Goiter medical therapy: Difference between revisions

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__NOTOC__
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{{Goiter}}
{{Goiter}}
{{CMG}}; {{AE}}{{ARK}}
{{CMG}}; {{AE}}{{ARK}} {{MJ}}


==Overview==
==Overview==
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==Medical Therapy==
==Medical Therapy==
*[[Pharmacological|Pharmacologic]] medical [[therapy]] is recommended for [[patients]] with goiter.<ref name="Astwood1960">{{cite journal|last1=Astwood|first1=E. B.|title=Treatment of Goiter and Thyroid Nodules with Thyroid|journal=JAMA|volume=174|issue=5|year=1960|pages=459|issn=0098-7484|doi=10.1001/jama.1960.03030050001001}}</ref><ref name="pmid2709545">{{cite journal |vauthors=Sawin CT, Geller A, Hershman JM, Castelli W, Bacharach P |title=The aging thyroid. The use of thyroid hormone in older persons |journal=JAMA |volume=261 |issue=18 |pages=2653–5 |year=1989 |pmid=2709545 |doi= |url=}}</ref><ref name="Sawin1989">{{cite journal|last1=Sawin|first1=Clark T.|title=The Aging Thyroid|journal=JAMA|volume=261|issue=18|year=1989|pages=2653|issn=0098-7484|doi=10.1001/jama.1989.03420180077034}}</ref><ref name="pmid23008749">{{cite journal |vauthors=Führer D, Bockisch A, Schmid KW |title=Euthyroid goiter with and without nodules--diagnosis and treatment |journal=Dtsch Arztebl Int |volume=109 |issue=29-30 |pages=506–15; quiz 516 |year=2012 |pmid=23008749 |pmc=3441105 |doi=10.3238/arztebl.2012.0506 |url=}}</ref><ref name="BaskinCobin2002">{{cite journal|last1=Baskin|first1=H. Jack|last2=Cobin|first2=Rhoda H.|last3=Duick|first3=Daniel S.|last4=Gharib|first4=Hossein|last5=Guttler|first5=Richard B.|last6=Kaplan|first6=Michael M.|last7=Segal|first7=Robert L.|last8=Garber|first8=Jeffrey R.|last9=Hamilton|first9=Carlos R.|last10=Handelsman|first10=Yehuda|last11=Hellman|first11=Richard|last12=Kukora|first12=John S.|last13=Levy|first13=Philip|last14=Palumbo|first14=Pasquale J.|last15=Petak|first15=Steven M.|last16=Rettinger|first16=Herbert I.|last17=Rodbard|first17=Helena W.|last18=Service|first18=F. John|last19=Shankar|first19=Talla P.|last20=Stoffer|first20=Sheldon S.|last21=Tourtelot|first21=John B.|title=AMERICAN ASSOCIATION OF CLINICAL ENDOCRINOLOGISTS MEDICAL GUIDELINES FOR CLINICAL PRACTICE FOR THE EVALUATION AND TREATMENT OF HYPERTHYROIDISM AND HYPOTHYROIDISM|journal=Endocrine Practice|volume=8|issue=6|year=2002|pages=457–469|issn=1530-891X|doi=10.4158/1934-2403-8.6.457}}</ref><ref name="WescheTiel-v Buul2001">{{cite journal|last1=Wesche|first1=Maria F. T.|last2=Tiel-v Buul|first2=Monique M. C.|last3=Lips|first3=Paul|last4=Smits|first4=Nico J.|last5=Wiersinga|first5=Wilmar M.|title=A Randomized Trial Comparing Levothyroxine with Radioactive Iodine in the Treatment of Sporadic Nontoxic Goiter|journal=The Journal of Clinical Endocrinology & Metabolism|volume=86|issue=3|year=2001|pages=998–1005|issn=0021-972X|doi=10.1210/jcem.86.3.7244}}</ref><ref name="BonnemaBertelsen1999">{{cite journal|last1=Bonnema|first1=Steen J.|last2=Bertelsen|first2=Henrik|last3=Mortensen|first3=Jesper|last4=Andersen|first4=Peter B.