Franklyn JA. Medical guidelines for clinical practice for the evaluation and treatment of hyperthyroidism and hypothyroidism. Rare causes of hyperthyroidism include metastatic thyroid cancer, ovarian tumors that produce thyroid hormone (struma ovarii), trophoblastic tumors that produce human chorionic gonadotrophin and activate highly sensitive TSH receptors, and TSH-secreting pituitary tumors.5, A diagnostic approach to patients who present with signs and symptoms of hyperthyroidism is summarized in Figure 2.5,13 Measurement of the TSH level is the only initial test necessary in a patient with a possible diagnosis of hyperthyroidism without evidence of pituitary disease. Iodine deficiency remains the most common cause of hypothyroidism worldwide.4 However, in Australia and other iodine replete countries, autoimmune chronic lymphocytic thyroiditis is the most common aetiology.5The main causes of hypothyroidism and associated clinical features are shown in Table 1. Miller CC III, Shipton B, J Clin Endocrinol Metab. Solomon BL, Has a currently accepted medical use in treatment in the United States or a currently accepted medical use with severe restrictions. The medication gradually lowers cholesterol levels elevated by the disease and may reverse any weight gain. Buyukbese M, New York: McGraw-Hill, 2005:1102–10. et al. Differences in the signs and symptoms of hyperthyroidism in older and younger patients. Luukkaala T, Etiologic diagnosis influences prognosis and therapy. Radioactive iodine. Zhuang W, 36. Revilla C, Bogazzi F, Huhtala H, Braga M, Lalezari S, Antithyroid drugs, radioactive iodine, and surgery are the main treatment options for persistent hyperthyroidism (Table 3).5,8,9,14–24 Each therapy can produce satisfactory outcomes if properly used.16, Prompt control of symptoms; treatment of choice for thyroiditis; first-line therapy before surgery, radioactive iodine, and antithyroid drugs; short-term therapy in pregnancy, Use with caution in older patients and in patients with pre-existing heart disease, chronic obstructive pulmonary disease, or asthma, Block the conversion of T4 to T3 and inhibit hormone release, Rapid decrease in thyroid hormone levels; preoperatively when other medications are ineffective or contraindicated; during pregnancy when antithyroid drugs are not tolerated; with antithyroid drugs to treat amiodarone- (Cordarone-) induced hyperthyroidism, Paradoxical increases in hormone release with prolonged use; common side effects of sialadenitis, conjunctivitis, or acneform rash; interferes with the response to radioactive iodine; prolongs the time to achieve euthyroidism with antithyroid drugs, Antithyroid drugs (methimazole [Tapazole] and PTU), Interferes with the organification of iodine; PTU can block peripheral conversion of T4 toT3 in large doses, Long-term treatment of Graves’ disease (preferred first-line treatment in Europe, Japan, and Australia); PTU is treatment of choice in patients who are pregnant and those with severe Graves’ disease; preferred treatment by many endocrinologists for children and for adults who refuse radioactive iodine; pretreatment of older and cardiac patients before radioactive iodine or surgery; both medications considered safe for use while breastfeeding, High relapse rate; relapse more likely in smokers, patients with large goiters, and patients with positive thyroid-stimulating antibody levels at end of therapy; major side effects include polyarthritis (1 to 2 percent), agranulocytosis (0.1 to 0.5 percent); PTU can cause elevated liver enzymes (30 percent), and immunoallergic hepatitis (0.1 to 0.2 percent); methimazole can cause rare cholestasis and rare congenital abnormalities; minor side effects (less than 5 percent) include rash, fever, gastrointestinal effects, and arthralgia, Concentrates in the thyroid gland and destroys thyroid tissue, High cure rates with singledose treatment (80 percent); treatment of choice for Graves’ disease in the United States, multinodular goiter, toxic nodules in patients older than 40 years, and relapses from antithyroid drugs, Delayed control of symptoms; posttreatment hypothyroidism in majority of patients with Graves’ disease regardless of dosage (82 percent after 25 years); contraindicated in patients who are pregnant or breastfeeding; can cause transient neck soreness, flushing, and decreased taste; radiation thyroiditis in 1 percent of patients; may exacerbate Graves’ ophthalmopathy; may require pretreatment with antithyroid drugs in older or cardiac patients, Treatment of choice for patients who are pregnant and children who have had major adverse reactions to antithyroid drugs, toxic nodules in patients younger than 40 years, and large goiters with compressive symptoms; can be used for patients who are noncompliant, refuse radioactive iodine, or fail antithyroid drugs, and in patients with severe disease who could not tolerate recurrence; may be done for cosmetic reasons, Risk of hypothyroidism (25 percent) or hyperthyroid relapse (8 percent); temporary or permanent hypoparathyroidism orlaryngeal paralysis (less than 1 percent); higher morbidity and cost than