Prevention, screening and therapy of thyroid diseases and their cost-effectiveness

2003 ◽  
Vol 42 (05) ◽  
pp. 181-189 ◽  
Author(s):  
D. Moka ◽  
M. Schmidt ◽  
P. Theissen ◽  
H. Schicha ◽  
M. Dietlein
Keyword(s):  
Cost Effectiveness ◽  
Radioiodine Therapy ◽  
Cost Effective ◽  
Therapeutic Strategies ◽  
Thyroid Diseases ◽  
Tertiary Prevention ◽  
Antithyroid Drugs ◽  
Graves Disease ◽  
Screening Programs ◽  
Risk Of Relapse

Summary:Cost-effectiveness analyses focused on benign thyroid diseases are under-represented in the literature. The calculation of costs per additionally gained life year is difficult: The benefit of prevention is shifted into the distant future. The influence of an untreated subclinical thyroid disease on life expectancy can only be demonstrated by a long-term follow-up and by epidemiological databases. Iodine supplementation and programs for the prevention of tobacco smoking (primary prevention) are very cost-effective. Smoking increases the risk both of multinodular goiter and of Graves’ disease. Screening programs (secondary prevention) are discussed for the laboratory parameters thyrotropin (TSH), calcium and calcitonin. TSH testing seems to be very cost-effective for epidemiological considerations in a certain lifespan (newborn, pregnancy, postpartal, older persons, hospitalisation due to acute diseases) and in persons with previously elevated TPO-antibodies or TSH-values >2 mU/l, but dedicated cost-effectiveness analyses are lacking. On the other hand, the cost-effectiveness of a routine TSH testing beyond the age of 35 years has been shown by a high-quality decision analysis. Therapeutic strategies (tertiary prevention) aim at the avoidance of complications (atrial fibrillation, myocardial infarction, death for cardiac reasons) and of iatrogenic complications. Examples of a tertiary prevention are: firstly the definitive therapy of Graves’ disease in patients who have an increased risk of relapse after antithyroid drugs (ATD), secondly the radioiodine therapy for subclinical hyperthyroidism and the radioiodine therapy of large goiters in older patients or in patients suffering from a relevant comorbidity. Cost-effectiveness analyses for different therapeutic strategies of Graves’ disease were published using a lifelong time-horizon. The ablative radioiodine dose-regime is cost-effective as a first line therapy if the risk of relapse after ATD exceeds 60%.

Guideline for radioiodine therapy for benign thyroid diseases (version 3)

2004 ◽  
Vol 43 (06) ◽  
pp. 217-220 ◽  
Author(s):  
J. Dressler ◽  
F. Grünwald ◽  
B. Leisner ◽  
E. Moser ◽  
Chr. Reiners ◽  
...  
Keyword(s):  
Radioiodine Therapy ◽  
Thyroid Volume ◽  
Thyroid Diseases ◽  
Antithyroid Drugs ◽  
Graves Disease ◽  
Co Morbidity ◽  
History Of ◽  
Individual Decisions ◽  
Prophylactic Use ◽  
Benign Thyroid

SummaryThe version 3 of the guideline for radioiodine therapy for benign thyroid diseases presents first of all a revision of the version 2. The chapter indication for radioiodine therapy, surgical treatment or antithyroid drugs bases on an interdisciplinary consensus. The manifold criteria for decision making consider the entity of thyroid disease (autonomy, Graves’ disease, goitre, goitre recurrence), the thyroid volume, suspicion of malignancy, cystic nodules, risk of surgery and co-morbidity, history of subtotal thyroidectomy, persistent or recurrent thyrotoxicosis caused by Graves’ disease including known risk factors for relapse, compression of the trachea caused by goitre, requirement of direct therapeutic effect as well as the patient’s preference. Because often some of these criteria are relevant, the guideline offers the necessary flexibility for individual decisions. Further topics are patients’ preparation, counseling, dosage concepts, procedural details, results, side effects and follow-up care. The prophylactic use of glucocorticoids during radioiodine therapy in patients without preexisting ophthalmopathy as well as dosage and duration of glucocorticoid medication in patients with preexisting ophthalmopathy need to be clarified in further studies. The pragmatic recommendations for the combined use of radioiodine and glucocorticoids remained unchanged in the 3rd version.

