Graves' disease hyperthyroidism medical therapy: Difference between revisions
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__NOTOC__ | __NOTOC__ | ||
{Graves' disease} | {{Graves' disease}} | ||
{{CMG}},{{AE}}{{MehdiP}} | {{CMG}},{{AE}}{{MehdiP}} | ||
==Overview== | ==Overview== | ||
Antithyroid drugs are the first line treatment in Europe but ablation therapy either by [[thyroidectomy]] or [[Iodine-131|radioactive iodine]] is more accepted in North America. | |||
==Hyperthyroidism Therapy== | ==Hyperthyroidism Therapy== | ||
===Genreral aspects=== | ===Genreral aspects=== | ||
*In a small proportion of patients, spontaneous remission occurs. | *In a small proportion of patients, spontaneous remission occurs. | ||
*Smoking cessation is one of the | *Smoking cessation is one of the mainstay of treatment. | ||
*Antithyroid drugs are the first line treatment in Europe. | *Antithyroid drugs are the first line treatment in Europe. | ||
*Ablation therapy either by thyroidectomy or radioactive iodine is more accepted in North America. | *Ablation therapy either by thyroidectomy or radioactive iodine is more accepted in North America. | ||
*Each treatment approach has advantages and drawbacks. The patient’s preference | *Each treatment approach has advantages and drawbacks. The patient’s preference after receiving adequate counseling, remains a critical factor in therapy decisions. | ||
The following table summarizes the medical therapy and surgical option for treatment. | The following table summarizes the medical therapy and surgical option for treatment. | ||
<SMALL> | |||
{| class="wikitable" | {| class="wikitable" | ||
!Treatment | !Treatment | ||
| Line 41: | Line 42: | ||
* Use calcium-channel blockers as alternative | * Use calcium-channel blockers as alternative | ||
|- | |- | ||
|Antithyroid drugs (methimazole, | |Antithyroid drugs ([[methimazole]], | ||
carbimazole, | [[carbimazole]], | ||
and propylthiouracil) | and [[propylthiouracil]]) | ||
| | | | ||
* Methimazole, carbimazole, and propylthiouracil block thyroid peroxidase and thyroid hormone synthesis | * Methimazole, carbimazole, and propylthiouracil block thyroid peroxidase and thyroid hormone synthesis | ||
| Line 55: | Line 56: | ||
* Low risk of hypothyroidism | * Low risk of hypothyroidism | ||
* No radiation hazard or surgical risk | * No radiation hazard or surgical risk | ||
* Remission rate | * Remission rate 40–50% | ||
| | | | ||
* High recurrence rate | * High recurrence rate | ||
| Line 63: | Line 64: | ||
* Agranulocytosis in <0.2% of patients | * Agranulocytosis in <0.2% of patients | ||
* Hepatotoxicity in ≤0.1% | * Hepatotoxicity in ≤0.1% | ||
* | * Cholestasis for the thionamides and hepatocellular necrosis for propylthiouracil | ||
* Antineutrophil cytoplasmic antibody–associated vasculitis in ≤0.1% of patients | * Antineutrophil cytoplasmic antibody–associated vasculitis in ≤0.1% of patients | ||
|- | |- | ||
|Radioactive iodine | |[[Iodine-131|Radioactive iodine]] | ||
(iodine-131) | (iodine-131) | ||
| Line 73: | Line 74: | ||
|Oral; activity either fixed (e.g., 15 mCi [555 MBq]) or calculated on the basis of goiter size and uptake and turnover investigations | |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 | * Normally outpatient procedure | ||
* Definitive therapy | * Definitive therapy | ||
* Low cost | * Low cost | ||
* Few side effects | * Few side effects | ||
* Effectively reduces goiter size | * Effectively reduces goiter size | ||
| | | | ||
* Potential radiation hazards | * Potential radiation hazards | ||
* Adherence to a country’s particular radiation regulations | * Adherence to a country’s particular radiation regulations | ||
* Radiation thyroiditis | * Radiation thyroiditis | ||
* Decreasing efficacy with increasing goiter size | * Decreasing efficacy with increasing goiter size | ||
* Eventual hypothyroidism in most patients | * Eventual hypothyroidism in most patients | ||
| Line 92: | Line 93: | ||
| ----- | | ----- | ||
| | | | ||
* Rapid euthyroidism | * Rapid euthyroidism | ||
* Recurrence extremely | * Recurrence extremely rare | ||
* No radiation hazard, | * No radiation hazard, | ||
| Line 100: | Line 101: | ||
| | | | ||
* Most expensive therapy | * Most expensive therapy | ||
* Hypothyroidism is the aim | * Hypothyroidism is the aim | ||
* Risks associated with surgery and anesthesiology | * Risks associated with surgery and anesthesiology | ||
* Minor complications in 1–2% of patients (bleeding, infection, scarring), | * Minor complications in 1–2% of patients (bleeding, infection, scarring), | ||
* Major complications in 1–4% (hypoparathyroidism, recurrent laryngeal-nerve damage) | * Major complications in 1–4% (hypoparathyroidism, recurrent laryngeal-nerve damage) | ||