|last5=Knudsen|first5=Dorthe U.|last6=Bastholt|first6=Lars|last7=Hegedüs|first7=Laszlo|title=The Feasibility of High Dose Iodine 131 Treatment as an Alternative to Surgery in Patients with a Very Large Goiter: Effect on Thyroid Function and Size and Pulmonary Function1|journal=The Journal of Clinical Endocrinology & Metabolism|volume=84|issue=10|year=1999|pages=3636–3641|issn=0021-972X|doi=10.1210/jcem.84.10.6052}}</ref><ref name="NygaardKnudsen1997">{{cite journal|last1=Nygaard|first1=Birte|last2=Knudsen|first2=Jens Helmer|last3=Hegedüs|first3=Laszlo|last4=Scient|first4=Annegrete Veje Cand|last5=Mølholm Hansen|first5=Jens Erik|title=Thyrotropin Receptor Antibodies and Graves’ Disease, a Side-Effect of131I Treatment in Patients with Nontoxic Goiter1|journal=The Journal of Clinical Endocrinology & Metabolism|volume=82|issue=9|year=1997|pages=2926–2930|issn=0021-972X|doi=10.1210/jcem.82.9.4227}}</ref><ref name="GreerAstwood1953">{{cite journal|last1=Greer|first1=Monte A.|last2=Astwood|first2=E. B.|title=TREATMENT OF SIMPLE GOITER WITH THYROID*|journal=The Journal of Clinical Endocrinology & Metabolism|volume=13|issue=11|year=1953|pages=1312–1331|issn=0021-972X|doi=10.1210/jcem-13-11-1312}}</ref><ref name="SquatritoVigneri1986">{{cite journal|last1=Squatrito|first1=S.|last2=Vigneri|first2=R.|last3=Rybello|first3=F.|last4=Ermans|first4=A. M.|last5=Polley|first5=R. D.|last6=Ingbar|first6=S. H.|title=Prevention and Treatment of Endemic Iodine-Deficiency Goiter by Iodination of a Municipal Water Supply*|journal=The Journal of Clinical Endocrinology & Metabolism|volume=63|issue=2|year=1986|pages=368–375|issn=0021-972X|doi=10.1210/jcem-63-2-368}}</ref><ref name="HegedüsBonnema2010">{{cite journal|last1=Hegedüs|first1=Laszlo|last2=Bonnema|first2=Steen J.|title=Approach to Management of the Patient with Primary or Secondary Intrathoracic Goiter|journal=The Journal of Clinical Endocrinology & Metabolism|volume=95|issue=12|year=2010|pages=5155–5162|issn=0021-972X|doi=10.1210/jc.2010-1638}}</ref><ref name="HainesKeating1948">{{cite journal|last1=Haines|first1=Samuel F.|last2=Keating|first2=F. Raymond|last3=Power|first3=Marschelle H.|last4=Williams|first4=Marvin M. D.|last5=Kelsey|first5=Mavis P.|title=THE USE OF RADIOIODINE IN THE TREATMENT OF EXOPHTHALMIC GOITER*|journal=The Journal of Clinical Endocrinology & Metabolism|volume=8|issue=10|year=1948|pages=813–825|issn=0021-972X|doi=10.1210/jcem-8-10-813}}</ref><ref name="Reveno1948">{{cite journal|last1=Reveno|first1=William S.|title=PROPYLTHIOURACIL IN THE TREATMENT OF TOXIC GOITER|journal=The Journal of Clinical Endocrinology & Metabolism|volume=8|issue=10|year=1948|pages=866–874|issn=0021-972X|doi=10.1210/jcem-8-10-866}}</ref><ref name="BrentaSchnitman2003">{{cite journal|last1=Brenta|first1=G.|last2=Schnitman|first2=M.|last3=Fretes|first3=O.|last4=Facco|first4=E.|last5=Gurfinkel|first5=M.|last6=Damilano|first6=S.|last7=Pacenza|first7=N.|last8=Blanco|first8=A.|last9=Gonzalez|first9=E.|last10=Pisarev|first10=M. A.|title=Comparative Efficacy and Side Effects of the Treatment of Euthyroid Goiter with Levo-Thyroxine or Triiodothyroacetic Acid|journal=The Journal of Clinical Endocrinology & Metabolism|volume=88|issue=11|year=2003|pages=5287–5292|issn=0021-972X|doi=10.1210/jc.2003-030095}}</ref>  