radioactive iodine; requires patient to be euthyroid preoperatively with antithyroid drugs or iodides to avoid thyrotoxic crisis. Tisell LE. 2001;86:3016–21. Indian J Med Sci. There are 3 recognised modalities of treatment for hyperthyroidism: antithyroid drugs, surgery and radioiodine. Meier DA, Brill DR, Becker DV, Clarke SE, Silberstein EB, Royal HD, et al. These drugs are also often given for a short period to render the patient euthyroid before definitive therapy with radioiodine or thyroidectomy. Howard R. Update on the management of hyperthyroidism and hypothyroidism. Perrotta A, Taube A, Kitagawa W, Hall R, Rev Invest Clin. Daykin J, Braga M, Akasu H, Tallstedt L, Nonselective beta blockers such as propranolol, are preferred because they have a more direct effect on hypermetabolism.25 Therapy with propranolol should be initiated at 10 to 20 mg every six hours. Hyperthyroidism: Diagnosis and Treatment. The best approach for you depends on your age, physical condition, the underlying cause of the hyperthyroidism, personal preference and the severity of your disorder. Patient information:A handout on treating hyperthyroidism, written by the authors of this article. Immune, endocrine and metabolic disorders. 5. Betteridge J, It can be familial and associated with other autoimmune diseases. Other common causes include thyroiditis, toxic multinodular goiter, toxic adenomas, and side effects of certain medications. Kadioglu P, Salmi J. For the missing item, see the original print version of this publication. Arranging endocrinology referral or advice for … Walpert N, Relation between therapy for hyperthyroidism and the course of Graves’ ophthalmopathy. Benvenga S, et al. 2005;352:905–17. Hosp Pract (1995). Brewis M, A typical starting combination would include methimazole 20 mg with atenolol 25 mg, both given once daily. Graves’ disease, toxic multinodular goiter, and toxic adenoma can be treated with radioactive iodine, antithyroid drugs, or surgery, but in the United States, radioactive iodine is the treatment of choice in patients without contraindications. Get Permissions, Access the latest issue of American Family Physician. Vischer UM, et al. Patients treated for hyperthyroidism have an increased all-cause mortality risk, as well as increased risk of mortality from thyroid, cardiovascular and cerebrovascular diseases, and hip fractures.5,15,40 Morbidity can be attributed to the same causes, and patients should be screened and treated for osteoporosis and atherosclerotic risk factors. 41. In: Carlson KJ, Eisenstat SA, eds. Thyroid. Thyroid disease in the elderly. CMAJ. The spectrum of thyroid disease in a community: the Whickham survey. All are effective but no single method offers an absolute cure. Wahba H. NLM 35. 2010 Nov-Dec;132(11-12):355-60. Kadioglu P, The causes of hyperthyroidism, and key clinical features that differentiate each condition, are outlined in Table 2.6,7, Lymphocytic thyroiditis, postpartum thyroiditis, medication-induced thyroiditis, Graves’ disease (thyroid-stimulating antibody), Increased glandular stimulation (substance causing stimulation), Iodine-induced hyperfunctioning of thyroid gland (iodide ingestion, radiographic contrast, amiodarone [Cordarone]), Functioning pituitary adenoma (thyroid-stimulating hormone); trophoplastic tumors (human chorionic gonadotropin), Graves’ disease is the most common cause of hyperthyroidism, accounting for 60 to 80 percent of all cases.8 It is an autoimmune disease caused by an antibody, active against the thyroid-stimulating hormone (TSH) receptor, which stimulates the gland to synthesize and secrete excess thyroid hormone. The spectrum of thyroid disease in a community: the Whickham survey. In this study, patients had white cell counts every two weeks for the first two months, then monthly. et al. Nedrebo BG, This site needs JavaScript to work properly. An undetectable TSH level is diagnostic of hyperthyroidism. 3d ed. There has been reluctance to use radioactive iodine in women of childbearing years because of the theoretical risk of cancer of the thyroid, leukemia, or genetic damage in future offspring. Patients who have been treated previously for hyperthyroidism have an increased incidence of obesity41 and insulin resistance.42 The effect of hyperthyroidism on endothelial function may be an independent risk factor for thromboembolism.43, Amiodarone- (Cordarone-) induced hyperthyroidism, Endocrinologist or surgeon (if contraindications to antithyroid drugs), Failed drug therapy or refusal to take radioactive iodine, Visual impairment caused by ophthalmopathy, Hospital admission with urgent ophthalmology consult, Severe cardiovascular symptoms Such as congestive heart failure, Rapid atrial fibrillation, or angina, Hospital admission with endocrine and cardiac consultation. 