Endocrine Block 1 Lecture Dr. Usman Ghani

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1 Endocrine Block 1 Lecture Dr. Usman Ghani
Biochemistry of Thyroid Hormones and Thermogenesis Endocrine Block 1 Lecture Dr. Usman Ghani

2 Overview Types and biosynthesis of thyroid hormones
Thyroid hormone action Regulation of thyroid hormones Thyroid function tests Goitre Hypo and hyperthyroidism Causes Diagnosis Treatment Thermogenesis

3 Types and biosynthesis of thyroid hormones
Thyroxine (T4) and tri-iodothyronine (T3) Synthesized in the thyroid gland by: Iodination Coupling of two tyrosine molecules Attaching to thyroglobulin protein Thyroid gland mostly secretes T4 Peripheral tissues (liver, kidney, etc.) deiodinate T4 to T3 3

4 Types and biosynthesis of thyroid hormones
T3 is more biologically active form T4 can be converted to rT3 (reverse T3) – inactive form Most of T4 is transported in plasma as protein-bound Thyroglobulin-bound (70%) Albumin-bound (25%) Transthyretin-bound (5%) The unbound (free) form of T4 and T3 are biologically active 4

5 Plasma level: 100 nmol/L Plasma level: 2 nmol/L 5

6 Thyroid hormone action
Essential for normal maturation and metabolism of all body tissues Affects the rate of protein, carbohydrate and lipid metabolism Regulates thermogenesis 6

7 Thyroid hormone action
Hypothyroid children have delayed skeletal maturation, short stature, delayed puberty Untreated congenital hypothyroidism causes permanent brain damage Hypothyroid patients have high serum cholesterol due to: Down regulation of LDL receptors on liver cells Failure of sterol excretion via the gut 7

8 Regulation of thyroid hormone secretion
The hypothalamic-pituitary-thyroid axis regulates thyroid secretion The hypothalamus senses low levels of T3/T4 and releases thyrotropin releasing hormone (TRH) TRH stimulates the pituitary to produce thyroid stimulating hormone (TSH) 8

9 Regulation of thyroid hormone secretion
TSH stimulates the thyroid to produce T3/T4 until levels return to normal T3/T4 exert negative feedback control on the hypothalamus and pituitary Controlling the release of both TRH and TSH 9

10 High thyroid levels suppress TRH and TSH Low thyroid levels
stimulate TRH and TSH to produce more hormone 10

11 Thyroid function tests
TSH measurement: Indicates thyroid status Total T4 or free T4: Monitors anti-thyroid treatment Monitors thyroid supplement treatment TSH may take upto 8 weeks to adjust to new level during treatment TSH and T4 (total or free) are ensitive, first-line test Some labs only measure TSH as first-line test 11

12 Thyroid function tests
Total T3 or free T3: Rise in T3 is independent of T4 In some patients only T3 rises (T4 is normal) For earlier identification of T3 thyrotoxicosis Antibodies: Diagnosis and monitoring of autoimmune thyroid disease (Hashimoto’s thyroiditis) 12

13 Goitre Enlarged thyroid gland May be associated with: Causes:
Hypofunction Hyperfunction Normal function of thyroid gland Causes: Iodine deficiency Selenium deficiency Hashimoto’s thyroiditis Congenital hypothyroidism Graves' disease (hyperthyroidism) Thyroid cancer 13

14 Hypothyroidism Deficiency of thyroid hormones Primary hypothyroidism:
Failure of thyroid gland Secondary hypothyroidism: Failure of the pituitary to secrete TSH (rare) Failure of the hypothalamic-pituitary-thyroid axis 14

15 Hypothyroidism Causes: Clinical features Hashimoto’s disease
Radioiodine or surgical treatment of hyperthyroidism Drug effects TSH deficiency Congenital defects Severe iodine deficiency Clinical features Tiredness Cold intolerance Weight gain Dry skin 15

16 Hypothyroidism Diagnosis Treatment Neonatal hypothyroidism
Elevated TSH level confirms hypothyroidism Treatment T4 replacement therapy (tablets) Monitoring TSH level to determine dosage Patient has to continue treatment for life Neonatal hypothyroidism Due to genetic defect in thyroid gland of newborns Diagnosed by TSH screening Hormone replacement therapy May cause cretinism, if untreated 16

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18 Hypothyroidism Non-thyroidal illness
In some diseases, the normal regulation of TSH, T3 and T4 secretion and metabolism is disturbed Most of T4 is converted to rT3 (inactive) Causing thyroid hormone deficiency TSH secretion is suppressed Secretion of T4 and T3 is decreased 18

19 Hyperthyroidism Over-activity of the thyroid gland
Increased secretion of thyroid hormones Tissues are exposed to high levels of thyroid hormones (thyrotoxicosis) Increased pituitary stimulation of the thyroid gland Causes: Graves' disease Toxic multinodular goitre Thyroid adenoma Thyroiditis Intake of iodine / iodine drugs Excessive intake of T4 and T3 19

20 Hyperthyroidism Clinical features Weight loss with normal appetite
Sweating / heat intolerance Fatigue Palpitation / agitation, tremor Angina, heart failure Diarrhea Eyelid retraction and lid lag 20

21 Graves' disease Most common cause of hyperthyroidism
An autoimmune disease Antibodies against TSH receptors on thyroid cells mimic the action of pituitary hormone Normal regulation of synthesis/control is disturbed 21

22 Hyperthyroidism Diagnosis Suppressed TSH level
Raised thyroid hormone level Confirms primary hyperthyroidism Problems in diagnosis Total serum T4 conc. changes due to changes in binding protein levels In pregnancy, high estrogens increase TBG synthesis Total T4 will be high 22

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24 Hyperthyroidism Congenital TBG deficiency can also influence results
Free T4 and TSH are first-line tests for thyroid dysfunction Treatment Antithyroid drugs: carbimazole, propylthiouracil Radioiodine: sodium 131I inhibits T4/T3 synthesis Surgery: thyroidectomy 24

25 Thermogenesis Thyroid hormone has an active role in thermogenesis
About 30% thermogenesis depends on thyroid Thyroid regulates metabolism and ATP turnover It increases ATP synthesis and consumption by many possible mechanisms 25

26 Thermogenesis Na/K gradient requires ATP to maintain it
The gradient is used to transport nutrients inside the cell Thyroid reduces Na/K gradient across the cell membrane Causing more nutrient transport in the cell (increasing metabolism) This increases the demand for ATP to maintain the gradient ATP synthesis and consumption is increased that produce heat 26

27 Thermogenesis Thyroid hormones cause increased proton leak into the matrix across the inner mitochondrial membrane Protons are pumped back into the matrix by uncoupling proteins (UCPs) without ATP synthesis This process produces heat The mitochondria of brown adipose tissue contain UCP-1 (thermogenin) Produces heat via uncoupling of electron transport chain and oxidative phosphorylation 27

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