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Feldkamp JD, Feldkamp J. Indications for Intravenous T3 and T4. Horm Metab Res 2024. [PMID: 38698631 DOI: 10.1055/a-2318-5156] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 05/05/2024]
Abstract
Therapy with thyroid hormones normally is restricted to substitution therapy of patients with primary or secondary hypothyroidism. Typically, thyroid hormones are given orally. There are few indications for intravenous use of thyroid hormones. Indications for parenteral application are insufficient resorption of oral medications due to alterations of the gastrointestinal tract, partial or total loss of consciousness, sedation in the intensive care unit or shock. In almost all cases, levothyroxine is the therapy of choice including congenital hypothyroidism. In preterm infants with an altered thyroid hormone status, studies with thyroid hormones including intravenous liothyronine showed a normalisation of T3 levels and in some cases an amelioration of parameters of ventilation. A benefit for mortality or later morbidity could not be seen. Effects on neurological improvements later in life are under discussion. Decreased thyroid hormone levels are often found after cardiac surgery in infants and adults. Intravenous therapy with thyroid hormones improves the cardiac index, but in all other parameters investigated, no substantial effect on morbidity and mortality could be demonstrated. Oral liothyronine therapy in these situations was equivalent to an intravenous route of application. In myxoedema coma, intravenous levothyroxine is given for 3 to 10 days until the patient can take oral medication and normal resorption in the gastrointestinal tract is achieved by restoring at least peripheral euthyroidism. Intravenous levothyroxine is the standard in treating patients with myxoedema coma. A protective effect on the heart of i.v. levothyroxine in brain-dead organ donors may be possible.
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Affiliation(s)
- Jasper David Feldkamp
- Division of Hematology, Oncology, and Cancer Immunology, Charite Medical Faculty Berlin, Berlin, Germany
| | - Joachim Feldkamp
- Klinikum Bielefeld, Academic Department of General Internal Medicine, Endocrinology and Diabetes, Infectiology, Bielefeld University, Medical School and University Medical Center East Westphalia-Lippe, Bielefeld, Germany
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Chen DH, Hurtado CR, Chang P, Zakher M, Angell TE. Clinical Features and Outcomes of Myxedema Coma in Patients Hospitalized for Hypothyroidism: Analysis of the United States National Inpatient Sample. Thyroid 2024; 34:419-428. [PMID: 38279788 DOI: 10.1089/thy.2023.0559] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/29/2024]
Abstract
Background: Hypothyroidism is a common endocrine condition and chronic thyroid hormone deficiency is associated with adverse effects across multiple organ systems. In compensated hypothyroidism, however, patients remain clinically stable due to gradual physiological adaptation. In contrast, the clinical syndrome of decompensated hypothyroidism referred to as myxedema coma (MC) is an endocrine emergency with high risk of mortality. Because of its rarity, there are currently limited data regarding MC. This study analyzes the clinical features and hospital outcomes of MC compared with hypothyroid patients without MC (nonMChypo) in national United States hospital data. Methods: A retrospective analysis of the National Inpatient Sample, a public database of inpatient admissions to nonfederal hospitals in the United States, 2016-2018, including adult patients with primary diagnosis of MC (International Classification of Diseases 10th Revision [ICD-10]: E03.5) or nonMChypo (E03.0-E03.9, E89.0). Patient demographics, relevant clinical features, mortality, length of stay (LOS), and hospital costs were compared. Results: Of 18,635 patients hospitalized for hypothyroidism, 2495 (13.4%) had a diagnosis of MC. Sex distribution and race/ethnicity were similar between patients with MC and nonMChypo, whereas MC was associated with older patient age (p = 0.02), public insurance (p = 0.01), and unhoused status (p = 0.04). More admissions with MC occurred in winter compared with other seasons (p = 0.01). The overall mortality rate for MC was 6.8% versus 0.7% for nonMChypo (p < 0.001), and MC was independently associated with in-hospital mortality after adjusted regression analysis (adjusted odds ratio = 9.92 [CI 5.69-17.28], p < 0.001). Mean LOS ± standard error was 9.64 ± 0.73 days for MC versus 4.62 ± 0.12 days for nonMChypo (p < 0.001), and total hospital cost for MC was $21,768 ± $1759 versus $8941 ± $276 for nonMChypo (p = 0.07). In linear regression analyses, MC was an independent predictor of both increased LOS and total hospital cost. Conclusions: In summary, MC remains a clinically significant diagnosis in the modern era, independently associated with high mortality and health care costs. This continued burden demonstrates a need for further efforts to prevent, identify, and optimize treatment for patients with MC.