*[[Pharmacological|Pharmacologic]] medical [[therapy]] is recommended for [[patients]] with goiter. <ref name="Astwood1960">{{cite journal|last1=Astwood|first1=E. B.|title=Treatment of Goiter and Thyroid Nodules with Thyroid|journal=JAMA|volume=174|issue=5|year=1960|pages=459|issn=0098-7484|doi=10.1001/jama.1960.03030050001001}}</ref><ref name="pmid2709545">{{cite journal |vauthors=Sawin CT, Geller A, Hershman JM, Castelli W, Bacharach P |title=The aging thyroid. The use of thyroid hormone in older persons |journal=JAMA |volume=261 |issue=18 |pages=2653–5 |year=1989 |pmid=2709545 |doi= |url=}}</ref><ref name="Sawin1989">{{cite journal|last1=Sawin|first1=Clark T.|title=The Aging Thyroid|journal=JAMA|volume=261|issue=18|year=1989|pages=2653|issn=0098-7484|doi=10.1001/jama.1989.03420180077034}}</ref><ref name="pmid23008749">{{cite journal |vauthors=Führer D, Bockisch A, Schmid KW |title=Euthyroid goiter with and without nodules--diagnosis and treatment |journal=Dtsch Arztebl Int |volume=109 |issue=29-30 |pages=506–15; quiz 516 |year=2012 |pmid=23008749 |pmc=3441105 |doi=10.3238/arztebl.2012.0506 |url=}}</ref><ref name="BaskinCobin2002">{{cite journal|last1=Baskin|first1=H. Jack|last2=Cobin|first2=Rhoda H.|last3=Duick|first3=Daniel S.|last4=Gharib|first4=Hossein|last5=Guttler|first5=Richard B.|last6=Kaplan|first6=Michael M.|last7=Segal|first7=Robert L.|last8=Garber|first8=Jeffrey R.|last9=Hamilton|first9=Carlos R.|last10=Handelsman|first10=Yehuda|last11=Hellman|first11=Richard|last12=Kukora|first12=John S.|last13=Levy|first13=Philip|last14=Palumbo|first14=Pasquale J.|last15=Petak|first15=Steven M.|last16=Rettinger|first16=Herbert I.|last17=Rodbard|first17=Helena W.|last18=Service|first18=F. John|last19=Shankar|first19=Talla P.|last20=Stoffer|first20=Sheldon S.|last21=Tourtelot|first21=John B.|title=AMERICAN ASSOCIATION OF CLINICAL ENDOCRINOLOGISTS MEDICAL GUIDELINES FOR CLINICAL PRACTICE FOR THE EVALUATION AND TREATMENT OF HYPERTHYROIDISM AND HYPOTHYROIDISM|journal=Endocrine Practice|volume=8|issue=6|year=2002|pages=457–469|issn=1530-891X|doi=10.4158/1934-2403-8.6.457}}</ref><ref name="WescheTiel-v Buul2001">{{cite journal|last1=Wesche|first1=Maria F. T.|last2=Tiel-v Buul|first2=Monique M. C.|last3=Lips|first3=Paul|last4=Smits|first4=Nico J.|last5=Wiersinga|first5=Wilmar M.|title=A Randomized Trial Comparing Levothyroxine with Radioactive Iodine in the Treatment of Sporadic Nontoxic Goiter|journal=The Journal of Clinical Endocrinology & Metabolism|volume=86|issue=3|year=2001|pages=998–1005|issn=0021-972X|doi=10.1210/jcem.86.3.7244}}</ref><ref name="BonnemaBertelsen1999">{{cite journal|last1=Bonnema|first1=Steen J.|last2=Bertelsen|first2=Henrik|last3=Mortensen|first3=Jesper|last4=Andersen|first4=Peter B.|last5=Knudsen|first5=Dorthe U.