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==Overview==
==Overview==
*The mainstay of treatment for Toxic multinodular goiter is Surgery.
The mainstay of treatment for Toxic multinodular goiter is [[Surgery]]. Patients with symptomatic [[hyperthyroidism]], sub-clinical [[hyperthyroid]] patients with expected compilations and patients refusing surgical therapy are treated with [[beta blockers]] and [[antithyroid|anti-thyroid pharmacological groups]].
*Patients with symptomatic hyperthyroidism, sub-clinical hyperthyroid patients with expected compilations and patients refusing surgical therapy are treated with beta blockers and anti-thyroid pharmacological groups.
 


==Medical Therapy==
==Medical Therapy==
===Indications===
===Indications===
Pharmacologic medical therapy for toxic multinodular goiter (TMG) is recommended for the patients with the following:
Symptomatic therapy for toxic multinodular goiter (TMG) is recommended for the patients with the following:<ref name="pmid3753814">{{cite journal| author=Laurberg P, Buchholtz Hansen PE, Iversen E, Eskjaer Jensen S, Weeke J| title=Goitre size and outcome of medical treatment of Graves' disease. | journal=Acta Endocrinol (Copenh) | year= 1986 | volume= 111 | issue= 1 | pages= 39-43 | pmid=3753814 | doi= | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=3753814  }} </ref><ref>name="pmid1283983">{{cite journal| author=van Soestbergen MJ, van der Vijver JC, Graafland AD| title=Recurrence of hyperthyroidism in multinodular goiter after long-term drug therapy: a comparison with Graves' disease. | journal=J Endocrinol Invest | year= 1992 | volume= 15 | issue= 11 | pages= 797-800 | pmid=1283983 | doi=10.1007/BF03348807 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=1283983  }} </ref><ref name="pmid4107462">{{cite journal| author=Becker DV, Hurley JR| title=Complications of radioiodine treatment of hyperthyroidism. | journal=Semin Nucl Med | year= 1971 | volume= 1 | issue= 4 | pages= 442-60 | pmid=4107462 | doi= | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=4107462  }} </ref>
*Symptomatic [[hyperthyroidism]]
*[[Thyroid storm]]
*Sub-clinical [[hyperthyroidism]]
*Overt [[hyperthyroidism]]
*Patients refusing surgical therapy.
*[[Hyperthyroidism]] with cardiovascular complications
*[[Hyperthyroidism]] with [[central nervous system]] complications
*Elderly patients
*Patient with coexisting [[cardiac]] condition


Treatment of TMG is based on:
=== Pharmacological drug therapy ===
Following are drugs used in the symptomatic management of toxic multinodular goiter:
*[[Propanolol]]
*[[Atenolol]]
*[[Metoprolol]]
*[[Nadolol]]
*[[Esmolol]]


Following are antithyroid medicines used in  the management of TMG:
*[[Propylthiouracil]]
*[[Methimazole]]
Anti-thyroid therapy for toxic multinodular goiter (TMG) is recommended for the patients with the following:
*Patients refusing [[radiation therapy]]
*Patients refusing [[surgery]]
*Patients on peri-operative preparation
*Pregnancy with caution as [[Antithyroid agents|anti-thyroid]] medication is [[teratogenic]]
*Recently gone through [[surgery]] or [[radiation]]
*Unfit for [[radiation]] of [[surgery]]
*Lack of professional expertise or medical facilities.
*Limited life expectancy
Treatment of TMG should be decided on:
*Severity of disease
*Severity of disease
*Biochemical evaluation of [[TFT|thyroid profile]] level of TSH, T3, and T4
*[[Biochemical]] evaluation of [[Thyroid|thyroid profile]] level of [[TSH]], [[T3]], and [[T4]]
*Cardiac evaluation([[echocardiogram]], [[electrocardiogram]], [[Holter monitor]], or [[myocardial perfusion studies]])
*Cardiac evaluation```([[echo-cardiogram]], [[electrocardiogram]], [[Holter monitor]], or [[myocardial perfusion studies]])
*[[Neuromuscular]] complications
*[[Neuromuscular]] complications
*Age
*Age
*Size of goiter
*[[Goiter]] size
*Physical examination including vitals as [[pulse rate]] and [[respiratory rate]]
 
