Population: Adults with hyperthyroidism.
Organizations
NICE 2019, ATA 2016, AACE 2013
Recommendations
–Determine etiology of thyrotoxicosis. If the diagnosis is not apparent, consider obtaining a thyroid receptor antibody level (TRAb) +/− determination of the radioactive iodine uptake (RAIU).
–Use beta-adrenergic blockade in all patients with symptomatic thyrotoxicosis.
–For overt Graves’ disease (GD), treat with either radioiodine (RI) therapy, antithyroid drugs (ATDs), or thyroidectomy. Prefer RI unless ATD likely to achieve remission (ie, mild or uncomplicated disease) or patient not an RI/surgery candidate; treat with total thyroidectomy if concern for compression, malignancy, or patient not an RI/surgery candidate.
–For toxic goiter, use RI as first-line if multinodular, then consider total thyroidectomy or ADT; if single nodule, consider RI or hemithyroidectomy.
–For RI therapy:
• Obtain a pregnancy test within 48 h prior to treatment in any woman with childbearing potential who is to be treated with RAI.
• Recheck a T4, T3, and TSH level in 4–8 wk after RAI therapy.
• Assess patients 1–2 mo after 131I therapy with a free T4 and total triiodothyronine (T3) level; repeat q 4–6 wk if thyrotoxicosis persists.
• Consider retreatment with 131I therapy if hyperthyroidism persists 6 mo after 131I treatment.
–For antithyroid drug therapy:
• When using ADTs for hyperthyroidism, check CBC and liver enzymes prior to starting, and use titration method in young adult vs. either block and replace or titration method in older adults.
• Choose methimazole as the preferred antithyroid drug except during the first trimester of pregnancy.
• Educate patients on the signs and symptoms of agranulocytosis and hepatic injury.
• Monitor free T4 and total T3 every 4–8 wk. Once normal, monitor every 3 mo. Serum TSH will remain suppressed for several months so is not of value to trend.
• Continue antithyroid medications at least 12–18 mo, then taper or stop if TSH level is normal.
• Measure TSH receptor antibody level prior to stopping antithyroid drug therapy.
–Thyroidectomy:
• If near total or total thyroidectomy is chosen as treatment for GD, render patients euthyroid prior to the procedure with ATD pretreatment and beta-adrenergic blockade. Give potassium iodide in the immediate preoperative period.
• Follow serial calcium or intact PTH levels postoperatively.
• Start levothyroxine 1.6 μg/kg/d immediately postoperatively.
• Check a serum TSH level 6–8 wk postoperatively.
• Wean beta-blockers following thyroidectomy.
–Treat subclinical hyperthyroidism in all individuals ≥65 of age, and in patients with cardiac disease, osteoporosis, or symptoms of hyperthyroidism when the TSH is persistently <0.1 mIU/L. (ATA)
–Treat thyroid storm in the ICU with beta-blockers, antithyroid drugs, inorganic iodide, corticosteroid therapy, volume resuscitation, and aggressive cooling with acetaminophen and cooling blankets. (ATA)
Sources
–2016 American Thyroid Association guidelines for diagnosis and management of hyperthyroidism and other causes of thyrotoxicosis. Thyroid. 2016;26(10):1343-1421.
–https://www.aace.com/files/hyperguidelinesapril2013.pdf