# Hyperthyroidism (Thyrotoxicosis) - Category: chronic - Review status: reviewed (every claim checked against a document named on this page) - Sources: ATA Guidelines for Diagnosis and Management of Hyperthyroidism 2016 · Egyptian National Drug Formulary - Cardiovascular 2024 (propranolol monograph) · Egyptian National Drug Formulary - Endocrine System 2024 (propylthiouracil monograph) · Hyperthyroidism - disease-level clinical article (hyperthyroidism-clinical.txt) · Egyptian National Drug Formulary - Cardiovascular 2024 (verapamil monograph) - Verified date: 2026-08 ## Verified against - Egyptian National Drug Formulary - Cardiovascular 2024 (propranolol monograph) - Egyptian National Drug Formulary - Endocrine System 2024 (propylthiouracil monograph) - Hyperthyroidism - disease-level clinical article (hyperthyroidism-clinical.txt) - Egyptian National Drug Formulary - Cardiovascular 2024 (verapamil monograph) ## Treatment metadata - Carbimazole — 5 mg — oral.solid - Referral & safety-netting (no drug therapy) - Propylthiouracil — 50 mg — oral.solid - Propranolol — 10 mg — oral.solid - Verapamil — 40 mg — oral.solid ## Complete treatment card ```text HYPERTHYROIDISM (THYROTOXICOSIS) Sources: ATA Guidelines for Diagnosis and Management of Hyperthyroidism 2016 · Egyptian National Drug Formulary - Cardiovascular 2024 (propranolol monograph) · Egyptian National Drug Formulary - Endocrine System 2024 (propylthiouracil monograph) · Hyperthyroidism - disease- level clinical article (hyperthyroidism-clinical.txt) · Egyptian National Drug Formulary - Cardiovascular 2024 (verapamil monograph) Review status: REVIEWED against 3 sources listed above (2026-08) IS IT THIS? - reference only, to read alongside your own examination SYMPTOMS - what the patient reports (5) - Common complaints include unintended weight loss, though about 10% of patients gain weight instead due to increased appetite [weight loss] - Patients often report palpitations, tremor, heat intolerance, breathlessness on exertion, anxiety, irritability, fatigue, and muscle weakness [anxiety · breathlessness · fatigue · heat intolerance · irritability · muscle weakness · palpitations · tremor] - Bowel movements become more frequent, and some patients develop significant diarrhea [diarrhoea] - Hair loss, reduced libido, and irregular or absent periods in women can also occur [absent periods · hair loss] - Subacute thyroiditis classically presents with marked anterior neck pain and fever [fever · neck pain] SIGNS - what you find (5) - Exam often shows a fast pulse (sometimes atrial fibrillation), high blood pressure, tremor, warm moist skin, brisk reflexes, and an anxious appearance [anxiety · hyperreflexia · hypertension · tremor] - Lid lag or lid retraction is seen with any cause of overactive thyroid because it reflects a hyperadrenergic state, not Graves disease specifically - True eye involvement - double vision, excess tearing, conjunctival redness, and eye bulging - only occurs with Graves disease [double vision · eye discharge · eye redness] - Graves disease can also produce thick, scaly skin plaques on the shins and soft-tissue swelling with clubbing of the fingers [finger clubbing · plaques · scaling] - On palpation, the thyroid is diffusely and evenly enlarged in Graves disease, unevenly nodular in toxic multinodular goiter, shows one large lump in a toxic adenoma, and is exquisitely tender in subacute thyroiditis [goitre] TESTS (9) - Suspected disease is confirmed with TSH, free T4, and total T3; overt disease shows a suppressed TSH with high T4 and T3 - Subclinical disease has a low TSH with normal T4 and T3, while T3 toxicosis has a low TSH, a normal T4, but a raised T3 - Heterophile antibodies can falsely raise the TSH result, and high-dose biotin (5 to 30 mg) can