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Affiliation(s)
- Dennis H Chen
- Department of Internal Medicine, University of Southern California, Los Angeles, California, USA
| | - Carolina R Hurtado
- Division of Endocrinology, Diabetes and Metabolism, Los Angeles General Medicine Center, Los Angeles, California, USA
| | - Patrick Chang
- Division of Gastroenterology and Liver Diseases, University of Southern California, Los Angeles, California, USA
| | - Mariam Zakher
- Division of Endocrinology and Diabetes; Keck School of Medicine, University of Southern California, Los Angeles, California, USA
| | - Trevor E Angell
- Division of Endocrinology and Diabetes; Keck School of Medicine, University of Southern California, Los Angeles, California, USA
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Che L, Zhu A, Chen W, Yu C. Profound postinduction hypotension precipitated by immune checkpoint inhibitors: a case report. J Med Case Rep 2024; 18:146. [PMID: 38459576 PMCID: PMC10924312 DOI: 10.1186/s13256-024-04375-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/09/2023] [Accepted: 01/11/2024] [Indexed: 03/10/2024] Open
Abstract
BACKGROUND With the increasing use of immune checkpoint inhibitors (ICIs) in cancer therapy, perioperative healthcare professionals need to be vigilant about potential immune-related adverse events (irAEs). We report a case of severe postinduction hypotension in a patient undergoing laparotomy due to suspected intraabdominal bleeding from gastric cancer and Krukenberg tumors, caused by unrecognized hypothyroidism precipitated by ICIs. CASE PRESENTATION A 65-year-old Chinese female with a history of gastric adenocarcinoma and Krukenberg tumors, previously treated with nivolumab, presented to the emergency room with abdominal pain and hypotension. Despite ruling out other causes, including hypovolemia and anaphylaxis, her hypotension persisted. The patient was found to have severe hypothyroidism, likely an irAE from the use of nivolumab. Thyroxine replacement therapy resolved the hypotension, and the patient recovered uneventfully after surgery. CONCLUSIONS This case underscores the importance of considering irAEs, such as hypothyroidism, in patients treated with ICIs. Perioperative healthcare providers must remain vigilant for potential complications and promptly recognize and manage irAEs to optimize patient outcomes.
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Affiliation(s)
- Lu Che
- Department of Anesthesiology, Peking Union Medical College Hospital, Beijing, 100730, China
| | - Afang Zhu
- Department of Anesthesiology, Peking Union Medical College Hospital, Beijing, 100730, China
| | - Wen Chen
- Department of Anesthesiology, Peking Union Medical College Hospital, Beijing, 100730, China
| | - Chunhua Yu
- Department of Anesthesiology, Peking Union Medical College Hospital, Beijing, 100730, China.