37. Walpert N, Ruggeri RM, Arterial embolization: a novel approach to thyroid ablative therapy for Graves’ disease. Giorgio A, Because amiodarone contains 37 percent iodine, type I is an iodine-induced hyperthyroidism (see above). Wallin G, Soyasal T, Primary care of women. Turnbridge WM, Sheppard MC, Radio-iodine treatment of hyperthyroidism-prognostic factors for outcome. Landrin I, Radioactive Iodine Therapy and Glucose Tolerance. Harper MB, Mayeaux EJ Jr. Thyroid disease. Oksala H, Thyroid. Marcocci C, Maia AL. Chen G, J Community Hosp Intern Med Perspect. Betteridge J, J Clin Endocrinol Metab. All are effective but no single method offers an absolute cure. / afp Guidelines for the Treatment of Hypothyroidism: Prepared by the American Thyroid Association Task Force on Thyroid Hormone Replacement (2014) Jonklaas, Bianco, et al., Thyroid 24(12): 1670-1751, 2014 . Predictors of outcome and comparison of different drug regimens for the prevention of relapse in patients with Graves’ disease. 19. ), The treatment of hyperthyroidism depends on the cause and severity of the disease, as well as on the patient’s age, goiter size, comorbid conditions, and treatment desires. Regardless of the cause of hyperthyroidism, the adrenergic symptoms are controlled by beta blockers (Table 5).2528 Propranolol has the theoretical advantage of also inhibiting 5-monodeiodinase, thus blocking peripheral conversion of T4 to T3.25 The choice of treatment modality for hyperthyroidism caused by overproduction of thyroid hormones depends on the patient's age, symptoms, comorbidities, and preference.25,26 Graves disease requires one of the three treatment options: an antithyroid medica… Patients with toxic nodular goiter or toxic adenomas are more radio resistant and generally need high-dose therapy to achieve remission. Differences in the signs and symptoms of hyperthyroidism in older and younger patients. Werner & Ingbar’s the thyroid: a fundamental and clinical text. Arterial embolization: a novel approach to thyroid ablative therapy for Graves’ disease. The dosage of either agent is 1 g per day for up to 12 weeks.26. Uhlving S, Solomon BL, Philadelphia: Lippincott Williams & Wilkins, 2000:564–72. Emeis JJ, N Engl J Med. Daykin J, Immune, endocrine and metabolic disorders. A recent randomized trial27 indicated that relapse was more likely in patients who smoked, had large goiters, or had elevated thyroid-stimulating antibody levels at the end of therapy. Skeie S, Mortality after the treatment of hyperthyroidism with radioactive iodine. The high-dose regimen is clearly favored in older patients, those with cardiac disease, and other groups who need prompt control of hyperthyroidism to avoid complications. Soyasal T, 25. Common symptoms and signs are listed in Table 1,3 with attention to the differences in clinical presentation between younger and older patients. N Engl J Med. Ambulatory medicine: the primary care of families. Akin P. 30. Nedrebo BG, Information from references 5, 8, 9, and 14 through 24. 34. Possible treatments include: 1. Burch HB, Hyperthyroidism is a set of disorders that involve excess synthesis and secretion of thyroid hormones by the thyroid gland, which leads to the hypermetabolic condition of thyrotoxicosis. A review of treatment options for Graves' disease: why total thyroidectomy is a viable option in selected patients. Medications such as interferon and interleukin-2 (aldesleukin) also can cause type II.5. Solomon BL, 1993 Aug 10;82(32):840-4. In: Carlson KJ, Eisenstat SA, eds. Newer treatment options under investigation include endoscopic subtotal thyroidectomy,34 embolization of the thyroid arteries,35 plasmapheresis,36 and percutaneous ethanol injection of toxic thyroid nodules.37 Autotransplantation of cryopreserved thyroid tissue may become a treatment option for postoperative hypothyroidism.38 Nutritional supplementation with L-carnitine39 has been shown to have a beneficial effect on the symptoms of hyperthyroidism, andl-carnitine may help prevent bone demineralization caused by the disease. Hypothyroidism has multiple etiologies and manifestations. J Clin Endocrinol Metab. Senturk H, A person viewing it online may make one printout of the material and may use that printout only for his or her personal, non-commercial reference. The effect of methimazole pretreatment on the efficacy of radioactive iodine therapy in Graves’ hyperthyroidism: one-year follow-up of a prospective, randomized study. At one year, if the patient is clinically and biochemically euthyroid and a thyroid-stimulating antibody level is not detectable, therapy can be discontinued. afpserv@aafp.org for copyright questions and/or permission requests. Revilla C, Symptoms usually resolve within eight months. Clark OH. Arranging urgent endocrinology referral if a pituitary or hypothalamic disorder is suspected. 11. Wahba H. Please enable it to take advantage of the complete set of features! N Engl J Med. Lundholm K, What is the treatment of hyperthyroidism? Correction of insulin resistance in methimazole-treated patients with Graves disease. of Family and Community Medicine, University of Louisville, 3430 Newburg Rd., Louisville, KY 40218 (e-mail: Turnbridge WM, Jaatinen P, Lijec Vjesn. et al. T4 = thyroxine; T3 = triiodothyronine; PTU = propylthiouracil. Tanda ML, Correction of insulin resistance in methimazole-treated patients with Graves disease. 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