falsely lower TSH while raising free T4 - Checking TSH-receptor antibody first speeds up finding the cause and is more cost-effective than other work-up - When TSH-receptor antibody is normal, a radioiodine uptake scan is the next diagnostic step - Radioiodine scanning is avoided in pregnancy and breastfeeding - A toxic adenoma shows one hot spot of uptake matching the nodule, with the rest of the gland suppressed - Any thyroiditis shows low or absent uptake because inflamed follicular cells cannot take up iodine - Doppler ultrasound shows increased or normal blood flow in Graves disease (thyroid inferno) but low flow in thyroiditis IF NOT THIS - what else fits (4) - A non-tender, diffusely enlarged thyroid points to Graves disease or painless thyroiditis, or, rarely, to deliberately taken thyroid hormone - A tender, enlarged thyroid suggests De Quervain (subacute) thyroiditis instead - One palpable nodule points to a thyroid adenoma, while multiple nodules point to toxic multinodular goiter - Euthyroid hyperthyroxinemia - high total T4 and T3 with a normal TSH - and struma ovarii are other differentials to consider Source StatPearls "Hyperthyroidism" - disease-level clinical article Status traced to the source above 1. CARBIMAZOLE [1st line] Adult Initial 20 to 60 mg/day given in 2 to 3 divided doses until euthyroid (4 to 8 weeks), then maintenance 5 to 15 mg once daily x 12-18 months course Peds 3 years and over: Initial 15 mg daily; adjust dose according to response (Children ≥3 years and Adolescents: Initial: 15 mg/day; adjust dose according to response.) Source Egyptian National Drug Formulary - Endocrine System 2024 Why Thionamide antithyroid drug that blocks thyroid peroxidase to reduce new thyroid hormone synthesis; first-line for hyperthyroidism outside the first trimester of pregnancy, where propylthiouracil is preferred instead. Caution WARN PATIENTS to report sore throat, fever, or mouth ulcers immediately (risk of agranulocytosis). Perform baseline full blood count before starting treatment. Avoid in 1st trimester of pregnancy (propylthiouracil preferred). Egypt THYROCARBIN 5 MG 100 F.C. TABS. ROYAL LINK PH... 107.00 EGP (1.07/unit) THYROCARBIN 5 MG 50 F.C. TABS. ROYAL LINK PH... 55.00 EGP (1.10/unit) CARBIMAZOLE B.P 2007 5 MG 50 F.C. TABS. CID 60.00 EGP (1.20/unit) NEOMERCAZOLE(CARBIMAZOLE) 5 MG 100 TABS. (ILLEGAL IMPORT) AM... 40.00 EGP (0.40/unit) 2. REFERRAL & SAFETY-NETTING (NO DRUG THERAPY) [1st line] Adult Source Hyperthyroidism - disease-level clinical article (hyperthyroidism-clinical.txt) Why Carries the referral criteria and warning signs for this condition, which apply whichever treatment is chosen. Caution RED FLAG - Thyroid storm - a life-threatening complication of untreated/undertreated hyperthyroidism with a mortality rate around 16% in patients over 60 - requires immediate recognition and urgent (emergency/ICU-level) management. 3. PROPYLTHIOURACIL [2nd line] Adult 300-400 mg daily in 3-4 divided doses until euthyroid, then titrate to maintenance 50-150 mg daily Peds 6 to 10 years: 50 to 150 mg daily, divided every 8 hours 10 years and over: 150 to 300 mg daily, divided every 8 hours. Maintenance 50 mg twice daily. (Children 6 to 10 years: initial 50 to 150 mg/day divided every 8 hours. Age ≥10 years: 150 to 300 mg/day divided every 8 hours. Maintenance: 50 mg twice daily.) Source Egyptian National Drug Formulary - Endocrine System 2024 (propylthiouracil monograph) Why Thionamide antithyroid drug that blocks thyroid peroxidase like carbimazole but also reduces peripheral conversion of T4 to T3; preferred over carbimazole specifically in the first trimester of pregnancy despite its own risk of hepatotoxicity. Caution Propylthiouracil is the preferred antithyroid agent in the 1st trimester of pregnancy. There