| | | | ||
* Does not influence course of Graves’ ophthalmopathy during pregnancy | * Does not influence course of Graves’ ophthalmopathy during pregnancy | ||
* Is best performed during the second trimester | * Is best performed during the second trimester | ||
|} | |} | ||
</SMALL> | |||
===Antithyroid Drugs=== | ===Antithyroid Drugs=== | ||
*Methimazole, carbimazole and propylthiouracil are the available anti thyroid drugs. | *[[Methimazole]], [[carbimazole]] and [[propylthiouracil]] are the available anti thyroid drugs. | ||
*Methimazole is preferred for initial therapy in both Europe and North America because of its favorable side-effect profile.<ref name="pmid23043191">{{cite journal |vauthors=Burch HB, Burman KD, Cooper DS |title=A 2011 survey of clinical practice patterns in the management of Graves' disease |journal=J. Clin. Endocrinol. Metab. |volume=97 |issue=12 |pages=4549–58 |year=2012 |pmid=23043191 |doi=10.1210/jc.2012-2802 |url=}}</ref><ref name="pmid25581877">{{cite journal |vauthors=Bartalena L, Burch HB, Burman KD, Kahaly GJ |title=A 2013 European survey of clinical practice patterns in the management of Graves' disease |journal=Clin. Endocrinol. (Oxf) |volume=84 |issue=1 |pages=115–20 |year=2016 |pmid=25581877 |doi=10.1111/cen.12688 |url=}}</ref> | *Methimazole is preferred for initial therapy in both Europe and North America because of its favorable side-effect profile.<ref name="pmid23043191">{{cite journal |vauthors=Burch HB, Burman KD, Cooper DS |title=A 2011 survey of clinical practice patterns in the management of Graves' disease |journal=J. Clin. Endocrinol. Metab. |volume=97 |issue=12 |pages=4549–58 |year=2012 |pmid=23043191 |doi=10.1210/jc.2012-2802 |url=}}</ref><ref name="pmid25581877">{{cite journal |vauthors=Bartalena L, Burch HB, Burman KD, Kahaly GJ |title=A 2013 European survey of clinical practice patterns in the management of Graves' disease |journal=Clin. Endocrinol. (Oxf) |volume=84 |issue=1 |pages=115–20 |year=2016 |pmid=25581877 |doi=10.1111/cen.12688 |url=}}</ref> | ||
*Durable remission occurs in 40 to 50% of patients which is defined as euthroidism for at least 12 months following 1-2 years of treatment. | *Durable remission occurs in 40 to 50% of patients which is defined as euthroidism for at least 12 months following 1-2 years of treatment. | ||
| Line 118: | Line 119: | ||
===Radioactive Iodine=== | ===Radioactive Iodine=== | ||
*Radioactive iodine therapy offers relief from symptoms of hyperthyroidism within weeks. | *[[Iodine-131|Radioactive iodine]] therapy offers relief from symptoms of hyperthyroidism within weeks. | ||
*Radioiodine is not associated with an increased risk of cancer.<ref name="pmid9686552">{{cite journal |vauthors=Ron E, Doody MM, Becker DV, Brill AB, Curtis RE, Goldman MB, Harris BS, Hoffman DA, McConahey WM, Maxon HR, Preston-Martin S, Warshauer ME, Wong FL, Boice JD |title=Cancer mortality following treatment for adult hyperthyroidism. Cooperative Thyrotoxicosis Therapy Follow-up Study Group |journal=JAMA |volume=280 |issue=4 |pages=347–55 |year=1998 |pmid=9686552 |doi= |url=}}</ref> | *Radioiodine is not associated with an increased risk of cancer.<ref name="pmid9686552">{{cite journal |vauthors=Ron E, Doody MM, Becker DV, Brill AB, Curtis RE, Goldman MB, Harris BS, Hoffman DA, McConahey WM, Maxon HR, Preston-Martin S, Warshauer ME, Wong FL, Boice JD |title=Cancer mortality following treatment for adult hyperthyroidism. Cooperative Thyrotoxicosis Therapy Follow-up Study Group |journal=JAMA |volume=280 |issue=4 |pages=347–55 |year=1998 |pmid=9686552 |doi= |url=}}</ref> | ||
*It can provoke or worsen ophthalmopathy.<ref name="pmid19264688">{{cite journal |vauthors=Bartalena L, Tanda ML |title=Clinical practice. Graves' ophthalmopathy |journal=N. Engl. J. Med. |volume=360 |issue=10 |pages=994–1001 |year=2009 |pmid=19264688 |doi=10.1056/NEJMcp0806317 |url=}}</ref> | *It can provoke or worsen ophthalmopathy.<ref name="pmid19264688">{{cite journal |vauthors=Bartalena L, Tanda ML |title=Clinical practice. Graves' ophthalmopathy |journal=N. Engl. J. Med. |volume=360 |issue=10 |pages=994–1001 |year=2009 |pmid=19264688 |doi=10.1056/NEJMcp0806317 |url=}}</ref> | ||
| Line 125: | Line 126: | ||
{{reflist|2}} | {{reflist|2}} | ||
{{WH}} | |||
{{WS}} | |||
[[Category:Endocrinology]] | [[Category:Endocrinology]] | ||
[[Category:Medicine]] | [[Category:Medicine]] | ||
Latest revision as of 21:56, 29 July 2020
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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1],Associate Editor(s)-in-Chief: Seyedmahdi Pahlavani, M.D. [2]
Overview
Antithyroid drugs are the first line treatment in Europe but ablation therapy either by thyroidectomy or radioactive iodine is more accepted in North America.