===Drug Regimens===
Pharmacological medical therapy for toxic multinodular goiter is primarily based on [[beta blockers]] and [[antithyroid|anti-thyroid drugs]].<ref name="pmid27521067">{{cite journal| author=Ross DS, Burch HB, Cooper DS, Greenlee MC, Laurberg P, Maia AL et al.| title=2016 American Thyroid Association Guidelines for Diagnosis and Management of Hyperthyroidism and Other Causes of Thyrotoxicosis. | journal=Thyroid | year= 2016 | volume= 26 | issue= 10 | pages= 1343-1421 | pmid=27521067 | doi=10.1089/thy.2016.0229 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=27521067  }} </ref>
 
#'''Toxic Multinodular Goiter'''
#* '''Thyroid storm'''<ref name="pmid3753814">{{cite journal| author=Laurberg P, Buchholtz Hansen PE, Iversen E, Eskjaer Jensen S, Weeke J| title=Goitre size and outcome of medical treatment of Graves' disease. | journal=Acta Endocrinol (Copenh) | year= 1986 | volume= 111 | issue= 1 | pages= 39-43 | pmid=3753814 | doi= | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=3753814  }} </ref>
#** Preferred regimen (1):  [[Propylthiouracil]] 500–1000 mg load, then 250 mg PO / IV 4 hourly '''PLUS''' [[Propranolol]] 60–80 mg PO 4 hourly(Consider invasive monitoring in [[congestive heart failure]] patients) '''PLUS''' [[Hydrocortisone]] 300 mg [[Intravenous therapy|intravenous]] load, then 100 mg 8 hourly '''PLUS''' [[Cholestyramin]]e 4 g PO 6 hourly '''PLUS''' Iodine (saturated solution of [[potassium iodide]] 5 drops (0.25 mL or 250 mg) orally 6 hourly(start Iodine after 1 hour of administration of [[Thalidomide]] to so that iodine may not be used as [[substrate]]) 
#** Alternative regimen (1): [[Methimazole]]  60–80 mg PO in 24 hours  '''PLUS''' [[Propranolol]] 60–80 mg PO 4 hourly(Consider invasive monitoring in congestive heart failure patients) '''PLUS''' [[Hydrocortisone]]  300 mg intravenous load, then 100 mg 8 hourly '''PLUS'''  [[Cholestyramine]] 4 g PO 6 hourly '''PLUS''' [[Iodine]] (saturated solution of [[potassium iodide]] 5 drops (0.25 mL or 250 mg) orally 6 hourly (start [[Iodine]] after 1 hour of administration of [[Thalidomide]] to so that iodine may not be used as [[substrate]])


===Pharmacological drug therapy===
#* '''Hyperthyroidism'''<ref name="pmid1283983">{{cite journal| author=van Soestbergen MJ, van der Vijver JC, Graafland AD| title=Recurrence of hyperthyroidism in multinodular goiter after long-term drug therapy: a comparison with Graves' disease. | journal=J Endocrinol Invest | year= 1992 | volume= 15 | issue= 11 | pages= 797-800 | pmid=1283983 | doi=10.1007/BF03348807 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=1283983  }} </ref>
Pharmacologic medical therapy for toxic multinodular goiter mainly depends on [[beta blockers]] and [[antithyroid|anti-thyroid drugs]].
#** Preferred regimen (1): [[Propylthiouracil]] 500–1000 mg load, then 250 mg PO / IV 4 hourly '''PLUS''' [[Propranolol]] 60–80 mg PO 4 hourly(Consider invasive monitoring in [[congestive heart failure]] patients) '''PLUS''' [[Iodine]] (saturated solution of [[potassium iodide]] 5 drops (0.25 mL or 250 mg) orally 6 hourly(start Iodine after 1 hour of administration of [[Thalidomide]] to so that iodine may not be used as substrate) 
#** Alternative regimen (1): [[Methimazole]]  60–80 mg PO in 24 hours  '''PLUS''' [[Propranolol]] 60–80 mg PO 4 hourly(Consider invasive monitoring in [[congestive heart failure]] patients) '''PLUS''' [[Iodine]] (saturated solution of potassium iodide 5 drops (0.25 mL or 250 mg) orally 6 hourly (start [[Iodine]] after 1 hour of administration of [[Thalidomide]] to so that [[iodine]] may not be used as [[substrate]]) 
#* '''Subclinical hyperthyroidism with comorbid conditions such as diabetes mellitus, heart failure or CNS abnormality'''<ref name="pmid4107462">{{cite journal| author=Becker DV, Hurley JR| title=Complications of radioiodine treatment of hyperthyroidism. | journal=Semin Nucl Med | year= 1971 | volume= 1 | issue= 4 | pages= 442-60 | pmid=4107462 | doi= | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=4107462  }} </ref>
#** Preferred regimen (1): [[Propylthiouracil]] 5-10 mg q24h PO for long term to avoid remission with 3 month review of [[TSH]] 
#** Alternative regimen (1): [[Methimazole]] 5-10 mg q24h PO for long term to avoid remission with 3 month review of [[TSH]] 
#* '''Subclinical hyperthyroidism without comorbid conditions'''
#** Preferred: Monitoring/Review of [[TSH]] every 3 month
#** Alternative regimen (1):[[Propylthiouracil]] 5-10 mg q24h PO for long term to avoid remission with review of [[TSH]] every 3 month