Graves' disease and radioiodine therapy

2008 ◽  
Vol 47 (04) ◽  
pp. 153-166 ◽  
Author(s):  
I. Weber ◽  
W. Eschner ◽  
F. Sudbrock ◽  
M. Schmidt ◽  
M. Dietlein ◽  
...  
Keyword(s):  
Success Rate ◽  
Thyroid Function ◽  
Therapeutic Dose ◽  
Radioiodine Therapy ◽  
Antithyroid Drugs ◽  
Graves Disease ◽  
Inclusion Criteria ◽  
End Point ◽  
Point Measure ◽  
The Impact

SummaryAim: This study was performed to analyse the impact of the choice of antithyroid drugs (ATD) on the outcome of ablative radioiodine therapy (RIT) in patients with Graves' disease. Patients, material, methods: A total of 571 consecutive patients were observed for 12 months after RIT between July 2001 and June 2004. Inclusion criteria were the confirmed diagnosis of Graves' disease, compensation of hyperthyroidism and withdrawal of ATD two days before preliminary radioiodine-testing and RIT. The intended dose of 250 Gy was calculated from the results of the radioiodine test and the therapeutically achieved dose was measured by serial uptake measurements. The end-point measure was thyroid function 12 months after RIT; success was defined as elimination of hyperthyroidism. The pretreatment ATD was retrospectively correlated with the results achieved. Results: Relief from hyperthyroidism was achieved in 96 % of patients. 472 patients were treated with carbimazole or methimazole (CMI) and 61 with propylthiouracil (PTU). 38 patients had no thyrostatic drugs (ND) prior to RIT. The success rate was equal in all groups (CMI 451/472; PTU 61/61; ND 37/38; p=0.22). Conclusion: Thyrostatic treatment with PTU achieves excellent results in ablative RIT, using an accurate dosimetric approach with an achieved post-therapeutic dose of more than 200 Gy.

HIV Screening of Surgeons and Dentists: A Cost-Effectiveness Analysis

1994 ◽  
Vol 15 (10) ◽  
pp. 635-645 ◽  
Author(s):  
Randall L. Sell ◽  
Albert J. Jovell ◽  
Joanna E. Siegel
Keyword(s):  
Cost Effectiveness ◽  
Hiv Transmission ◽  
Program Effectiveness ◽  
Screening Program ◽  
Cost Effective ◽  
Hiv Positive ◽  
Hiv Screening ◽  
Case Scenario ◽  
Screening Programs ◽  
Voluntary Program

AbstractObjective:To assess the cost-effectiveness of human immunodeficiency virus (HIV) screening strategies of surgeons and dentists.Design:We constructed a model to project costs and HIV transmissions prevented over 15 years for four screening scenarios: 1) one-time voluntary screening, 2) one-time mandatory screening, 3) annual voluntary screening, and 4) annual mandatory screening. One-time screening occurs only in the first year of the program; annual screening occurs once each year. Under mandatory screening, all practitioners are tested and risks of practitioner-to-patient transmission are eliminated for all practitioners testing positive. Voluntary screening assumes 90% of HIV-positive and 50% of HIV-negative practitioners are tested, and risks of transmission in the clinical setting are eliminated for 90% of HIV-positive surgeons and dentists. All costs and benefits are discounted at 5% per annum over 15 years.Results:Using “best-case” scenario assumptions, we find for surgeons that a one-time voluntary screening program would be most cost-effective, at $899,336 for every HIV transmission prevented. For dentists, the one-time voluntary program also is the most cost-effective, at $139,571 per transmission prevented. Annual mandatory programs were least cost-effective for both surgeons and dentists, at $63.3 million and $2.2 million per transmission prevented, respectively.Conclusions:HIV screening of surgeons and dentists ranks among the more expensive medical lifesaving programs, even using liberal assumptions about program effectiveness. Frequency of screening and whether testing is mandatory or voluntary dramatically affect cost per transmission prevented; these features should be considered carefully in designing specific HIV screening programs.

Efficacy and Cost-Effectiveness of a Limited Phenotype Matching Transfusion Protocol for Children with Sickle Cell Disease

Blood ◽  
2008 ◽  
Vol 112 (11) ◽  
pp. 3043-3043
Author(s):  
Jerry E Squires ◽  
Vinu Jyothi ◽  
Sherron M. Jackson ◽  
Miguel Abboud ◽  
Ram Kalpatthi
Keyword(s):  
Cost Effectiveness ◽  
Sickle Cell ◽  
Cost Effective ◽  
Red Cells ◽  
Red Cell ◽  
Phenotype Matching ◽  
Screening Programs ◽  
Red Cell Antigens ◽  
Effective Manner ◽  
The Cost