Hyperthyroidism Therapy
Genreral aspects
- In a small proportion of patients, spontaneous remission occurs.
- Smoking cessation is one of the mainstay of treatment.
- Antithyroid drugs are the first line treatment in Europe.
- Ablation therapy either by thyroidectomy or radioactive iodine is more accepted in North America.
- Each treatment approach has advantages and drawbacks. The patient’s preference after receiving adequate counseling, remains a critical factor in therapy decisions.
The following table summarizes the medical therapy and surgical option for treatment.
| Treatment | Mechanism | Route of administration | Advantages | Disadvantages | Special considerations |
|---|---|---|---|---|---|
| Beta-blockers |
|
Oral; may be administered
intravenously in acute cases |
Ameliorates sweating, anxiety, tremulousness, palpitations, and tachycardia |
|
|
| Antithyroid drugs (methimazole,
carbimazole, and propylthiouracil) |
|
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) |
|
|
Major side effect usually within first 3 mo of therapy
|
| Radioactive iodine
(iodine-131) |
|
Oral; activity either fixed (e.g., 15 mCi [555 MBq]) or calculated on the basis of goiter size and uptake and turnover investigations |
|
|
|
| Thyroidectomy | Most or all thyroid tissue is removed surgically | ----- |
|
|
|
Antithyroid Drugs
- Methimazole, carbimazole and propylthiouracil are the available anti thyroid drugs.
- Methimazole is preferred for initial therapy in both Europe and North America because of its favorable side-effect profile.[1][2]
- Durable remission occurs in 40 to 50% of patients which is defined as euthroidism for at least 12 months following 1-2 years of treatment.
- Patients may be switched from one drug to another when necessitated by minor side effects.
- Monitoring by means of liver-function tests and white-cell counts before and during antithyroid drug therapy is advocated by some experts but is not currently supported by consensus opinion.
Radioactive Iodine
- Radioactive iodine therapy offers relief from symptoms of hyperthyroidism within weeks.
- Radioiodine is not associated with an increased risk of cancer.[3]
- It can provoke or worsen ophthalmopathy.[4]
References
- ↑ Burch HB, Burman KD, Cooper DS (2012). "A 2011 survey of clinical practice patterns in the management of Graves' disease". J. Clin. Endocrinol. Metab. 97 (12): 4549–58. doi:10.1210/jc.2012-2802. PMID 23043191.
- ↑ Bartalena L, Burch HB, Burman KD, Kahaly GJ (2016). "A 2013 European survey of clinical practice patterns in the management of Graves' disease". Clin. Endocrinol. (Oxf). 84 (1): 115–20. doi:10.1111/cen.12688. PMID 25581877.
- ↑ Ron E, Doody MM, Becker DV, Brill AB, Curtis RE, Goldman MB, Harris BS, Hoffman DA, McConahey WM, Maxon HR, Preston-Martin S, Warshauer ME, Wong FL, Boice JD (1998). "Cancer mortality following treatment for adult hyperthyroidism. Cooperative Thyrotoxicosis Therapy Follow-up Study Group". JAMA. 280 (4): 347–55. PMID 9686552.
- ↑ Bartalena L, Tanda ML (2009). "Clinical practice. Graves' ophthalmopathy". N. Engl. J. Med. 360 (10): 994–1001. doi:10.1056/NEJMcp0806317. PMID 19264688.