|last6=Bastholt|first6=Lars|last7=Hegedüs|first7=Laszlo|title=The Feasibility of High Dose Iodine 131 Treatment as an Alternative to Surgery in Patients with a Very Large Goiter: Effect on Thyroid Function and Size and Pulmonary Function1|journal=The Journal of Clinical Endocrinology & Metabolism|volume=84|issue=10|year=1999|pages=3636–3641|issn=0021-972X|doi=10.1210/jcem.84.10.6052}}</ref><ref name="NygaardKnudsen1997">{{cite journal|last1=Nygaard|first1=Birte|last2=Knudsen|first2=Jens Helmer|last3=Hegedüs|first3=Laszlo|last4=Scient|first4=Annegrete Veje Cand|last5=Mølholm Hansen|first5=Jens Erik|title=Thyrotropin Receptor Antibodies and Graves’ Disease, a Side-Effect of131I Treatment in Patients with Nontoxic Goiter1|journal=The Journal of Clinical Endocrinology & Metabolism|volume=82|issue=9|year=1997|pages=2926–2930|issn=0021-972X|doi=10.1210/jcem.82.9.4227}}</ref><ref name="GreerAstwood1953">{{cite journal|last1=Greer|first1=Monte A.|last2=Astwood|first2=E. B.|title=TREATMENT OF SIMPLE GOITER WITH THYROID*|journal=The Journal of Clinical Endocrinology & Metabolism|volume=13|issue=11|year=1953|pages=1312–1331|issn=0021-972X|doi=10.1210/jcem-13-11-1312}}</ref><ref name="SquatritoVigneri1986">{{cite journal|last1=Squatrito|first1=S.|last2=Vigneri|first2=R.|last3=Rybello|first3=F.|last4=Ermans|first4=A. M.|last5=Polley|first5=R. D.|last6=Ingbar|first6=S. H.|title=Prevention and Treatment of Endemic Iodine-Deficiency Goiter by Iodination of a Municipal Water Supply*|journal=The Journal of Clinical Endocrinology & Metabolism|volume=63|issue=2|year=1986|pages=368–375|issn=0021-972X|doi=10.1210/jcem-63-2-368}}</ref><ref name="HegedüsBonnema2010">{{cite journal|last1=Hegedüs|first1=Laszlo|last2=Bonnema|first2=Steen J.|title=Approach to Management of the Patient with Primary or Secondary Intrathoracic Goiter|journal=The Journal of Clinical Endocrinology & Metabolism|volume=95|issue=12|year=2010|pages=5155–5162|issn=0021-972X|doi=10.1210/jc.2010-1638}}</ref><ref name="HainesKeating1948">{{cite journal|last1=Haines|first1=Samuel F.|last2=Keating|first2=F. Raymond|last3=Power|first3=Marschelle H.|last4=Williams|first4=Marvin M. D.|last5=Kelsey|first5=Mavis P.|title=THE USE OF RADIOIODINE IN THE TREATMENT OF EXOPHTHALMIC GOITER*|journal=The Journal of Clinical Endocrinology & Metabolism|volume=8|issue=10|year=1948|pages=813–825|issn=0021-972X|doi=10.1210/jcem-8-10-813}}</ref><ref name="Reveno1948">{{cite journal|last1=Reveno|first1=William S.|title=PROPYLTHIOURACIL IN THE TREATMENT OF TOXIC GOITER|journal=The Journal of Clinical Endocrinology & Metabolism|volume=8|issue=10|year=1948|pages=866–874|issn=0021-972X|doi=10.1210/jcem-8-10-866}}</ref><ref name="BrentaSchnitman2003">{{cite journal|last1=Brenta|first1=G.|last2=Schnitman|first2=M.|last3=Fretes|first3=O.|last4=Facco|first4=E.|last5=Gurfinkel|first5=M.|last6=Damilano|first6=S.|last7=Pacenza|first7=N.|last8=Blanco|first8=A.|last9=Gonzalez|first9=E.|last10=Pisarev|first10=M. A.|title=Comparative Efficacy and Side Effects of the Treatment of Euthyroid Goiter with Levo-Thyroxine or Triiodothyroacetic Acid|journal=The Journal of Clinical Endocrinology & Metabolism|volume=88|issue=11|year=2003|pages=5287–5292|issn=0021-972X|doi=10.1210/jc.2003-030095}}</ref>  


