Antithyroid drugs and radioactive iodine. Fifteen years' experience with Graves' disease

OBJECTIVE: To review the etiology, diagnosis, and clinical presentation of Graves disease and provide an overview of the standard and adjunctive treatments. Specifically, antithyroid drugs, β-blockers, inorganic iodide, lithium, and radioactive iodine are discussed, focusing on current controversies. DATA SOURCES: Primary articles were identified through a MEDLINE search (1966–July 2000). Key word searches included β-blockers, Graves disease, inorganic iodide, lithium, methimazole, and propylthiouracil. Additional articles from these sources and endocrinology textbooks were also identified. We agreed to include articles that would highlight the most relevant points, as well as current areas of controversy. DATA SYNTHESIS: Graves disease is the most common cause of hyperthyroidism. The 3 main treatment options for patients with Graves hyperthyroidism include antithyroid drugs, radioactive iodine, and surgery. Although the antithyroid drugs propylthiouracil (PTU) and methimazole (MMI) have similar efficacy, there are situations when 1 agent is preferred. MMI has a longer half-life than PTU, allowing once-daily dosing that can improve patient adherence to treatment. PTU has historically been the drug of choice for treating pregnant and breast-feeding women because of its limited transfer into the placenta and breast milk. Adjuvant therapies for Graves disease include β-blockers, inorganic iodide, and lithium. β-Blockers are used to decrease the symptoms of hyperthyroidism. Inorganic iodide is primarily used to prepare patients for thyroid surgery because of its ability to decrease the vascularity of the thyroid gland. Lithium, which acts in a manner similar to iodine, is not routinely used due to its transient effect and the risk of potentially serious adverse effects. In the US, radioiodine therapy has become the preferred treatment for adults with Graves disease. It is easy to administer, safe, effective, and more affordable than long-term treatment with antithyroid drugs. Hypothyroidism is an inevitable consequence of radioiodine therapy. Radioiodine is contraindicated in pregnant women because it can damage the fetal thyroid gland, resulting in fetal hypothyroidism. Bilateral subtotal thyroidectomy, which was once the only treatment available, is now performed only in special circumstances. In addition to the normal risks associated with surgery, laryngeal nerve damage, hypoparathyroidism, and hypothyroidism can occur following that procedure. CONCLUSIONS: Despite extensive experience with medical management, controversy prevails regarding choosing among the various drugs for treatment of Graves disease. None of the treatment options, including antithyroid drugs, radioiodine, and surgery, is ideal. Each has risks and benefits, and selection should be tailored to the individual patient.

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Assessment of Factors Affecting the Treatment Efficacy of Radioactive Iodine (I-131) Therapy in Patients with Hyperthyroidism

The Journal of Tepecik Education and Research Hospital ◽

10.5222/terh.2021.90532 ◽

2021 ◽

Author(s):

Ferhat Arık ◽

Ferhat Gökay ◽

Bade Erturk Arık

Keyword(s):

Treatment Efficacy ◽

Radioactive Iodine ◽

Antithyroid Drugs ◽

Graves Disease ◽

Multinodular Goitre ◽

Toxic Adenoma ◽

Adequate Treatment ◽

Efficient Treatment ◽

Factors Affecting ◽

Iodine Treatment

Objective: Hyperthyroidism is an increase in hormone production in the thyroid gland and the exposure of tissues to the hormones of the thyroid glands in the circulation. The most common causes encountered are Graves’ Disease, Toxic Multinodular Goiter and Toxic Adenoma. The purpose of radioactive iodine treatment is to make patients become euthyroid or hypothyroid. Despite adequate treatment, hyperthyroidism persists or reccurs in some patients. The aim of our study is to investigate the factors affecting the efficacy of radioactive iodine treatment in hyperthyroidism. Methods: In this retrospective study, relevant clinical and laboratory data were recorded in database of Kayseri Training and Research Hospital, Endocrinology and Metabolism Diseases Outpatient Unit between 2013-2016. Results: A total of 79 cases including 17 (21%) male, and 62 (79%) female patients were enrolled in the study. There were 33 (42%) Graves’ disease 9 (11%) Toxic Multinodular Goitre and 37 (47%) Toxic Adenoma patients when grouped according to diagnoses. Mean age was 56.5 ± 16,80. Development of hypothyroidism or euthyroidism were accepted as efficient treatment, hyperthyroidism or recurrence were considered as treatment failure. In 71 (89%) patients, treatment efficiently resulted in hypothyroidism or euthyroidism, whereas in 8 (11%) patients, the treatment failed due to recurrence or persistent disease. Treatment was 100 % effective in Toxic Multinodular Goitre and Toxic Adenoma groups, while it was effective in 75.7 of patients with Graves’ Disease. Patients who did not use antithyroid drugs recovered faster than patients who did. Conclusion: Radioactive iodine therapy is an efficient treatment in patients with hyperthyroidism. It was determined that 1 mm increase in nodule size decreased the treatment efficacy by 1.07 times (p<0,05). However, there are many factors that affect the efficacy of this treatment. To elucidate these factors and improve clinical practice, prospective long-term studies providing more reliable data with larger samples needed.

