Toxic multinodular goiter medical therapy: Difference between revisions
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==Overview== | ==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. | 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== | ==Medical Therapy== | ||
===Indications=== | ===Indications=== | ||
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 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> | ||
*Thyroid storm | *[[Thyroid storm]] | ||
*Overt hyperthyroidism | *Overt [[hyperthyroidism]] | ||
*Hyperthyroidism with CVS complications | *[[Hyperthyroidism]] with CVS complications | ||
*Hyperthyroidism with CNS complications | *[[Hyperthyroidism]] with CNS complications | ||
*Elderly patients | *Elderly patients | ||
*Patient with coexisting cardiac condition | *Patient with coexisting cardiac condition | ||
Following are drugs used in the symptomatic management of TMG: | Following are drugs used in the symptomatic management of TMG: | ||
*Propanolol | *[[Propanolol]] | ||
*Atenolol | *[[Atenolol]] | ||
*Metoprolol | *[[Metoprolol]] | ||
*Nadolol | *[[Nadolol]] | ||
*Esmolol | *[[Esmolol]] | ||
Anti-thyroid therapy for toxic multinodular goiter (TMG) is recommended for the patients with the following: | Anti-thyroid therapy for toxic multinodular goiter (TMG) is recommended for the patients with the following: | ||
*Patients refusing radiation therapy | *Patients refusing [[radiation therapy]] | ||
*Patients refusing surgery | *Patients refusing surgery | ||
*Patients on peri-operative preparation | *Patients on peri-operative preparation | ||
| Line 34: | Line 34: | ||
Following are antithyroid medicines used in the management of TMG: | Following are antithyroid medicines used in the management of TMG: | ||
*Propylthiouracil | *[[Propylthiouracil]] | ||
*Methimazole | *[[Methimazole]] | ||
| Line 41: | Line 41: | ||
*Treatment should be decided on : | *Treatment should be decided on : | ||
* | *Severity of disease | ||
*Biochemical evaluation of thyroid profile level of TSH, T3 and T4 | *Biochemical evaluation of thyroid profile level of TSH, T3, and T4 | ||
*Cardiac evaluation```(echo-cardiogram, electrocardiogram, Holter monitor, or myocardial perfusion studies) | *Cardiac evaluation```([[echo-cardiogram]], [[electrocardiogram]], [[Holter monitor]], or [[myocardial perfusion studies]]) | ||
*Neuromuscular complications | *Neuromuscular complications | ||
*age | *age | ||
*Goiter size | *[[Goiter]] size | ||
* | *Physical examination including vitals as pulse rate and respiratory rate | ||
=== Pharmacological drug therapy === | === Pharmacological drug therapy === | ||
| Line 54: | Line 54: | ||
*'''Toxic Multinodular Goiter''' | *'''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> | ** '''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 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) | *** 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) | ||
*** 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 Thaimolide 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 [[Thaimolide]] to so that iodine may not be used as substrate) | ||
** '''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> | ** '''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> | ||
*** 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 | *** 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 c[[ongestive 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 [[Thaimolide]] 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 Thaimolide 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 Thaimolide to so that iodine may not be used as substrate) | ||
** '''Subclinical hyperthyroidism with comorbid conditions such as dibeties | ** '''Subclinical [[hyperthyroidism]] with comorbid conditions such as [[dibeties 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): | *** Preferred regimen (1): [[Propylthiouraci]]l 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 | *** 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''' | ** '''Subclinical hyperthyroidism without comorbid conditions''' | ||
*** Preferred regimen (1):3 month review of TSH | *** Preferred regimen (1):3 month review of [[TSH]] | ||
*** Alternative regimen (1):Propylthiouracil 5-10 mg q24h PO for long term to avoid remission with 3 month review of TSH | *** Alternative regimen (1):[[Propylthiouracil]] 5-10 mg q24h PO for long term to avoid remission with 3 month review of [[TSH]] | ||
==References== | ==References== | ||
Revision as of 14:10, 10 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]
- Thyroid storm
- Overt hyperthyroidism
- Hyperthyroidism with CVS complications
- Hyperthyroidism with CNS complications
- Elderly patients
- Patient with coexisting cardiac condition
Following are drugs used in the symptomatic management of TMG:
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 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
Following are antithyroid medicines used in the management of TMG:
Treatment of TMG is based on:
- Treatment should be decided on :
- Severity of disease
- Biochemical evaluation of thyroid profile level of TSH, T3, and T4
- Cardiac evaluation```(echo-cardiogram, electrocardiogram, Holter monitor, or myocardial perfusion studies)
- Neuromuscular complications
- age
- Goiter size
- Physical examination including vitals as pulse rate and respiratory rate
Pharmacological drug therapy
Pharmacological medical therapy for toxic multinodular goiter is primarily based on beta blockers and anti-thyroid drugs.[4]
- Toxic Multinodular Goiter
- Thyroid storm[1]
- 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)
- 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 Thaimolide to so that iodine may not be used as substrate)
- Hyperthyroidism[5]
- 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 Thaimolide 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 Thaimolide to so that iodine may not be used as substrate)
- Subclinical hyperthyroidism with comorbid conditions such as dibeties 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 regimen (1):3 month review of TSH
- Alternative regimen (1):Propylthiouracil 5-10 mg q24h PO for long term to avoid remission with 3 month review of TSH
- Thyroid storm[1]
References
- ↑ 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.
- ↑ 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.
- ↑ 3.0 3.1 Becker DV, Hurley JR (1971). "Complications of radioiodine treatment of hyperthyroidism". Semin Nucl Med. 1 (4): 442–60. PMID 4107462.
- ↑ 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.
- ↑ 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.