Difference between revisions of "Hyperthyroidism"

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There are numerous medical methods for managing hyperthyroidism.
 
There are numerous medical methods for managing hyperthyroidism.
*Oral [[carbimazole]] (Neomercazole®) - the active metabolite of [[methimazole]] and has fewer reported side-effects
+
*Oral [[carbimazole]] (Neomercazole®) - the active metabolite of [[methimazole]] and has fewer reported side-effects. Commonly used in Australia, United Kingdom, Europe and Canada
*Oral [[methimazole]] - an older oral treatment of hyperthyroidism
+
*Oral [[methimazole]] - most popular oral treatment in the United States for oral treatment of hyperthyroidism
 
*Oral [[Ipodate]] (Orograffin) or iopanoic acid (Telepaque) - an options in cats intolerant of methimazole or carbimazole.
 
*Oral [[Ipodate]] (Orograffin) or iopanoic acid (Telepaque) - an options in cats intolerant of methimazole or carbimazole.
 
*[[Radiotherapy]]
 
*[[Radiotherapy]]

Revision as of 03:38, 29 January 2010

File:Hyper1.jpg
Abyssinian with hyperthyroidism
File:Thyroid4.jpg
Feline hyperthyroidism, thyroid nodule
Enlarged thytroid gland in a DSH cat
Thyroidectomy being performed on above cat
File:Hyper3.jpg
Lateral and ventrodorsal radiographs of a cat with hyperthyroidism and hyperthyroid heart disease. Notice the enlarged cardiac silhouette

Hyperthyroidism is the most common endocrine disorder affecting older cats, characterised classically by elevated total T4 above the reference range of 20-40 nmol/L. It is uncommon to see hyperthyroidism in cats under 10 years of age, and is commonly caused by a benign thyroid adenoma or adenomatous hyperplasia present in one or both lobes of the thyroid gland. Fewer than 2% of cases occur as a result of a functional thyroid carcinoma[1].

Certain factors may contribute, since it is seen in cats;

  • fed a majority of tinned food in their diet
  • living strictly indoors, using litter
  • having a reported exposure to lawn herbicides, fertilizers and pesticides
  • having been regularly treated with flea sprays and powders

Goitrogenic compounds including phthalates, resorcinol, polyphenols (plasticised bisphenol A - BPA) and PCBs. Cats have a relatively slow capacity for glucuronidation, the metabolic pathway responsible for metabolising many goitrogenic compounds. Autoantibodies have been suggested as a risk factor for the development of hyperthyroidism, but have not been proven to exist in hyperthyroid cats. A genetic basis for hyperthyroidism also has been suggested. Decreased expression of a G-protein in adenomatous thyroid glands of some hyperthyroid cats has been shown to reduce the negative inhibition of the cAMP cascade in thyroid cells. This leads to autonomous growth of the thyroid and the hypersecretion of thyroxine. The results of one study indicated that over-expression of the c-ras oncogene in hyperthyroid cats was highly associated with areas of nodular follicular hyperplasia and adenomas of the thyroid glands. Currently, the precise aetiology of hyperthyroidism is unclear.

Clinical signs

Hyperthyroidism affects older cats most commonly. It is seen occasionally in cats as young as 4 years of age. The clinical signs include weight loss, increased activity, polyphagia, vomiting or diarrhoea, increased vocalisation, increased drinking and increased urination. The increase in thyroid hormone causes the cat's heart to beat faster (often > 240 beats per minute). Heart murmurs may be present. Heart damage is a common result of this disease, although it is usually reversible with treatment. The coat may look scruffy. Enlarged thyroid glands may be found. Effects on the kidneys from the circulatory changes can make existing kidney disease worse or cause the appearance of kidney disease in some cats.

Diagnosis

The diagnosis of feline hyperthyroidism by veterinarians usually requires the combination of a detailed medical history, thorough physical examination, and confirmation of disease via laboratory testing. The medical history should note any changes in activity, behaviour, or appearance that are suggestive of hyperthyroidism.

