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V E T E R I N A R Y

Understanding

Hyperthyroidism

Feline
H

Gigi Davidson, BS, RPh, FSVHP, DICVP North Carolina State University College of Veterinary Medicine Raleigh, North Carolina

yperthyroidism is one of the most common endocrine disorders found in middle-aged to older cats. Insidious in onset, it is thought to affect one in every 300 felines. Cats aged 4 to 22 years have been diagnosed with hyperthyroidism, but only about 5% of cats develop hyperthyroidism before the age of 10; the average age of onset is 13. 1 Although there are multiple treatment options, including radiation and surgical excision of the thyroid gland, medical treatment with methimazole remains the most common therapy. Novel compounded dosage forms of methimazole (avored suspensions, chewable treats and transdermal gels) are more readily accepted by feline patients than the commercially available, human-approved tablets. As a result, compounding pharmacists have greatly contributed to improved compliance in the treatment of this disease.

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Suggested Reading
Chandler EA, Gaskell CJ, Gaskell RM (eds). Feline Medicine and Therapeutics. 2nd ed. Cambridge, MA:Blackwell Science, Inc.; 1994:506-514. Sherding RG (ed). The Cat: Diseases and Clinical Management. 2nd ed. New York:Churchill Livingstone; 1994:524. Tilley LP, Smith FWK. The 5-Minute Veterinary Consult: Canine and Feline. Baltimore:Williams and Wilkins; 1997:708-709.

Clinical Signs
Typically, cats with feline hyperthyroidism begin to show signs of hyperactivity, dementia and increased nocturnal vocalization. They soon progress to symptoms of weight loss, increased appetite, increased thirst and increased volumes of fecal and urinary elimination. Almost all hyperthyroid cats exhibit vomiting and panting, and they become tachycardic. Approximately one half of cats with feline hyperthyroidism develop arrhythmias and murmurs. Many owners complain that their cats shed excessively and that the cats now have a very poor hair coat. A common symptom of hyperthyroidism in a cat is hypertrophied claws, which become unretractable to the point that the cats approach can be heard when it walks on hard surfaces. It is important to note that the increased organ blood ow caused by hyperthyroidism can mask the onset of other diseases. Once hyperthyroidism is corrected, kidney disease, diabetes mellitus and cardiovascular disease may emerge post-treatment. It is important to emphasize to clients that these diseases were already present in the cat and are not a result of medical or surgical therapy.

Pathophysiology
Located in the neck proximal to the trachea and carotid arteries, thyroid glands produce hormones that regulate cellular metabolism. Once circulating thyroid hormones have elicited the necessary physiologic responses, the pituitary gland exerts a negative feedback that stops the production of thyroid hormones. Approximately 70% of

hyperthyroid cats develop a benign tumor of the thyroid gland, which causes the thyroid to become overactive. 1 Once the thyroid glands become overactive, the usual negative feedback that is provided by the pituitary gland is no longer effective. Overproduction of thyroid hormones results in a multitude of systemic adverse effects and clinical signs.

Diagnosis
Diagnosis of feline hyperthyroidism is relatively simple and is usually made with a single blood test. The normal blood levels of levothyroxine (T4) are from 1.0 ng/dL to 4 ng/dL. Although both liothyronine (T3) and T4 can be elevated in hyperthyroidism, serum T4 levels are primarily used in diagnosis. Serum T4 values that exceed 4.0 ng/dL are diagnostic. However, occasionally serum T4 levels are not elevated above normal, even though the cat is clinically hyperthyroid. Veterinarians then employ other diagnostic methods such as the T3 suppression test, the thyrotropinreleasing hormone stimulation test, and thyroid radionucleotide uptake and imaging. It is extremely important to note that doses of diagnostic agents are designed to evoke a very specic

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physiological response from the thyroid. The use of novel compounded dosage forms of diagnostic agents is not warranted and may cause equivocal results in diagnostic tests.

Treatment
Three treatment options for feline hyperthyroidism are currently available, as follows:

Surgerysurgical excision of the affected glands (curative), Radioactive iodinea single treatment of radioactive iodine that destroys the affected glands (curative), and Antithyroid medicationchronic treatment (supportive, not curative).