Abstract Alloimmunization to red cell antigens can seriously compromise the treatment of chronically transfused sickle cell patients by increasing the risk of delayed hemolytic transfusion reactions and decreasing the availability of suitable red cell units. In an effort to reduce the rate of alloimmunization, many institutions routinely provide transfusions that are phenotypically matched for selected red cell antigens. Controversy exists in this approach with some advocating the use of extensive matching protocols in which 9 or more red cell antigens are screened while others follow a more limited approach in which only 3–5 antigens are screened. Neither the relative clinical efficacy nor the cost-effectiveness of these approaches has been compared. In our institution a limited phenotype matching program was instituted in June 1999 in which red cells provided to all pediatric sickle cell patients are negative for C, E, and Kell antigens only. All patients are screened for the presence of red cell allo-antibodies prior to each transfusion and additional phenotype matching was performed for patients who develop specific antibodies other than C, E and/or Kell. We present here our experience with this limited phenotype matching approach in 169 pediatric sickle cell patients. The patients in our study have received a mean of 100.7 red cell transfusions (range 1–555). Overall, 36 (21.3%) patients developed at least one red cell alloantibody. However, 15 of these patients had developed antibodies to C, E, or Kell (or a combination) as a result of transfusion prior to referral to our hospital or as a result of transfusion here, prior to the routine implementation of our limited matching program. Therefore, only 21 patients (12.4%) developed red cell alloantibodies that could not be prevented by the consistent use of our protocol. These antibodies include; Jka (4), M (4), Fya (3), S (3), Cw (3), Lua (3), V (2), Jsa (2), and Lea, Leb, Kpa, Kna, Jkb, c (1 each). The rate of antibody production was 0.17/100 units transfused. Our results favorably compare with other reports of more extensive phenotypic matching programs (e.g, 6.7% of patients with red cell alloantibodies; 0.06 antibodies/100 units transfused). In addition, only 6 of our patients (3.6%) developed multiple (non-C, E, Kell) allo-antibodies. In 3 of these patients the antibodies developed were of questionable clinical significance (Lea, Leb, Kna) or would generally not be screened even in the most thorough phenotype matching program (Cw, Lua). Among our patients with multiple alloantibodies, compatible red cell units were easily available with 4–13% of ABO/Rh compatible units collected from a non-ethnically selected population being suitable. The extended screening carried out for this limited number of patients (3.6%) is a far more cost-effective and sustainable approach for a large sickle cell treatment program than would be possible with an extended phenotyping program including essentially all patients. It should be noted that none of our patients have demonstrated clinical evidence of either acute or delayed hemolysis. Finally, it is important to consider the relative cost-effectiveness of various phenotype matching protocols. At an approximate cost of $200 for each red cell unit and a fee of $85 for each additional antigen screened by our local blood supplier, each unit of red cells for our patients costs $455. In screening programs requiring more extensive matching (8–9 antigens screened) the cost per unit would be almost double this amount ($880–$965). Our study suggests that this limited antigen matching is effective in reducing alloimmunization in chronically transfused pediatric sickle cell patients and additionally does so in a more cost-effective manner than more extensive screening programs. Finally, even in those patients who ultimately developed red cell antibodies, the availability of suitable red cell products was never seriously compromised.

Antithyroid drugs as a factor influencing the outcome of radioiodine therapy in Graves' disease and toxic nodular goitre?

2001 ◽  
Vol 28 (9) ◽  
pp. 1360-1364 ◽  
Author(s):  
C. Körber ◽  
P. Schneider ◽  
N. Körber-Hafner ◽  
H. Hänscheid ◽  
C. Reiners
Keyword(s):  
Radioiodine Therapy ◽  
Antithyroid Drugs ◽  
Graves Disease ◽  
Nodular Goitre ◽  
Toxic Nodular Goitre

Diagnosis and Treatment of Graves Disease

2003 ◽  
Vol 37 (7-8) ◽  
pp. 1100-1109 ◽  
Author(s):  
Darcie D Streetman ◽  
Ujjaini Khanderia
Keyword(s):  
Thyroid Gland ◽  
Radioactive Iodine ◽  
Radioiodine Therapy ◽  
Patient Adherence ◽  
Treatment Options ◽  
Antithyroid Drugs ◽  
Graves Disease ◽  
Extensive Experience ◽  
Long Term Treatment ◽  
Β Blockers

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.

T lymphocyte subpopulations in Graves' disease: relationship with clinical conditions

1983 ◽  
Vol 102 (2) ◽  
pp. 213-219 ◽  
Author(s):  
M. Bagnasco ◽  
G. W. Canonica ◽  
S. Ferrini ◽  
P. Biassoni ◽  
G. Melioli ◽  
...  
Keyword(s):  
T Lymphocyte ◽  
Radioiodine Therapy ◽  
Cell Activity ◽  
Suppressor Cell ◽  
Lymphocyte Subpopulations ◽  
Antithyroid Drugs ◽  
Graves Disease ◽  
T Lymphocyte Subpopulations ◽  
Clinical Conditions

Abstract. T lymphocytes were franctionated according to their receptors for IgG (TG) or IgM (TM) and scored in 37 patients with Graves' disease (17 hyperthyroid and untreated, 10 euthyroid on antithyroid drugs, 10 in long-term remission after radioiodine therapy). TG percentages were very low both in untreated and in drugtreated patients. By contrast, normal TG levels were observed in patients in long-term remission. These data are consistent with the hypothesis of a defective suppressor cell activity in Graves' disease.

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