Graves' disease hyperthyroidism medical therapy: Difference between revisions

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* 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 55:
* Low risk of hypothyroidism
* Low risk of hypothyroidism
* No radiation hazard or surgical risk
* No radiation hazard or surgical risk
* Remission rate, 40–50%56†
* Remission rate 40–50%56
|
|
* High recurrence rate
* High recurrence rate
Line 66: Line 66:
* 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)
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|
|
* Rapid euthyroidism,  
* Rapid euthyroidism,  
* Recurrence extremely rare‡
* Recurrence extremely rare


* No radiation hazard,
* No radiation hazard,
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===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 118:


===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>

Revision as of 19:36, 20 December 2016

{Graves' disease} Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1],Associate Editor(s)-in-Chief: Seyedmahdi Pahlavani, M.D. [2]

Overview

Hyperthyroidism Therapy

Genreral aspects

  • In a small proportion of patients, spontaneous remission occurs.
  • Smoking cessation is one of the main stays 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
  • 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%56
  • 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%
  • Cholestatic 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

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

  1. ↑ 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.
  2. ↑ 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.
  3. ↑ 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.
  4. ↑ Bartalena L, Tanda ML (2009). "Clinical practice. Graves' ophthalmopathy". N. Engl. J. Med. 360 (10): 994–1001. doi:10.1056/NEJMcp0806317. PMID 19264688.

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