Surgery
Surgery is curative but not without risks. Older cats are already poor candidates for anesthesia, and thyrotoxic cardiomyopathy may make hyperthyroid cats poor candidates for surgery. Another potential risk of surgery is that the thyroid glands reside in extremely close proximity to the parathyroid gland. Accidental removal of the parathyroid can result in hypoparathyroidism, which severely disturbs calcium regulation. Hypoparathyroidism results in hypocalcemia, weak and fragile bones, muscle cramps and weakness, and potentially tetanic seizures. Also, removal of both glands may result in permanent hypothyroidism, for which the only therapy is lifelong levothyroxine replacement. Many veterinarians do not perform this surgery, and referral to a specialist may be necessary. The average cost of surgery is from $600 to $1000 (phone survey of veterinary practices that perform this surgery in the Piedmont region of North Carolina, unpublished data, March 2002).

inconvenient, is less risky than surgery. Although some adverse drug reactions may occur with methimazole, eg, vomiting, hair loss, decreased white blood cell count, these reactions are usually resolved once the medication is discontinued. Methimazole is a human-labeled tablet for oral administration. Cats that resist administration of the commercially available tablets can receive methimazole compounded into avored suspensions, chewable treats or a transdermally penetrating gel. 3,4 Voluntary and noninvasive acceptance of medication is critical for cats that have cardiovascular compromise from thyrotoxicosis. For cats that do not respond to methimazole, calcium ipodate has been effective (in a few cats). T4 levels have returned to the normal range in cats that have been given calcium ipodate in daily doses of 50 mg to 150 mg per cat. 5 Calcium ipodate is not commercially available and can only be obtained from compounding pharmacists. Propylthiouracil is not used for treatment, as it is associated with a high incidence of inducement of autoimmune disease in cats. In rare circumstances, some veterinarians have also imported carbimazole for therapy. Medical management is not curative; therefore, thyroid levels and other blood work must be monitored on a quarterly basis. The estimated cost for medical management and follow-up laboratory work is approximately $600 per year. 6

Prognosis
Once feline hyperthyroidism is corrected by surgery or radiation or it is controlled medically, the cats prognosis for leading a normal, healthy, happy life is excellent.

References
1. Tilley LP, Smith FWK, eds. The 5 Minute Veterinary Consult: Canine and Feline. Baltimore, MD:Williams and Wilkins; 1997:708-709. 2. Ward CE. Radcats of the Carolinas. Available at: http://www.radcats.com. Accessed February 4, 2003. 3. Wingate G. Transdermal methimazole in the treatment of 16 cats with hyperthyroidism. IJPC 2002;6:344-345. 4. Hoffman G, Marks SL, Taboada J et al. Transdermal methimazole treatment in cats with hyperthyroidism. J Feline Med Surg 2003;5:77-82. 5. Murray LA, Peterson ME. Ipodate treatment of hyperthyroidism in cats. J Am Vet Med Assoc 1997;211:63-67. 6. Herring DS, Wachsstock RS. Radiocats. Available at: http://www.radiocat.com. Accessed February 4, 2003.

Radioactive Iodine
Currently, the safest and most effective treatment for hyperthyroidism in cats is radioactive iodine therapythe optimal treatment. There was a rapid return-to-normal thyroid function in approximately 95% of cats treated with a single dose of radioactive 131 I. 2 However, there are disadvantages to radioactive iodine therapy:

Only specially trained veterinarians are licensed to offer it. In some cases, owners have to drive long distances to a specialty referral center. Cats must remain isolated for a period of 5 to 7 days (occasionally as long as 2 weeks) in the facility until their radiation levels no longer pose a threat to human health. The average cost of
131 I

therapy is $850 to $1200. 2

Address correspondence to: Gigi Davidson, BS, RPh, FSVHP, DICVP, North Carolina State University, College of Veterinary Medicine, Raleigh, NC 27606. E-mail: gigi_davidson@ncsu.edu

Antithyroid Medication
Medical management does not cure the disease. To properly regulate the overactive thyroid, medications such as methimazole (Tapazole) must be given once or twice daily for the remainder of the cats life. Because of the risk of removal of the parathyroid gland during surgery, daily medication, although

International Journal of Pharmaceutical Compounding 347 Vol. 7 No. 5 September/October 2003