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Clinical experience with radioactive iodine in the treatment of childhood and adolescent Graves' disease

Endocrine Connections ◽

10.1530/ec-12-0049 ◽

2013 ◽

Vol 2 (1) ◽

pp. 32-37 ◽

Cited By ~ 7

Author(s):

Adriano N Cury ◽

Verônica T Meira ◽

Osmar Monte ◽

Marília Marone ◽

Nilza M Scalissi ◽

...

Keyword(s):

Children And Adolescents ◽

Medical Records ◽

Radioactive Iodine ◽

Antithyroid Drugs ◽

Graves Disease ◽

Age Group ◽

Large Goiter ◽

Definitive Therapy

Background/aims Treatments for Graves' disease (GD) in children and adolescents include oral antithyroid drugs (ATDs), near total thyroidectomy, and radioactive iodine (RAI). ATDs remain the preferred choice in this age group, but because persistent remission occurs in 30% of cases, RAI is becoming a common option for definitive therapy. Methods We performed a review of 65 medical records of GD patients under age 19 years who were followed between 1985 and 2005. Results The prevalence of GD was higher in females (3:1) and during puberty (for both genders). If no remission was detected during ATD treatment, RAI was indicated when the following criteria were present: non-compliance, relapse, or side effects that were related to ATDs, large goiter, and long-term use of ATDs. The majority of patients developed hypothyroidism within 6 months after RAI. A progressive higher dose regimen was implemented in the last 10 years of the study period. A second RAI dose was necessary in eight cases. During the follow-up period, three pregnancies occurred. One patient with a thyroid nodule and benign cytology was detected. Conclusions RAI therapy is effective and safe in the treatment of GD in children and adolescents.

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Surgery for thyrotoxicosis

Oxford Textbook of Endocrinology and Diabetes ◽

10.1093/med/9780199235292.003.3198 ◽

2011 ◽

pp. 484-489

Author(s):

Mauricio Moreno ◽

Nancy D. Perrier ◽

Orlo Clark

Keyword(s):

Radioactive Iodine ◽

Critical Role ◽

Antithyroid Drug ◽

Thyroid Storm ◽

Antithyroid Drugs ◽

Graves Disease ◽

Cardiac Morbidity ◽

The Usa ◽

Antithyroid Drug Treatment ◽

Needle Aspiration Cytology

Surgical intervention plays a critical role in the management of thyrotoxicosis. Despite this, radioactive iodine is still the most popular treatment modality in the USA. Thyrotoxicosis, the condition of hyperthyroidism, is due to the increased secretion of thyroid hormone, and may be caused by toxic solitary nodules, toxic multinodular goitre (Plummer’s disease), or diffuse toxic goitre (Graves’ disease). Graves’ disease is the condition of goitre and associated clinical features of tachycardia and bulging eyes described by Dr Robert James Graves (1797–1853) in 1835 (1). Understanding the pathophysiology of the condition of thyrotoxicosis is essential in the appropriate selection of surgical candidates and planning the most suitable technique. Generally, accepted indications for thyroidectomy for thyrotoxicosis include: suspicion of malignancy by physical examination (firmness, irregularity, or attachment to local structures) or by fine-needle aspiration cytology of nodules; pregnancy; women desiring pregnancy within 6–12 months of treatment; lactation; medical necessity for rapid control of symptoms (patients with cardiac morbidity); local compression (pain, dysphagia); recurrence after antithyroid drug treatment; fear of radioactive iodine treatment; resistance to 131I or antithyroid drugs; or thyroid storm unresponsive to medical therapy. Other more relative indications for thyroidectomy also include: large goitres greater than 100 g that are less likely to respond to radioactive treatment and require a large treatment dose of 131I; severe Graves’ ophthalmopathy; poor compliance with antithyroid drugs; children and adolescents; a large, bothersome, and unsightly goitre; amiodarone-induced thyrotoxicosis, in cases when medical treatment is ineffective and amiodarone is necessary to treat cardiac disease; or hypersensitivity to iodine.

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A questionnaire survey concerning the most favourable treatment for Graves' disease in children and adolescents

Acta Endocrinologica ◽

10.1530/eje.0.1510155 ◽

2004 ◽

pp. 155-156 ◽

Cited By ~ 8

Author(s):

GE Krassas ◽

Z Laron

Keyword(s):