is a black box warning for severe, life-threatening hepatotoxicity; monitor LFTs. Report sore throat/fever immediately (agranulocytosis risk). Egypt PROPYLTHIOURACIL 50MG 20 TAB. B.P 2002 MEMPHIS 14.00 EGP (0.70/unit) THYROCIL 50 MG 30 TABS. AMOUN 72.00 EGP (2.40/unit) 4. PROPRANOLOL [add-on - not a substitute] Adult 10-40 mg three to four times daily PRN for rapid control of adrenergic symptoms (tachycardia, tremor, anxiety) Peds 0.25-0.5 mg/kg/dose [child max 40 mg] (0.25-0.5 mg/kg per dose, 3-4 times daily, under specialist guidance. The formulary ceiling is 1 mg/kg per dose four times a day; the 40 mg cap here is the adult per-dose maximum and binds first above 40 kg.) 3kg -> 0.75-1.5 mg/dose 4kg -> 1-2 mg/dose 5kg -> 1.2-2.5 mg/dose 6kg -> 1.5-3 mg/dose 7kg -> 1.8-3.5 mg/dose 8kg -> 2-4 mg/dose 9kg -> 2.2-4.5 mg/dose 10kg -> 2.5-5 mg/dose 11kg -> 2.8-5.5 mg/dose 12kg -> 3-6 mg/dose 13kg -> 3.2-6.5 mg/dose 14kg -> 3.5-7 mg/dose 15kg -> 3.8-7.5 mg/dose 16kg -> 4-8 mg/dose 17kg -> 4.2-8.5 mg/dose 18kg -> 4.5-9 mg/dose 19kg -> 4.8-9.5 mg/dose 20kg -> 5-10 mg/dose 21kg -> 5.2-10.5 mg/dose 22kg -> 5.5-11 mg/dose 23kg -> 5.8-11.5 mg/dose 24kg -> 6-12 mg/dose 25kg -> 6.2-12.5 mg/dose 26kg -> 6.5-13 mg/dose 27kg -> 6.8-13.5 mg/dose 28kg -> 7-14 mg/dose 29kg -> 7.2-14.5 mg/dose 30kg -> 7.5-15 mg/dose 31kg -> 7.8-15.5 mg/dose 32kg -> 8-16 mg/dose 33kg -> 8.2-16.5 mg/dose 34kg -> 8.5-17 mg/dose 35kg -> 8.8-17.5 mg/dose 36kg -> 9-18 mg/dose 37kg -> 9.2-18.5 mg/dose 38kg -> 9.5-19 mg/dose 39kg -> 9.8-19.5 mg/dose 40kg -> 10-20 mg/dose 41kg -> 10.2-20.5 mg/dose 42kg -> 10.5-21 mg/dose 43kg -> 10.8-21.5 mg/dose 44kg -> 11-22 mg/dose 45kg -> 11.2-22.5 mg/dose 46kg -> 11.5-23 mg/dose 47kg -> 11.8-23.5 mg/dose 48kg -> 12-24 mg/dose 49kg -> 12.2-24.5 mg/dose 50kg -> 12.5-25 mg/dose Source Egyptian National Drug Formulary - Cardiovascular 2024 (propranolol monograph) Why Non-selective beta-blocker added for rapid symptomatic control of the adrenergic features of thyrotoxicosis such as tachycardia and tremor; it does not affect thyroid hormone synthesis and does not replace the antithyroid drug. Caution Contraindicated in asthma and severe bronchospasm. This is symptomatic management only; it does not affect underlying thyroid hormone synthesis. Thyroid disease: May mask signs of hyperthyroidism (e.g., tachycardia). Monitor; gradual withdrawal when needed. Egypt INDOLOL 10 MG 50 TAB KAHIRA 12.50 EGP (0.25/unit) PROLOL 10 MG 50 TABS. EIPICO 16.25 EGP (0.33/unit) INDERAL 10 MG 50 TABS ASTRA ZENECA 75.00 EGP (1.50/unit) 5. VERAPAMIL [add-on - not a substitute] Adult Immediate release: 40 mg 3 to 4 times daily, increased as needed for rate control (maximum 480 mg/day in 1 to 3 divided doses) - until euthyroid Peds The ENDF verapamil monograph gives no paediatric rate-control figure, so none is stated here. Source Egyptian National Drug Formulary - Cardiovascular 2024 (verapamil monograph) Why Rate control for the patient who cannot take a beta-blocker; the card offered propranolol alone. Caution Do not use in patients with pre-excitation associated with an accessory pathway, to avoid ventricular arrhythmias. Contraindicated in AV block, cardiogenic shock, and acute porphyrias. Contraindicated in atrial flutter or fibrillation associated with accessory conducting pathways, e.g. Wolff-Parkinson-White syndrome. 'Until euthyroid' is the clinical framing of the disease article, not a duration stated by the ENDF Egypt VERPAMIL 40MG 20 F.C.TAB. EL NASR 4.50 EGP (0.23/unit) VERATENS 40MG 10 F.C. TAB. PHAROPHARMA 3.50 EGP (0.35/unit) Prices are indicative (dataset snapshot 2026-06); verify with the pharmacy. ``` --- Dawaa Reference is a reference for prescribers, not a medical device, and does not replace clinical judgement. [Privacy policy](/privacy)