==== Hypothyroidism: ====
*In cases of [[hypothyroidism]], [[thyroid hormone]] replacement with [[levothyroxine]] may help resolve [[symptoms]] of [[hypothyroidism]] and also help with the slow release of [[Thyroid-stimulating hormone|thyroid stimulating hormone]] ([[Thyroid-stimulating hormone|TSH]]) from [[pituitary]] which would result in the decrease in the size of the goiter.
*In cases of [[hypothyroidism]], [[thyroid hormone]] replacement with [[levothyroxine]] may help resolve [[symptoms]] of [[hypothyroidism]] and also help with the slow release of [[Thyroid-stimulating hormone|thyroid stimulating hormone]] ([[Thyroid-stimulating hormone|TSH]]) from [[pituitary]] which would result in the decrease in the size of the goiter.
*The drug used in the treatment of [[hypothyroidism]] is:
*#[[Levothyroxine]]:
*#*Lifelong synthetic [[levothyroxine]] (L-[[T4]]) is used to treat the hypothyroidism.
*#*Main goals of levothyroxine replacement therapy are:
*#**Resolution of the [[hypothyroid]] symptoms and signs including biological and physiologic markers of [[hypothyroidism]],
*#**Normalization of serum [[thyrotropin]] with improvement in thyroid hormone concentrations,
*#**To avoid overtreatment (iatrogenic thyrotoxicosis).
*#*Side effects include [[atrial fibrillation]] and [[osteoporosis]]. Drug Regimen:
**[[Levothyroxine (oral)|Synthetic levothyroxine]] (L-[[T4]]) 1.6–1.8 μg/kg of body weight per day orally.
==== Hyperthyroidism: ====
*In [[hyperthyroidism]], treatment targeted at normalizing [[thyroid hormone]] levels is considered.
*In [[hyperthyroidism]], treatment targeted at normalizing [[thyroid hormone]] levels is considered.
*In cases of [[inflammation]] of [[thyroid gland]], medication to treat the [[inflammation]] are generally prescribed. For goiters associated with [[hyperthyroidism]], you may need [[medications]] to normalize [[thyroid hormone]] levels.
*In cases of [[inflammation]] of [[thyroid gland]], medication to treat the [[inflammation]] are generally prescribed. For goiters associated with [[hyperthyroidism]], you may need [[medications]] to normalize [[thyroid hormone]] levels.
*'''[[Radioactive Iodine]]:''' In some cases, [[radioactive iodine]] may be used to treat an overactive [[thyroid gland]]. [[Radioactive iodine]] is prescribed as an [[oral]] medication which helps destroy thyroid cells resulting in the decreasing the size of the goiter. This therapy may also lead to under-activity of the [[thyroid gland]].
*'''[[Radioactive Iodine]]:''' In some cases, [[radioactive iodine]] may be used to treat an overactive [[thyroid gland]]. [[Radioactive iodine]] is prescribed as an [[oral]] medication which helps destroy thyroid cells resulting in the decreasing the size of the goiter. This therapy may also lead to under-activity of the [[thyroid gland]].
*[[Lugol's iodine]]:
*[[Lugol's iodine]]:
**Decreases [[thyroid hormone]] synthesis  
**Decreases [[thyroid hormone]] synthesis,
**Decreases [[vascularity]]  
**Decreases [[vascularity]].
*[[Antithyroid drugs]] such as [[carbimazole]]:
*[[Antithyroid drugs]] such as [[carbimazole]], [[methimazole]]:
**Used to restore the patient to a [[euthyroid]] state  
**Used to restore the patient to a [[euthyroid]] state  
*[[β-adrenergic blockers]] such as [[propranolol]]:
*[[β-adrenergic blockers]] such as [[propranolol]]:
**Lowers [[Tachycardia]] and [[palpitations]]
**Lowers [[tachycardia]] and [[palpitations]],
**Used to restore the patient to a [[euthyroid]]
**Used to restore the patient to a [[euthyroid]] state,
**It also decreases [[vascularity]]
**It also decreases [[vascularity]].
 