Children And Adolescents ◽

Radioactive Iodine ◽

High Rate ◽

Treatment Modalities ◽

Antithyroid Drugs ◽

Graves Disease ◽

Toxic Adenoma ◽

Or Groups ◽

The Usa ◽

Toxic Goiter

Graves' disease (GD) is the most common cause of juvenile thyrotoxicosis in children and adolescents (1, 2). Three treatment modalities are now available for the treatment of Graves' thyrotoxicosis in childhood: antithyroid drugs (ATD), surgery and radioactive iodine (RAI). However, none of these treatments has been shown to be ideal or clearly superior to the others. Physicians in different countries have different approaches concerning the optimal treatment of juvenile GD.In a European questionnaire study (3), which was conducted by the European Thyroid Association in 1993 and in which 99 individuals or groups from 22 countries participated, it was found that 22 out of 99 physicians from nine countries would consider RAI treatment as the treatment of choice for children with recurrent thyrotoxicosis after surgery, or with recurrent thyrotoxicosis 2 years after ATD. However, RAI is preferred by only a small percentage of physicians for this group of patients in Europe. Hardly any of the respondents chose RAI for the patients with a toxic adenoma or a multinodular toxic goiter (3). On the other hand, in view of the difficulties with medical therapy in children and adolescents, including poor compliance, a high rate of relapse, drug toxicity and continued thyroid enlargement, some eminent American physicians emphasize the safety, simplicity and economic advantages of (131)I ablation which should be considered more commonly in children (4, 5).We had the opportunity to conduct a similar study during a pediatric thyroidology symposium, which was organized by Professors Buyugkebiz and Laron in Izmir (Smyrna) Turkey from 30 October to 1 November 2003. During the congress a questionnaire with the following four questions was circulated among the 120 participants from eight countries who were mainly paediatric endocrinologists. Most of them were from Turkey and the rest, except for one who came from the USA, were Europeans. Sixty-one out of the 120 physicians responded.

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Treatment of Grave’s Disease in Adults

10.5772/intechopen.97563 ◽

2021 ◽

Author(s):

Mauricio Alvarez Andrade ◽

Lorena Pabón Duarte

Keyword(s):

Autoimmune Disease ◽

Lower Risk ◽

Radioactive Iodine ◽

Antithyroid Drug ◽

Poor Response ◽

Antithyroid Drugs ◽

Graves Disease ◽

Radioactive Iodine Therapy ◽

Common Cause ◽

Multiple Factors

Graves disease is an autoimmune disease, with a genetic susceptibility, activated by environmental factors like stress, iodine excess, infections, pregnancy and smoking. It is caused by thyroid stimulating immunoglobulin (TSI) or thyroid stimulating antibody (TSAb) and is the most common cause of hyperthyroidism with an incidence of 21 per 100,000 per year. Treatment of Graves disease includes antithyroid drugs such as methimazole and propylthiouracil, radioactive iodine therapy and thyroidectomy. Methimazole, an antithyroid drug that belongs to the thioamides class, is usually the first line of treatment due to lower risk of hepatotoxicity compared to propylthiouracil. Radioactive iodine therapy is reserved for those patients who do not respond to antithyroid drugs or have contraindication or adverse effects generated by antithyroid drugs, and thyroid surgery is an option in people with thyroid nodular disease with suspected malignancy or large goiters such as predictors of poor response to antithyroid drugs and radioactive iodine therapy. Multiple factors influence the management of patients with Graves disease including patient and physician preferences, access to medical services and patients features such as age, complications and comorbidities.

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Evaluating the Efficacy of Primary Treatment for Graves’ Disease Complicated by Thyrotoxic Periodic Paralysis

International Journal of Endocrinology ◽

10.1155/2014/949068 ◽

2014 ◽

Vol 2014 ◽

pp. 1-6 ◽

Cited By ~ 4

Author(s):

Rita Yuk-Kwan Chang ◽

Brian Hung-Hin Lang ◽

Ai Chen Chan ◽

Kai Pun Wong

Keyword(s):

Radioactive Iodine ◽

Primary Treatment ◽

Periodic Paralysis ◽

Antithyroid Drugs ◽

Graves Disease ◽

Thyrotoxic Periodic Paralysis ◽

Term Efficacy ◽

Life Threatening ◽

Life Threatening Complication

Objective. Thyrotoxic periodic paralysis (TPP) is a potentially life-threatening complication of Graves’ disease (GD). The present study compared the long-term efficacy of antithyroid drugs (ATD), radioactive iodine (RAI), and surgery in GD/TPP.Methods. Sixteen patients with GD/TPP were followed over a 14-year period. ATD was generally prescribed upfront for 12–18 months before RAI or surgery was considered. Outcomes such as thyrotoxic or TPP relapses were compared between the three modalities.Results. Eight (50.0%) patients had ATD alone, 4 (25.0%) had RAI, and 4 (25.0%) had surgery as primary treatment. Despite being able to withdraw ATD in all 8 patients for 37.5 (22–247) months, all subsequently developed thyrotoxic relapses and 4 (50.0%) had ≥1 TPP relapses. Of the four patients who had RAI, two (50%) developed thyrotoxic relapse after 12 and 29 months, respectively, and two (50.0%) became hypothyroid. The median required RAI dose to render hypothyroidism was 550 (350–700) MBq. Of the 4 patients who underwent surgery, none developed relapses but all became hypothyroid.Conclusion. To minimize future relapses, more definitive primary treatment such as RAI or surgery is preferred over ATD alone. If RAI is chosen over surgery, a higher dose (>550 MBq) is recommended.

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