36F With Graves Disease Diagnosed August 2023 Telangana PaJR
14-03-2025
THIS IS AN ONLINE E LOG BOOK TO DISCUSS OUR PATIENT'S DE-IDENTIFIED HEALTH DATA SHARED AFTER TAKING HER SIGNED INFORMED CONSENT. HERE WE DISCUSS OUR PATIENT'S PROBLEMS THROUGH SERIES OF INPUTS FROM AVAILABLE GLOBAL ONLINE COMMUNITY EXPERTS WITH AN AIM TO SOLVE THOSE PATIENT'S CLINICAL PROBLEMS WITH COLLECTIVE CURRENT BEST EVIDENCE BASED INPUTS.
[06-03-2025 12.44] PPM 1: OPD now: 36F with Graves disease first diagnosed August 2023 and on
Medical management with carbimazole 10 mg since then once daily!
On examination, mild eye signs, fine tremors and also complains of increased sweating!
Has recently developed increased thyroid swelling and nail changes since a year.
[08-03-2025 12.41] PPM 1: 👆was on 10 once daily!
[08-03-2025 12.41] PPM 1: 👆 Same patient's Update in OPD now @PPM2 from our rural endocrine
clinic.
[08-03-2025 12:42] PPM 2: I mean why USG guided FNAC when we know this is Graves'?
[08-03-2025 12:43] PPM 2: Surely she needs at least double or even 25mg
[08-03-2025 12:49] PPM 1: She was complaining of a recent nodule
[08-03-2025 12:49] PPM 1: Yes 10 tid now to be reviewed in a month
[08-03-2025 12:50] PPM 2: Which has now been ruled out.
[08-03-2025 12:50] PPM 2: Carbimazole is usually BD dosing sir. Would check BNF
Methimazole can be TDS is what I know of.
[08-03-2025 13:04] PPM 1: They may have FNA ed her cervical lymph nodes
[08-03-2025 13:18] PPM 2: What value is it adding for an already established diagnosis of Graves'
[08-03-2025 13:22] PPM 1: Thanks for that pointer and drive to review this which I have been
procrastinating ever since one of our medicine students brought a patient with thyrotoxicosis who had
given up her antithyroid meds just because she wanted it once daily while our medical student reviewed
in the OPD at that time and found that the once daily preparation was only available in UK for cats but
not tested in humans (and i recalled providing some inputs for one of our UK batchmate's cat with
thyrotoxicosis)!
However here's this beautiful paper that waters down quite a few of my past constructs around
carbimazole and to quote 👇
"Carbimazole has a plasma half-life of ~5.3 h (35) and traditionally was prescribed in divided doses
(36). However, several studies have demonstrated that a single dose of carbimazole is just as effective
at inducing euthyroidism (16, 37–40). Furthermore, methimazole is concentrated in thyroid follicular
tissue (41, 42) and has a longer biological duration of action than suggested by pharmacokinetic levels.
Moreover, compliance is increased by once daily dosing of ATD (43). In the present study, we did not
find any evidence that splitting the dose or adjusting the dose for body weight significantly altered the
fall in the thyroid hormones following carbimazole."
Also "carbimazole is entirely metabolized to methimazole" in the body!
Wish I could tag that student here to ask her patient to start taking her carbimazole once daily at same
dosage @PPM3
[08-03-2025 13:23] PPM 4: Neoplasia?
[08-03-2025 13:23] PPM 1: There's always a paranoia around thyroid swelling and
malignancy! One of your PG batchmates had the same paranoia and even got operated!
[08-03-2025 13:25] PPM 2: Yes absolutely. Once euthyroid state is reached, we usually step down from
a BD dose to once daily Carbimazole.
[08-03-2025 13:26] PPM 2: Yes, also aware that Carbimazole is entirely metabolized to Methimazole
but I think BNF quotes that there is much higher risk of Pancreatitis and hypersensitivity reactions with
Methimazole directly.
[08-03-2025 13:26] PPM 2: What is the risk of Neoplasia in Graves' disease?
[08-03-2025 13:27] PPM 3: Will try to find out sir
[08-03-2025 14.00] PPM 4:
[08-03-2025 14:00] PPM 4: As said sir
[08-03-2025 14:01] PPM 2: Are you sure?
[08-03-2025 14:02] PPM 4: Google searched honestly
[08-03-2025 14:02] PPM 4: There can be a possibility
[08-03-2025 14:03] PPM 2: Do you think this statement helps any patient?
Put yourself in the patient shoes and ask what information would they want to know ideally?
That is the information the doctor too should be looking for.
[08-03-2025 14:05] PPM 4: Etiology n treatment insight
[08-03-2025 15:09] PPM 1: You need to click into those links shown by Google AI and not trust what it
churns out blindly.
[14-03-2025 12.51] PPM 1:
Reviewed this patient again today in OPD. Had shared about this patient here in the collective group
from the angle of her thyrotoxicosis and once daily vs thrice daily treatment that can all be archived in
her case report and will now also share more about another sticky diagnosis that she's painfully bearing
with an injection benzathine penicillin every month that needs to be unstuck!
Here's her first evaluation for palpitations by a cardiologist attached from 2023 when while the
cardiologist obtained a thyroid function test for her palpitations he also did an echocardiography which
made him observe certain things that made him decide to start this 36-40 year old lady on injection
benzathine penicillin!
[14-03-2025 12.54] PPM 1: Today's chest X-ray. Will repeat her echo today to see if we can remove that
diagnosis of CRHD and a good review of the available scientific evidence around rheumatic fever
prophylaxis may allow us to discontinue it anyways inspite of the CRHD tag @PPM2
[14-03-2025 13:23] PPM 2: Hopefully yes.
[15-03-2025 10.21] PPM 1: The final echo with comments on why we decided to stop her rheumatic
fever prophylaxis:
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