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): Propylthiouracil 5-10 mg q24h PO for long term to avoid remission with 3 month review of TSH(patients with dibeties malletis, heart failure or CNS abnormality)
- Alternative regimen (1): Methimazole 5-10 mg q24h PO for long term to avoid remission with 3 month review of TSH(patients with dibeties malletis, heart failure or CNS abnormality)
- 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