Diagnostico:
Brenta G, Vaisman M, Sgarbi JA, et al, for the Task Force on Hypothyroidism of the Latin American Thyroid Society (LATS) Study Group.
Clinical practice guidelines for the management of hypothyroidism. Arq Bras Endocrinol Metabol 2013; 57: 265–91.
18. DIAGNOSTICO:
Vanderpump MP, Ahlquist JA, Franklyn JA, Clayton RN. Consensus statement for good practice and audit measures in the management of
hypothyroidism and hyperthyroidism. The Research Unit of the Royal College of Physicians of London, the Endocrinology and Diabetes
Committee of the Royal College of Physicians of London, and the Society for Endocrinology. BMJ 1996; 313: 539–44.
19. CRIBADO:
• Pacientes > 35 años cada 5 años.
• Mujeres > 60 años.
• Pacientes con enfermedades autoinmunes.
Garber JR, Cobin RH, Gharib H, et al, for the American Association of Clinical Endocrinologists and American Thyroid Association Taskforce
on Hypothyroidism in Adults Study Groups. Clinical practice guidelines for hypothyroidism in adults: cosponsored by the American
Association of Clinical Endocrinologists and the American Thyroid Association.Endocr Pract 2012; 18: 988–1028
20. Tratamiento:
McAninch EA, Bianco AC. New insights into the variable effectiveness of levothyroxine monotherapy for
hypothyroidism. Lancet Diabetes Endocrinol 2015; 3: 756–58.
21. Objetivos:
• Normalizacion de niveles
de TSH.
• Mejoria de
sintomatologia.
• Hasta un 30 a 60% de los
pacientes no alcanzan
metas terapeuticas.
Taylor PN, Iqbal A, Minassian C, et al. Falling threshold for treatment of borderline elevated thyrotropin levels-balancing benefits and risks:
evidence from a large community-based study. JAMA Intern Med 2014; 174: 32–39.
23. 1. TSH ELEVADA
112. Vita R, Saraceno G, Trimarchi F, Benvenga S. Switching levothyroxine from the tablet to the oral solution formulation corrects the
impaired absorption of levothyroxine induced by proton-pump inhibitors. J Clin Endocrinol Metab 2014; 99: 4481–86.
24. 2. ¿TSH NORMAL?
Seng Yue C, Benvenga S, Scarsi C, Loprete L, Ducharme MP. When bioequivalence in healthy volunteers may not translate to bioequivalence
in patients: differential effects of increased gastric pH on the pharmacokinetics of levothyroxine capsules and tablets. J Pharm Pharm Sci 2015;
18: 844–55.
25. 3. TSH DISMINUIDA
Taylor PN, Iqbal A, Minassian C, et al. Falling threshold for treatment of borderline elevated thyrotropin levels-balancing benefits and risks:
evidence from a large community-based study. JAMA Intern Med 2014; 174: 32–39.
29. Díez JJ et al; Spontaneous subclinical hypothyroidism in patients older than 55 years: analysis of natural
course and risk factors for the development of overt thyroid failure. J Clin Endocinol Metab 2014; 89: 4890-
97.
30. ESQUEMA A SEGUIR
Burns RB, Bates CK, Hartzband P, Smetana GW. Should we treat for subclinical hypothyroidism?: Grand rounds discussion
from Beth Israel Deaconess Medical Center. Ann Intern Med 2016; 164(11):764– 770. doi:10.7326/M16-0857
31. Grossman A, Weiss A, Koren-Morag N, Shimon I, Beloosesky Y, Meyerovitch J. Subclinical thyroid disease and mortality in the
elderly: a Retrospective Cohort Study. Am J Med. (2016) 129:423–30. doi: 10.1016/j.amjmed.2015.11.027
32. ¿SIN METAS
TERAPEUTICAS?
Walker JN, Shillo P, Ibbotson V, et al. A thyroxine absorption test followed by weekly thyroxine administration: a method to assess non-
adherence to treatment. Eur J Endocrinol 2013; 168: 913–17.
33. LEVOTIROXINA- LIOTIRINONA
• Mejor perfil metabolico.
• Sin mejoria sobre monoterapia de Levotiroxina
Bunevicius R, Kazanavicius G, Zalinkevicius R, Prange AJ Jr. Effects of thyroxine as compared with thyroxine plus triiodothyronine in patients
with hypothyroidism. N Engl J Med 1999; 340: 424–29.
34. • Las recomendaciones actuales de la ATA, TES, AACE alientan a los pacientes a
permanecer con un mismo producto.
• Cuando los pacientes deben cambiar entre comercial y genérico, la TSH debe ser
revisada cada 2 a 4 semanas, y en base a esto modificar la dosis.
Endocrinol Metab Clin N Am 36 (2014) 595– 615
35. And in the end
The love you take
Is equal to
The love you make.