* '''Thyroid storm'''
'''Ultrasound-Guided percutaneous ethanol injection (PEI)''':<ref name="pmid27375551">{{cite journal| author=Felício JS, Conceição AM, Santos FM, Sato MM, Bastos Fde A, Braga de Souza AC et al.| title=Ultrasound-Guided Percutaneous Ethanol Injection Protocol to Treat Solid and Mixed Thyroid Nodules. | journal=Front Endocrinol (Lausanne) | year= 2016 | volume= 7 | issue=  | pages= 52 | pmid=27375551 | doi=10.3389/fendo.2016.00052 | pmc=4893597 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=27375551 }} </ref>
** Preferred regimen (1):  Propylthiouracil 500–1000 mg load, then 250 mg PO / IV 4 hourly PLUS Propranolol 60–80 mg PO 4 hourly(Consider invasive monitoring in congestive heart failure patients) PLUS Hydrocortisone 300 mg intravenous load, then 100 mg 8 hourly PLUS Cholestyramine 4 g PO 6 hourly PLUS Iodine (saturated solution of potassium iodide 5 drops (0.25 mL or 250 mg) orally 6 hourly(start Iodine after 1 hour of administration of Thaimolide to so that iodine may not be used as substrate) 
* Patients [[Toxic multinodular goiter|Toxic Multinodular Goiter]] differing treatment with surgery, [[Antithyroid agents|antithyroid medication]] and [[radiation therapy]] can benefit from [[injection]] of [[ethanol]] to destroy [[Autonomous agent|autonomous]] functioning [[thyroid]] nodules to decrease production of thyroid and also considerable reduction in [[thyroid gland]] size.
** Alternative regimen (1): [[drug name]] 500 mg PO q6h for 7–10 days 
*It is a safe procedure without serious complications
*Some of complications are
**[[ethanol]] leakage into the surrounding tissues
**local pain
**[[dysphonia]]
**[[flushing]]
**[[dizziness]]
**recurrent [[nerve palsy]]
**[[Horner's syndrome|Horner’s syndrome]]
**necrosis of the [[larynx]] and [[skin]]
**local [[fibrosis]]


* '''Hyperthyroidism'''
** Preferred regimen (1): [[drug name]] 100 mg PO q12h for 10-21 days '''(Contraindications/specific instructions)''' 
** Preferred regimen (2): [[drug name]] 500 mg PO q8h for 14-21 days
** Preferred regimen (3): [[drug name]] 500 mg q12h for 14-21 days
** Alternative regimen (1): [[drug name]] 500 mg PO q6h for 7–10 days 
** Alternative regimen (2): [[drug name]] 500 mg PO q12h for 14–21 days
** Alternative regimen (3): [[drug name]] 500 mg PO q6h for 14–21 days
* '''Subclinical hyperthyroidism with comorbid conditions'''
** Preferred regimen (1): [[drug name]] 100 mg PO q12h for 10-21 days '''(Contraindications/specific instructions)''' 
** Preferred regimen (2): [[drug name]] 500 mg PO q8h for 14-21 days
** Preferred regimen (3): [[drug name]] 500 mg q12h for 14-21 days
** Alternative regimen (1): [[drug name]] 500 mg PO q6h for 7–10 days 
** Alternative regimen (2): [[drug name]] 500 mg PO q12h for 14–21 days
** Alternative regimen (3): [[drug name]] 500 mg PO q6h for 14–21 days
* '''Subclinical hyperthyroidism without comorbid conditions'''
** Preferred regimen (1): [[drug name]] 100 mg PO q12h for 10-21 days '''(Contraindications/specific instructions)''' 
** Preferred regimen (2): [[drug name]] 500 mg PO q8h for 14-21 days
** Preferred regimen (3): [[drug name]] 500 mg q12h for 14-21 days
** Alternative regimen (1): [[drug name]] 500 mg PO q6h for 7–10 days 
** Alternative regimen (2): [[drug name]] 500 mg PO q12h for 14–21 days
** Alternative regimen (3): [[drug name]] 500 mg PO q6h for 14–21 days