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Yu G, Liu S, Song C, Ma Q, Chen X, Jiang Y, Duan H, He Y, Wang D, Wan H, Shen J. Association of sensitivity to thyroid hormones with all-cause mortality in euthyroid US adults: A nationwide cohort study. Eur Thyroid J 2024; 13:ETJ-23-0130. [PMID: 38189656 PMCID: PMC10895331 DOI: 10.1530/etj-23-0130] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/10/2023] [Accepted: 01/08/2024] [Indexed: 01/09/2024] Open
Abstract
Background This study aimed to examine the associations of thyroid hormone sensitivity indices, including free triiodothyronine to free thyroxine (FT3/FT4) ratio, thyroid feedback quantile-based index by FT4 (TFQIFT4), thyroid-stimulating hormone index (TSHI), and thyrotrophic thyroxine resistance index (TT4RI) with all-cause mortality in euthyroid adults. Methods The study included 6243 euthyroid adults from the National Health and Nutrition Examination Survey (NHANES) 2007-2012. FT3/FT4 ratio, TFQIFT4, TSHI, and TT4RI were calculated. The multivariable Cox proportional hazard regression, restricted cubic spline (RCS), and subgroup analysis were conducted. Results Individuals in quartile 4th (Q4) had lower all-cause mortality than those in quartile 1st (Q1) of FT3/FT4 ratio (OR 0.70, 95% CI (0.51, 0.94)). Regarding TFQIFT4, individuals in Q4 of TFQIFT4 had a 43% higher all-cause mortality than those in Q1 (OR 1.43, 95% CI (1.05, 1.96)) (P <0.05, all). Compared with participants in Q1, no associations of TSHI and TT4RI with mortality were found. TFQIFT4 was linearly and positively associated with mortality. However, the FT3/FT4 ratio showed a U-shaped association with mortality. Conclusions Increased risk for all-cause mortality was positively associated with TFQIFT4, suggesting that increased risk for all-cause mortality was associated with decreased central sensitivity to thyroid hormones. Furthermore, the FT3/FT4 ratio showed a U-shaped association with mortality, with an inflection point at 0.5. However, more cohort studies are needed to validate the conclusions.
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Affiliation(s)
- Genfeng Yu
- G Yu, Department of Endocrinology and Metabolism, Shunde Hospital of Southern Medical University, Foshan, China
| | - Siyang Liu
- S Liu, Department of Endocrinology and Metabolism, Shunde Hospital of Southern Medical University, Foshan, China
| | - Cheng Song
- C Song, Department of Endocrinology and Metabolism, Shunde Hospital of Southern Medical University, Foshan, China
| | - Qintao Ma
- Q Ma, Department of Endocrinology and Metabolism, Shunde Hospital of Southern Medical University, Foshan, China
| | - Xingying Chen
- X Chen, Department of Endocrinology and Metabolism, Shunde Hospital of Southern Medical University, Foshan, China
| | - Yuqi Jiang
- Y Jiang, Department of Endocrinology and Metabolism, Shunde Hospital of Southern Medical University, Foshan, China
| | - Hualin Duan
- H Duan, Department of Endocrinology and Metabolism, Shunde Hospital of Southern Medical University, Foshan, China
| | - Yajun He
- Y He, Department of Endocrinology and Metabolism, Shunde Hospital of Southern Medical University, Foshan, China
| | - Dongmei Wang
- D Wang, Department of Endocrinology and Metabolism, Shunde Hospital of Southern Medical University, Foshan, China
| | - Heng Wan
- H Wan, Department of Endocrinology and Metabolism, Shunde Hospital of Southern Medical University, Foshan, China
| | - Jie Shen
- J Shen, Department of Endocrinology and Metabolism, Shunde Hospital of Southern Medical University, Foshan, China
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Mandyam S, Valisekka SS, Parghi D, Chirrareddy Y, Kalluru PKR, Ibie NC. Myxedema Coma: A Grave Phenomenon Partially Reversed CKD Status With Treatment of Hypothyroidism. Cureus 2023; 15:e40221. [PMID: 37435271 PMCID: PMC10332427 DOI: 10.7759/cureus.40221] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/10/2023] [Indexed: 07/13/2023] Open
Abstract
Myxedema coma is a grave medical condition that warrants emergent medical management to avoid adverse effects and unfavorable outcomes. Intravenous thyroid hormones (T3 and T4), along with intravenous hydrocortisone and frequent vital monitoring, are the mainstays of the management of myxedema coma. The interplay between CKD and hypothyroidism is fascinating and can affect each other. It is often very difficult for physicians to differentiate between sepsis and myxedema coma, especially in the early stages. Infections and medication non-compliance are the leading causes of precipitation myxedema coma. We describe a case report presented with myxedema coma and CKD, which was successfully managed and also led to a partial reversal of CKD status.
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Affiliation(s)
| | | | - Devam Parghi
- Internal Medicine, Southeast Health Medical Center, Dothan, USA
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