Toxic multinodular goiter medical therapy

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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:

• Thyroid storm
• Overt hyperthyroidism
• Hyperthyroidism with CVS complications
• Hyperthyroidism with CNS complications
• Elderly patients
• Patient with coexisting cardiac condition

Following are medicine used in symtopatic managmen of TMG:

• Propanolol
• Atenolol
• Metoprolol
• Nadolol
• Esmolol

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 management of TMG:

• Propylthiouracil
• Methimazole

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

Pharmacologic medical therapy for toxic multinodular goiter mainly depends on beta blockers and anti-thyroid drugs.

• Thyroid storm
  • 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
  • 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
  • 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