Treatments of Hyperthyroidism: Radioactive Iodine Therapy and Surgery
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Treatments of Hyperthyroidism: Radioactive Iodine Therapy and Surgery

Most widely used treatment for adults with thyrotoxicosis in the United States. There are no known adverse effects on the health of offspring of treated patients.

 B-Adrenergic Antagonists

• Ameliorate several of the clinical manifestations of hyperthyroidism.

• Also impair conversion of T4 to T3.

• Propranolol (80 mg/d), atenolol (50 mg/d), metoprolol (50 mg/d), or nadolol (40mg/d) are possible drug choices with their usual starting doses.

• The dose of B-blocker can be titrated to relieve the symptoms of hyperthyroidism (anxiety, palpitations, tremor, nervousness, and heat intolerance).

• Calcium channel blockers, such as diltiazem, can be substituted if B-blockers are contraindicated.

Radioactive Iodine Therapy

• Most widely used treatment for adults with thyrotoxicosis in the United States.

• I-131 is the isotope of choice. It is administered orally as a capsule or a liquid. I-131 is effective as a single dose approximately 90% of the time. The typical dose range is 5 to 15 mcg. It takes 3 to 6 months for the patient to achieve a euthyroid or hypothyroid state after administering I-131.

• Contraindications

  • Pregnancy
  • Breast-feeding

• Relative Contraindications

  • Children
  • Adolescents

• It is advisable to avoid pregnancy for 6 to 12 months after I-131 therapy

  • There are no known adverse effects on the health of offspring of treated patients.

• Hypothyroidism will probably occur after therapy (50% in 10 years)

Surgery for Hyperthyroidism

• Subtotal or total thyroidectomy is the oldest form of therapy for thyrotoxicosis.

• Very infrequently used today.

• Surgery is limited to special circumstances

  • Children
  • Adolescents
  • Middle trimester of pregnancy
  • Patients with large goiters
  • Patients with Graves ophthalmopathy
  • Patient choice

• Mortality is close to zero

• Morbidity

  • Recurrent laryngeal nerve damage
  • Hypoparathyroidism (transient or permanent) and hypocalcemia

• Preoperative preparation

  • Use ATDs to induce a euthyroid state
  • Potassium iodide (SSKI) or Lugol’s solution for 10 days prior to surgery
  • B-Adrenergic antagonists are also administered

Hyperthyroidism and Pregnancy and Lactation

• ATD therapy with PTU is the treatment of choice

• MMI is an acceptable alternative, but it has been associated with minor birth defects (aplasia cutis).

• ATDs are not believed to be teratogenic, however, neonatal thyroid function may be affected by transplacental passage of the ATD.

• The free T4 and free T3 are controlled to slightly above the normal range to minimize the dose of ATD.

• Thyroid function tests are monitored every 4 weeks.

• Graves disease often spontaneously improves in the later months of pregnancy.

• B-Adrenergic antagonists can be used to alleviate symptoms.

Thyroid Storm

• Rare complication of poorly controlled hyperthyroidism.

• Potentially fatal.

• Pathogenesis is unknown.

• It is a clinical diagnosis—lab tests are done to confirm the clinical impression.

• Treatment

Large doses of ATDs: PTU 300 to 400 mg every 4 hours by mouth (PO)

Iodine: SSKI 3 to 5 drops every 6 hours orally

Dexamethasone 8 mg IV daily until adrenal insufficiency is ruled out

B-adrenergic antagonists either IV or PO

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