❗️Thyroid storm treatment includes

- Beta-blocker
- Methimazole (MMI)/propylthiouracil (PTU)
- Iodine
- Corticosteroids

🤔There is a great discussion about which antithyroid drug to use in this setting

🧐This is a methimazole x propylthiouracil in thyroid storm 🧵
Let's start with a poll
Which drug would you use?
PTU blocks T4 -> T3 conversion. As T3 is the active hormone, this is an advantage in an emergency setting.

MMI is safer than PTU, especially concerning liver injury. In an emergency setting with potential liver damage, it is also an advantage.

Let's dive into data!
In a retrospective analysis of 356 patients from Japan:

- 9% did not use an antithyroid drug
- 13% used PTU only
- 77,5% used MMI only
- 0,5% used both PTU and MMI

❗️Drug choice did not affect mortality, even after correction in a multivariate analysis.

Another retrospective analysis of 1,324 pts, also from Japan:

- MMI alone: 66%
- PTU alone: 6%
- Both MMI and PTU: 7%
- No antithyroid drug: 21%

Mortality (not adjusted):
MMI alone: 8.8%
PTU alone: 13%
P: 0.13 for MMI x PTU x PTU+MMI x none

An assessment of 1,244 pts treated in Taiwan showed a more balanced choice between MMI and PTU:

- PTU: 47%
- MMI: 46%

According to the authors: "outcomes were similar between the two medications."

What about the American Thyroid Association guideline?

They list both MMI and PTU as options but prefer PTU.

There is a fragment in which it is written that thyroid storm is an exception for the rule that MMI should be used in "virtually every patient".

Ok, it is clear that in Japan MMI is preferred (solid clinical data).

In Europe and in the US, maybe PTU is preferred (solid data for lowering T3).

There is a very interesting and easy-to-read editorial discussing different approaches

Let's wrap up with the same poll.
Which drug would you use?
Do you have any thoughts or evidence to add?

Please, help me in making this 🧵 better!

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More from @mendesthiagob

15 Aug
Hey #MedTwitter,

❗️It is common to be told not to assess thyroid function in severely ill patients unless clearly indicated.


Today's 🧵 is about the famous euthyroid-sick syndrome.🔎

#EndoTwitter #ICU #thyroid
Let's start with a poll.

Do you feel comfortable discussing euthyroid-sick syndrome?
How are thyroid function tests in euthyroid-sick syndrome?
Read 9 tweets
14 Aug
Hey #MedTwitter,

Have you ever heard of Lp(a)?🤔

It is a powerful atherosclerotic lipoprotein.

Let's go with a short Lp(a)🧵

Lp(a) is a type of LDL with the apo(a).

Problem 1: Lp(a) is strongly related to CVD, with increased risk at values ≥ 30 mg/dL (baseline) or ≥ 50 mg/dL (on statin).

Problem 2: Lp(a) does not respond to diet, exercise, and statin
Up to 20% of the population has ⬆️ Lp(a).

A clue to suspect: LDL does not ⬇️ as expected after statin therapy.

How to diagnose? Measuring.

What about the future? There is evidence that drugs targeting mRNA are the key, decreasing Lp(a) by up to 80%!
Read 4 tweets
13 Aug
Hey #MedTwitter,

In endocrinology, the concept of "inappropriately normal" is the basis for the interpretation of several labs results.

Do you understand this concept? It is definitely one of the most important for understanding endocrine diseases.

Follow the 🧵
📢 Clinically, it means the problem is not with the hormone itself. It means the problem is with the "hormone coordinator", which may sound normal when it is actually failing to respond as it should.

Let's clarify it!
With few exceptions, hormones control their own secretion by a mechanism called "negative feedback".

Let's use an example:
- Thyroid secretes T3/T4 controlled by TSH.
- T3/T4 act in the pituitary controlling TSH secretion.
--> T3/T4 negatively impact TSH secretion
Read 7 tweets
16 Jul
Empagliflozin, an SGLT2 inhibitor, showed positive results for heart failure with preserved ejection fraction according to Boehringer's statement.♥️

Full results will be released in August.

Let's discuss SGLT2 inhibitors?


Follow the 🧵

#MedEd #FOAMed
Sodium-glucose transport proteins (SGLT) are found both in the small intestines (SGLT1) and in the kidneys (SGLT2).

In the nephron, SGLT2 is the main responsible for the reabsorption of the filtered glucose. For this reason, its inhibition⬆️ glucosuria, decreasing hyperglycemia.
Phlorizin, a non-selective SGLT inhibitor, was isolated in the 1800s.

Why don't we use it?
- Instability;
- ⬇️ bioavailability;
- Inhibition of SGLT1, leading to ⬇️ intestinal glucose absorption and diarrhea
Read 10 tweets
22 May
Have you ever heard that nocturnal hypoglycemia causes rebound hyperglycemia in the morning?

This is also known as the Somogyi effect - published in 1938.

Did you know this concept has been contested in the last decades?

Follow the 🧵

#MedEd #diabetes #MedTwitter
Somogyi has claimed that hypoglycemia response (increase in glucagon, GH, cortisol, and) could overcompensate leading to hyperglycemia.

This is not true for most hormones' feedback. Let's use the thyroid to make a parallel:
When the thyroid loses function, TSH gets ⬆️. Can this high TSH overcompensate loss of thyroid function and cause hyperthyroidism? No!

What about glucose?
Read 8 tweets
21 May
Hey #MedTwitter,

An asymptomatic patient came to the outpatient clinic because of low TSH, high fT4/T3, and positive TRAb

Final diagnosis: Biotin supplement use🤔

Follow the 🧵

#Endotip #MedEd
Biotin supplements are commonly used and do not change thyroid function.

On the other hand, biotin often causes lab assay interference mimicking Graves' disease:

⬇️ TSH

⬆️ fT4 and T3

⬆️ TRAb
TRAb is a marker of Graves' disease, the most common cause of thyrotoxicosis/hyperthyroidism, and has a high accuracy :
- Sensitivity: ~ 97%
- Specificity: ~ 99%

📢Beware that despite high reliability, TRAb result can be falsely elevated in the setting of biotin use
Read 5 tweets

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