Testing for hyperthyroidism is done by;

  • Thyroid palpation is important in the detection of thyroid gland abnormalities. Palpation is best performed by raising the cat’s chin to a 45º angle and turning the head 45º to the right, placing the left index finger in the groove between the trachea and muscles to the left of the larynx. The index finger should be moved downward to the thoracic inlet. The direction of the head should be reversed and palpation repeated to examine the right cervical area. Palpation can be highly sensitive in detecting hyperthyroid cats, but many euthyroid cats also may possess palpable goiters. However, a large number of elderly, euthyroid cats with palpable goiters ultimately develop hyperthyroidism[2].
  • Total thyroxine (T4) and triiodothyronine (T3) levels - the total T4 is the first test used to assess thyroid function. In most cats with hyperthyroidism, these levels will be above normal. Total T4 values may fall within normal reference ranges in early hyperthyroidism, or where there is concurrent non-thyroidal illness present ('euthyroid sick syndrome). In house testing of T4 has been shown to be inaccurate for measurement of real T4 in cats. Free T4 can be helpful in diagnosing hyperthyroidism in a patient with high normal T4 along with clinical signs suggestive of hyperthyroidism. It must be noted that non-thyroidal illness can (in <1% of cats) cause artificial elevation of T4 resulting in misdiagnosis.
  • Thyrotropin-releasing hormone (TRH) stimulation test - has good accuracy but there is a 50% chance of transient malaise during testing.
  • T3-suppression test - a relatively easy test to perform but has a grey zone in that it is unclear which results signify hyperthyroidism or not.
  • TSH stimulation test - attempts to measure feline TSH in hyperthyroid cats using commercially available canine TSH assays have not shown the necessary sensitivity to clearly distinguish between low and normal concentrations.
  • Technetium scanning - requires a facility and personnel able to perform and interpret radio-uptake. This has led to the revelation that 20-25% of hyperthyroid cats have ectopic functional thyroid tissue located elsewhere (often intrathoracic) and thus warrants investigation and often precludes use of surgical intervention.

Hyperthyroid heart disease and cardiac disturbances also are quite common in hyperthyroid cats. These changes include tachycardia (rapid heart rate), murmurs, premature beats, or gallop rhythms. These findings generally are attributed to the high-output cardiac state caused by the effect of excess thyroid hormone on cardiac muscle as well as its effects on the sympathetic nervous system

Treatment

Because an irreversible decline in renal function occurs with many cases of definitive treatment of hyperthyroidism, it may be prudent to assess renal function before and after the hyperthyroid state has been corrected. There is anecdotal evidence suggesting that cats with normal blood urea and creatinine and USG > 1.035 having a reduced risk for the development of renal insufficiency after treatment for hyperthyroidism. Pretreatment GFR is also reported to be a predictor of post-treatment renal failure, with one study reporting that a pre-treatment GFR of less than 2.25 ml/kg/min was 100% sensitive and 78% specific for post-treatment renal failure. However, none of these predictors withstand thorough investigation and it is best to manage each case on an ad hoc basis[3].

There are numerous medical methods for managing hyperthyroidism.

  • Oral carbimazole (Neomercazole®) - the active metabolite of methimazole and has fewer reported side-effects. Commonly used in Australia, United Kingdom, Europe and Canada
  • Oral methimazole - most popular oral treatment in the United States for oral treatment of hyperthyroidism
  • Oral Ipodate (Orograffin) or iopanoic acid (Telepaque) - an options in cats intolerant of methimazole or carbimazole.
  • Radiotherapy

Radioiodine (131I) therapy remains the gold standard, although iatrogenic hypothyroidism can occur after 131I treatment in 6-30% of cases (van Hoek et al, 2009). It is effective in about 90% of cats. For patients in which the daily administration of pills is undesirable this is the best method of treatment. The major disadvantage to radioactive iodine therapy is the costs, and it also requires the isolation of your cat at the vet hospital for 7 to 14 days due to safety concerns[4].

  • Surgery

An effective procedure in most cats and usually suggested by your vet when medication no longer controls the symptoms.

In older cats, this disease is common enough that routine screening is considered to be necessary by many veterinarians. Due to the potential for numerous secondary complications, such as heart disease and digestive problems, early diagnosis is a good idea.

Further reading

Caring for a cat with hyperthyroidism (.pdf)

References

  1. August, JR (2006) Consultations in feline internal medicine. Vol 5. Elsevier Saunders, USA
  2. Harvey AM et al (2009) Scintigraphic findings in 120 hyperthyroid cats. JFMS 11:96-106
  3. Stortz, JS (2009) et al
  4. van Hoek IM et al (2009) Effect of reconbinant human thyroid stimulating hormone on serum thyroxin and thyroid scintigraphy in euthyroid cats. JFMS 11:309-314