*The following table summarizes the medical therapy and surgical option for treatment.
 
 
<SMALL>
{| class="wikitable"
!Treatment
!Mechanism
!Route of administration
!Advantages
!Disadvantages
!Special considerations
|-
|Beta-blockers
|
* Block β-adrenergic receptors;
 
* propranolol may block conversion of T4 to T3
|Oral; may be administered
intravenously in acute
 
cases
|Ameliorates sweating, anxiety, tremulousness, palpitations, and tachycardia
|
* Does not influence course of disease
 
* Use cautiously in patients with asthma, CHF , bradyarrhythmias or Raynaud’s phenomenon
|
* Use cardioselective beta-blockers, especially in patients with COPD
* Use calcium-channel blockers as alternative
|-
|Antithyroid drugs ([[methimazole]],
[[carbimazole]],
and [[propylthiouracil]])
|
* Methimazole, carbimazole, and propylthiouracil block thyroid peroxidase and thyroid hormone synthesis
 
* propylthiouracil also blocks conversion of thyroxine to triiodothyronine
|Given as either a single, high fixed dose (e.g., 10–30 mg of methimazole or 200–600 mg of propylthiouracil daily)
 
and adjusted as euthyroidism is achieved or combined with thyroxine to prevent hypothyroidism (“block–replace” regimen)
|
* Outpatient therapy
* Low risk of hypothyroidism
* No radiation hazard or surgical risk
* Remission rate 40–50%
|
* High recurrence rate
* Frequent  testing required unless block-replacement therapy is used
* Minor side effects in ≤5% of patients (rash, urticaria, arthralgia, fever, nausea, abnormalities of taste and smell)
|Major side effect usually within first 3 mo of therapy
* Agranulocytosis in <0.2% of patients
* Hepatotoxicity in ≤0.1%
* Cholestasis for the thionamides and hepatocellular necrosis for propylthiouracil
* Antineutrophil cytoplasmic antibody–associated vasculitis in ≤0.1% of patients
|-
|[[Iodine-131|Radioactive iodine]]
 
(iodine-131)
|
* Irradiation causes thyroid cell damage and cell death
|Oral; activity either fixed (e.g., 15 mCi [555 MBq]) or calculated on the basis of goiter size and uptake and turnover investigations
|
* Normally outpatient procedure
* Definitive therapy
* Low cost
* Few side effects
* Effectively reduces goiter size
|
* Potential radiation hazards
* Adherence to a country’s particular radiation regulations
* Radiation thyroiditis
* Decreasing efficacy with increasing goiter size
* Eventual hypothyroidism in most patients
|
* Should not be used in patients with active thyroid ophthalmopathy
* Contraindicated in women who are pregnant or breast-feeding and for 6 wk after breast-feeding has stopped
|-
|Thyroidectomy
|Most or all thyroid tissue is removed surgically
| -----
|
* Rapid euthyroidism
* Recurrence extremely rare
 
* No radiation hazard,
* Definitive histologic results
* Rapid relief of pressure symptoms
|
* Most expensive therapy
* Hypothyroidism is the aim
* Risks associated with surgery and anesthesiology
* Minor complications in 1–2% of patients (bleeding, infection, scarring),
* Major complications in 1–4% (hypoparathyroidism, recurrent laryngeal-nerve damage)
|
* Does not influence course of Graves’ ophthalmopathy during pregnancy
* Is best performed during the second trimester
|}
</SMALL>


==References==
==References==

Latest revision as of 19:51, 20 November 2017

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Aravind Reddy Kothagadi M.B.B.S[2] Mehrian Jafarizade, M.D [3]

Overview

Pharmacologic medical therapy for goiter involves normalizing thyroid hormone levels and treating the inflammation. Treatment regimen involves Lugol's iodine, antithyroid drugs and β-adrenergic blockers. In some cases, radioactive iodine may be used to treat an overactive thyroid gland.

Medical Therapy

Hypothyroidism:

Hyperthyroidism:

  • The following table summarizes the medical therapy and surgical option for treatment.


Treatment Mechanism Route of administration Advantages Disadvantages Special considerations
Beta-blockers
  • Block β-adrenergic receptors;
  • propranolol may block conversion of T4 to T3
 Oral; may be administered

intravenously in acute

cases

Ameliorates sweating, anxiety, tremulousness, palpitations, and tachycardia
  • Does not influence course of disease
  • Use cautiously in patients with asthma, CHF , bradyarrhythmias or Raynaud’s phenomenon
  • Use cardioselective beta-blockers, especially in patients with COPD
  • Use calcium-channel blockers as alternative
Antithyroid drugs (methimazole,

carbimazole, and propylthiouracil)

