Management Guidelines of the American Thyroid Association and American Association of Clinical Endocrinologists regarding treating Hyperthyroidism and other causes of Thyrotoxicosis

The below recommendations have been issued by those two reputable organizations to assists endocrinologist in treating hyperthyroidism conditions. To some reason, they are overlooked by many clinicians or just ignored. The purpose of this article is to give you some general information about how you should be treated, depending on your particular case. The outlined recommendations represent what the 2 organizations believe is current, rational, and optimal medical practice. It is not the intent of these guidelines to replace clinical judgment, individual decision making, or the wishes of the patient or family.

Thyrotoxicosis  is  a  condition  that has  multiple  etiologies, manifestations, and potential therapies. The term “thyrotoxicosis’’ refers to a clinical state that results from inappropriately high thyroid hormone action in tissues generally due to inappropriately high tissue thyroid hormone levels (hyperthyroidism). The most common causes include Graves’ disease (GD), toxic multinodular goiter (TMNG), and toxic adenoma (TA). GD is an autoimmune disorder in which thyrotropin receptor antibodies (TRAbs) stimulate the TSH receptor, increasing thyroid hormone production. In overt hyperthyroidism, usually both serum free T4  and T3 estimates  are  elevated,  and  serum  TSH  is  undetectable; however, in milder hyperthyroidism, serum T4  and free T4 estimates can be normal, only serum T3 may be elevated, and serum TSH will be <0.01 mU/L (or undectable).  I will not go in more details about diagnose procedures I’ll assume that this is already done by your physician. Let’s get to the treatment recommendations.

# 1. Beta-adrenergic blockade (i.e beta- blockers) should be given to elderly patients with symptomatic thyrotoxicosis and to other thyrotoxic patients with resting heart rates in excess of 90 bpm (palpitations) or coexistent cardiovascular disease. Beta- blockers should be considered in all patients with symptomatic thyrotoxicosis. So, if your pulse is over 90bpm, your doctor should prescribe a beta-blocker. Effects of beta- blockers: propranolol, atenolol, metoprolol, or other beta-blockers leads to a decrease  in  heart  rate,  systolic  blood  pressure,  muscle weakness, and tremor, as well as improvement in the degree of irritability, emotional lability, and exercise intolerance. (it’s not recommended though for patients with asthma).

# 2. Patients with overt Graves’ hyperthyroidism should be treated with any of the following modalities: 131I therapy, antithyroid medication, or thyroidectomy. In the United States, radioactive iodine has been the therapy most preferred by physicians. In Europe and Japan, there has been a greater physician preference for ATDs and/or surgery. Once the diagnosis has been made, the treating physician and patient should discuss each of the treatment options, including the logistics, benefits, expected speed of recovery, drawbacks, potential side effects, and cost. This sets the stage for the physician to make recommendations based on best clinical judgment and allows the final decision to incorporate the personal values and preferences of the patient.

Factors that favor a particular modality as treatment for Graves’ hyperthyroidism:

a. 131 I (RAI) : Females planning a pregnancy in the future (in more than 4-6 months following radioiodine therapy, provided thyroid hormone levels are normal), individuals with comorbidities increasing surgical risk, and patients with previously operated or externally irradiated necks, or lack of access to a high-volume thyroid surgeon or contraindications to ATD use.

b. ATDs (drugs): Patients with high chance of remission (patients, especially females, with mild disease, small goiters, and negative or low-titer TRAb); the elderly or others with comorbidities increasing surgical risk or with  limited  life  expectancy;  individuals  who are  unable  to  follow  radiation  safety regulations; patients with previously operated or irradiated necks; patients with lack of access to a high-volume thyroid surgeon; and patients with moderate to severe active GO (Graves’ ophtalmopathy).

c. Surgery: Symptomatic compression or large goiters (80 g); relatively low uptake of radioactive iodine; when  thyroid  malignancy  is  documented  or  suspected (e.g., suspicious or indeterminate cytology); large nonfunctioning, hypofunctioning nodule; coexisting hyperparathyroidism requiring surgery; females planning a pregnancy in <4-6 months (i.e., before thyroid hormone levels would be  normal  if  radioactive  iodine  were  chosen  as therapy), especially if TRAb levels are particularly high; and patients with moderate to severe active GO. (Graves’ ophtalmopathy).

Contraindications to the different treatment options for Graves’ hyperthyroidism:

  1. 131 I therapy (RAI): Definite contraindications include pregnancy, lactation, coexisting thyroid cancer, or suspicion of thyroid cancer, individuals unable to comply with radiation safety  guidelines  (more on that later) and  females  planning  a pregnancy within 4-6 months. Patients with Graves’ hyperthyroidism and active moderate-to-severe or sight-threatening ophthalmopathy should be treated with either methimazole or surgery.
  2. ATDs:  Definite contraindications  to  long-term  ATD therapy include previous known major adverse reactions to ATDs.
  3. Surgery: Factors that may mitigate against the choice of  surgery  include  substantial  comorbidity  such  as cardiopulmonary  disease,  end-stage  cancer,  or  other debilitating disorders.

Bottom line: if you have TED (or Graves’s ophtalmopathy) it is advisable to go with Anti-thyroid medication or surgery, not RAI, because it may worsen the symptoms. The reoccurrence of Graves’ disease is 0% after total thyroidectomy (because your thyroid is completely removed) and only 8% for subtotal thyroidectomy.  Methimazole should be used in virtually every patient who chooses antithyroid drug therapy for GD, except during the first trimester of pregnancy when propylthiouracil is preferred, in the treatment of thyroid storm, and in patients with minor reactions to methimazole who refuse radioactive iodine therapy or surgery.

The above are just few out of the 100 Recommendations listed on the American Thyroid Association website. More to follow on particular types of treatment.

Reference:  Hyperthyroidism and Other Causes of Thyrotoxicosis: Management Guidelines of the American Thyroid Association and American Association of Clinical Endocrinologists; The American Thyroid Association and American Association of Clinical Endocrinologists Taskforce on Hyperthyroidism and Other Causes of Thyrotoxicosis; Rebecca S. Bahn (Chair), Henry B. Burch, David S. Cooper,Jeffrey R. Garber, M. Carol Greenlee, Irwin Klein,Peter Laurberg, I. Ross McDougall, Victor M. Montori,Scott A. Rivkees,Douglas S. Ross, Julie Ann Sosa, and Marius N. Stan

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