==References==
==References==

Latest revision as of 19:48, 13 October 2017

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Sunny Kumar MD [2],Furqan M M. M.B.B.S[3]

Overview

The mainstay of treatment for Toxic multinodular goiter is Surgery. Patients with symptomatic hyperthyroidism, sub-clinical hyperthyroid patients with expected compilations and patients refusing surgical therapy are treated with beta blockers and anti-thyroid pharmacological groups.

Medical Therapy

Indications

Symptomatic therapy for toxic multinodular goiter (TMG) is recommended for the patients with the following:[1][2][3]

Pharmacological drug therapy

Following are drugs used in the symptomatic management of toxic multinodular goiter:

Following are antithyroid medicines used in the management of TMG:

Anti-thyroid therapy for toxic multinodular goiter (TMG) is recommended for the patients with the following:

Treatment of TMG should be decided on:

Drug Regimens

Pharmacological medical therapy for toxic multinodular goiter is primarily based on beta blockers and anti-thyroid drugs.[4]

  1. Toxic Multinodular Goiter
    • Hyperthyroidism[5]
    • Subclinical hyperthyroidism with comorbid conditions such as diabetes mellitus, heart failure or CNS abnormality[3]
      • Preferred regimen (1): Propylthiouracil 5-10 mg q24h PO for long term to avoid remission with 3 month review of TSH
      • Alternative regimen (1): Methimazole 5-10 mg q24h PO for long term to avoid remission with 3 month review of TSH
    • Subclinical hyperthyroidism without comorbid conditions
      • Preferred: Monitoring/Review of TSH every 3 month
      • Alternative regimen (1):Propylthiouracil 5-10 mg q24h PO for long term to avoid remission with review of TSH every 3 month

Ultrasound-Guided percutaneous ethanol injection (PEI):[6]


References

  1. ↑ 1.0 1.1 Laurberg P, Buchholtz Hansen PE, Iversen E, Eskjaer Jensen S, Weeke J (1986). "Goitre size and outcome of medical treatment of Graves' disease". Acta Endocrinol (Copenh). 111 (1): 39–43. PMID 3753814.
  2. ↑ name="pmid1283983">van Soestbergen MJ, van der Vijver JC, Graafland AD (1992). "Recurrence of hyperthyroidism in multinodular goiter after long-term drug therapy: a comparison with Graves' disease". J Endocrinol Invest. 15 (11): 797–800. doi:10.1007/BF03348807. PMID 1283983.
  3. ↑ 3.0 3.1 Becker DV, Hurley JR (1971). "Complications of radioiodine treatment of hyperthyroidism". Semin Nucl Med. 1 (4): 442–60. PMID 4107462.
  4. ↑ Ross DS, Burch HB, Cooper DS, Greenlee MC, Laurberg P, Maia AL; et al. (2016). "2016 American Thyroid Association Guidelines for Diagnosis and Management of Hyperthyroidism and Other Causes of Thyrotoxicosis". Thyroid. 26 (10): 1343–1421. doi:10.1089/thy.2016.0229. PMID 27521067.
  5. ↑ van Soestbergen MJ, van der Vijver JC, Graafland AD (1992). "Recurrence of hyperthyroidism in multinodular goiter after long-term drug therapy: a comparison with Graves' disease". J Endocrinol Invest. 15 (11): 797–800. doi:10.1007/BF03348807. PMID 1283983.
  6. ↑ Felício JS, Conceição AM, Santos FM, Sato MM, Bastos Fde A, Braga de Souza AC; et al. (2016). "Ultrasound-Guided Percutaneous Ethanol Injection Protocol to Treat Solid and Mixed Thyroid Nodules". Front Endocrinol (Lausanne). 7: 52. doi:10.3389/fendo.2016.00052. PMC 4893597. PMID 27375551.

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