  • Methimazole, carbimazole, and propylthiouracil block thyroid peroxidase and thyroid hormone synthesis
  • propylthiouracil also blocks conversion of thyroxine to triiodothyronine
 Given as either a single, high fixed dose (e.g., 10–30 mg of methimazole or 200–600 mg of propylthiouracil daily)

and adjusted as euthyroidism is achieved or combined with thyroxine to prevent hypothyroidism (“block–replace” regimen)

  • Outpatient therapy
  • Low risk of hypothyroidism
  • No radiation hazard or surgical risk
  • Remission rate 40–50%
  • High recurrence rate
  • Frequent testing required unless block-replacement therapy is used
  • Minor side effects in ≤5% of patients (rash, urticaria, arthralgia, fever, nausea, abnormalities of taste and smell)
 Major side effect usually within first 3 mo of therapy
  • Agranulocytosis in <0.2% of patients
  • Hepatotoxicity in ≤0.1%
  • Cholestasis for the thionamides and hepatocellular necrosis for propylthiouracil
  • Antineutrophil cytoplasmic antibody–associated vasculitis in ≤0.1% of patients
Radioactive iodine

(iodine-131)

  • Irradiation causes thyroid cell damage and cell death
 Oral; activity either fixed (e.g., 15 mCi [555 MBq]) or calculated on the basis of goiter size and uptake and turnover investigations
  • Normally outpatient procedure
  • Definitive therapy
  • Low cost
  • Few side effects
  • Effectively reduces goiter size
  • Potential radiation hazards
  • Adherence to a country’s particular radiation regulations
  • Radiation thyroiditis
  • Decreasing efficacy with increasing goiter size
  • Eventual hypothyroidism in most patients
  • Should not be used in patients with active thyroid ophthalmopathy
  • Contraindicated in women who are pregnant or breast-feeding and for 6 wk after breast-feeding has stopped
Thyroidectomy Most or all thyroid tissue is removed surgically -----
  • Rapid euthyroidism
  • Recurrence extremely rare
  • No radiation hazard,
  • Definitive histologic results
  • Rapid relief of pressure symptoms
  • Most expensive therapy
  • Hypothyroidism is the aim
  • Risks associated with surgery and anesthesiology
  • Minor complications in 1–2% of patients (bleeding, infection, scarring),
  • Major complications in 1–4% (hypoparathyroidism, recurrent laryngeal-nerve damage)
  • Does not influence course of Graves’ ophthalmopathy during pregnancy
  • Is best performed during the second trimester

References

  1. ↑ Astwood, E. B. (1960). "Treatment of Goiter and Thyroid Nodules with Thyroid". JAMA. 174 (5): 459. doi:10.1001/jama.1960.03030050001001. ISSN 0098-7484.
  2. ↑ Sawin CT, Geller A, Hershman JM, Castelli W, Bacharach P (1989). "The aging thyroid. The use of thyroid hormone in older persons". JAMA. 261 (18): 2653–5. PMID 2709545.
  3. ↑ Sawin, Clark T. (1989). "The Aging Thyroid". JAMA. 261 (18): 2653. doi:10.1001/jama.1989.03420180077034. ISSN 0098-7484.
  4. ↑ Führer D, Bockisch A, Schmid KW (2012). "Euthyroid goiter with and without nodules--diagnosis and treatment". Dtsch Arztebl Int. 109 (29–30): 506–15, quiz 516. doi:10.3238/arztebl.2012.0506. PMC 3441105. PMID 23008749.
  5. ↑ Baskin, H. Jack; Cobin, Rhoda H.; Duick, Daniel S.; Gharib, Hossein; Guttler, Richard B.; Kaplan, Michael M.; Segal, Robert L.; Garber, Jeffrey R.; Hamilton, Carlos R.; Handelsman, Yehuda; Hellman, Richard; Kukora, John S.; Levy, Philip; Palumbo, Pasquale J.; Petak, Steven M.; Rettinger, Herbert I.; Rodbard, Helena W.; Service, F. John; Shankar, Talla P.; Stoffer, Sheldon S.; Tourtelot, John B. (2002). "AMERICAN ASSOCIATION OF CLINICAL ENDOCRINOLOGISTS MEDICAL GUIDELINES FOR CLINICAL PRACTICE FOR THE EVALUATION AND TREATMENT OF HYPERTHYROIDISM AND HYPOTHYROIDISM". Endocrine Practice. 8 (6): 457–469. doi:10.4158/1934-2403-8.6.457. ISSN 1530-891X.
  6. ↑ Wesche, Maria F. T.; Tiel-v Buul, Monique M. C.; Lips, Paul; Smits, Nico J.; Wiersinga, Wilmar M. (2001). "A Randomized Trial Comparing Levothyroxine with Radioactive Iodine in the Treatment of Sporadic Nontoxic Goiter". The Journal of Clinical Endocrinology & Metabolism. 86 (3): 998–1005. doi:10.1210/jcem.86.3.7244. ISSN 0021-972X.
  7. ↑ Bonnema, Steen J.; Bertelsen, Henrik; Mortensen, Jesper; Andersen, Peter B.; Knudsen, Dorthe U.; Bastholt, Lars; Hegedüs, Laszlo (1999). "The Feasibility of High Dose Iodine 131 Treatment as an Alternative to Surgery in Patients with a Very Large Goiter: Effect on Thyroid Function and Size and Pulmonary Function1". The Journal of Clinical Endocrinology & Metabolism. 84 (10): 3636–3641. doi:10.1210/jcem.84.10.6052. ISSN 0021-972X.
  8. ↑ Nygaard, Birte; Knudsen, Jens Helmer; Hegedüs, Laszlo; Scient, Annegrete Veje Cand; Mølholm Hansen, Jens Erik (1997). "Thyrotropin Receptor Antibodies and Graves' Disease, a Side-Effect of131I Treatment in Patients with Nontoxic Goiter1". The Journal of Clinical Endocrinology & Metabolism. 82 (9): 2926–2930. doi:10.1210/jcem.82.9.4227. ISSN 0021-972X.
  9. ↑ Greer, Monte A.; Astwood, E. B. (1953). "TREATMENT OF SIMPLE GOITER WITH THYROID*". The Journal of Clinical Endocrinology & Metabolism. 13 (11): 1312–1331. doi:10.1210/jcem-13-11-1312. ISSN 0021-972X.
  10. ↑ Squatrito, S.; Vigneri, R.; Rybello, F.; Ermans, A. M.; Polley, R. D.; Ingbar, S. H. (1986). "Prevention and Treatment of Endemic Iodine-Deficiency Goiter by Iodination of a Municipal Water Supply*". The Journal of Clinical Endocrinology & Metabolism. 63 (2): 368–375. doi:10.1210/jcem-63-2-368. ISSN 0021-972X.
  11. ↑ Hegedüs, Laszlo; Bonnema, Steen J. (2010). "Approach to Management of the Patient with Primary or Secondary Intrathoracic Goiter". The Journal of Clinical Endocrinology & Metabolism. 95 (12): 5155–5162. doi:10.1210/jc.2010-1638. ISSN 0021-972X.
  12. ↑ Haines, Samuel F.; Keating, F. Raymond; Power, Marschelle H.; Williams, Marvin M. D.; Kelsey, Mavis P. (1948). "THE USE OF RADIOIODINE IN THE TREATMENT OF EXOPHTHALMIC GOITER*". The Journal of Clinical Endocrinology & Metabolism. 8 (10): 813–825. doi:10.1210/jcem-8-10-813. ISSN 0021-972X.
  13. ↑ Reveno, William S. (1948). "PROPYLTHIOURACIL IN THE TREATMENT OF TOXIC GOITER". The Journal of Clinical Endocrinology & Metabolism. 8 (10): 866–874. doi:10.1210/jcem-8-10-866. ISSN 0021-972X.
  14. ↑ Brenta, G.; Schnitman, M.; Fretes, O.; Facco, E.; Gurfinkel, M.; Damilano, S.; Pacenza, N.; Blanco, A.; Gonzalez, E.; Pisarev, M. A. (2003). "Comparative Efficacy and Side Effects of the Treatment of Euthyroid Goiter with Levo-Thyroxine or Triiodothyroacetic Acid". The Journal of Clinical Endocrinology & Metabolism. 88 (11): 5287–5292. doi:10.1210/jc.2003-030095. ISSN 0021-972X.

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