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Azizi F, Mehran L, Abdi H, Amouzegar A. Approach to the Patient Considering Long-term Antithyroid Drug Therapy for Graves' Disease. J Clin Endocrinol Metab 2024; 109:e1881-e1888. [PMID: 39018185 DOI: 10.1210/clinem/dgae456] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/17/2024] [Indexed: 07/19/2024]
Abstract
Antithyroid drugs (ATD) are the treatment of choice for the majority of patients with Graves' hyperthyroidism worldwide. However, relapse of hyperthyroidism after withdrawal of arbitrarily chosen conventional 12 to 18 months of therapy is very common. In the last 2 decades, many studies have shown that treatment with long-term ATD (LT-ATD) is effective and safe in the maintenance of euthyroidism. In addition, it has been reported that serum TSH receptor antibody may not decrease permanently before 5 to 6 years of ATD treatment, and clinical trials have shown that ≥5 years of ATD treatment is accompanied by remission in the majority of patients with Graves' hyperthyroidism. The objective of this article is to discuss the optimal time to withdraw of conventional ATD therapy, to illustrate the decision-making of the management of recurrent hyperthyroidism, to review the proper management of LT-ATD, and to generate suggestions for lifelong ATD treatment by discussing 4 scenarios of decision-making in patients with Graves' disease.
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Affiliation(s)
- Fereidoun Azizi
- Endocrine Research Center, Research Institute for Endocrine Sciences, Shahid Beheshti University of Medical Sciences, Tehran 1985717413, I.R.Iran
| | - Ladan Mehran
- Endocrine Research Center, Research Institute for Endocrine Sciences, Shahid Beheshti University of Medical Sciences, Tehran 1985717413, I.R.Iran
| | - Hengameh Abdi
- Endocrine Research Center, Research Institute for Endocrine Sciences, Shahid Beheshti University of Medical Sciences, Tehran 1985717413, I.R.Iran
| | - Atieh Amouzegar
- Endocrine Research Center, Research Institute for Endocrine Sciences, Shahid Beheshti University of Medical Sciences, Tehran 1985717413, I.R.Iran
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Kanokwongnuwat W, Penpong N. Prospective study to evaluate radioactive iodine of 20 mCi vs 10-15 mCi in Graves' disease. BMC Endocr Disord 2024; 24:54. [PMID: 38664774 PMCID: PMC11044547 DOI: 10.1186/s12902-024-01588-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/20/2024] [Accepted: 04/23/2024] [Indexed: 04/29/2024] Open
Abstract
OBJECTIVES To assess whether increasing radioactive iodine dose can increase treatment efficacy in Graves' disease. METHODS A prospective study was conducted, including 106 patients receiving 20 mCi (740 MBq) radioactive iodine (RAI), compared with a retrospective data, including 113 patients receiving 10-15 mCi (370-555 MBq) RAI. Remission and failure rates were evaluated at 6 months post-RAI. Statistical analysis was performed using logistic regression and Kaplan-Meier curves. RESULTS Patients receiving 20 mCi RAI demonstrated a significantly higher remission rate compared to the 10-15 mCi group (82.1% vs 66.4%, p = 0.009). Median time to remission was shorter in the 20 mCI group (3 vs 4 months, p = 0.002). Hypothyroidism at 6 months was more prevalent in the 20 mCi group (67% vs 53%, p = 0.03). Larger thyroid size (> 60 g) was associated with treatment failure (p = 0.02). CONCLUSIONS Higher dosage (20 mCi) RAI showed superior efficacy in achieving remission compared to lower dosages (10-15 mCi) in Graves' disease treatment.
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Affiliation(s)
- Wasit Kanokwongnuwat
- Division of Nuclear Medicine, Department of Radiology, Phrapokklao Hospital, No 38, Leab Neon Road, Mueang, Chanthaburi, 22000, Thailand.
| | - Nawarat Penpong
- Division of Endocrinology, Department of Internal Medicine, Phrapokklao Hospital, No 38, Leab Neon Road, Mueang, Chanthaburi, 22000, Thailand
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Dietlein M, Grünwald F, Schmidt M, Kreissl MC, Luster M. [Guideline for Radioiodine Therapy for Benign Thyroid Diseases (6/2022 - AWMF No. 031-003)]. Nuklearmedizin 2024; 63:8-20. [PMID: 37871629 DOI: 10.1055/a-2185-7885] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2023]
Abstract
This version of the guideline for radioiodine therapy of benign thyroid disorders is an update of the version, which was published by the German Society of Nuclear Medicine (Deutsche Gesellschaft für Nuklearmedizin, DGN) in co-ordination with the German Society of Endocrinology (Deutsche Gesellschaft für Endokrinologie, DGE, Sektion Schilddrüse) and the German Society of General- and Visceral-Surgery (Deutsche Gesellschaft für Allgemein- und Viszeralchirurgie, DGAV) in 2015. This guideline was harmonized with the recommendations of the European Association of Nuclear Medicine (EANM). According to the German "Directive on Radiation Protection in Medicine" the physician specialised in nuclear medicine ("Fachkunde in der Therapie mit offenen radioaktiven Stoffen") is responsible for the justification to treat with radioiodine. Therefore, relevant medical indications for radioiodine therapy and alternative therapeutic options are discussed within the guideline. This procedure guideline is developed in the consensus of an expert group. This fulfils the level S1 (first step) within the German classification of Clinical Practice Guidelines.
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Affiliation(s)
- M Dietlein
- Klinik und Poliklinik für Nuklearmedizin des Universitätsklinikums Köln
| | - F Grünwald
- Klinik für Nuklearmedizin des Universitätsklinikums Frankfurt
| | - M Schmidt
- Klinik und Poliklinik für Nuklearmedizin des Universitätsklinikums Köln
| | - M C Kreissl
- Bereich Nuklearmedizin, Klinik für Radiologie und Nuklearmedizin des Universitätsklinikums Magdeburg
| | - M Luster
- Klinik für Nuklearmedizin des Universitätsklinikums Marburg
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Campennì A, Avram AM, Verburg FA, Iakovou I, Hänscheid H, de Keizer B, Petranović Ovčariček P, Giovanella L. The EANM guideline on radioiodine therapy of benign thyroid disease. Eur J Nucl Med Mol Imaging 2023; 50:3324-3348. [PMID: 37395802 PMCID: PMC10542302 DOI: 10.1007/s00259-023-06274-5] [Citation(s) in RCA: 7] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/22/2023] [Accepted: 05/18/2023] [Indexed: 07/04/2023]
Abstract
This document provides the new EANM guideline on radioiodine therapy of benign thyroid disease. Its aim is to guide nuclear medicine physicians, endocrinologists, and practitioners in the selection of patients for radioiodine therapy. Its recommendations on patients' preparation, empiric and dosimetric therapeutic approaches, applied radioiodine activity, radiation protection requirements, and patients follow-up after administration of radioiodine therapy are extensively discussed.
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Affiliation(s)
- Alfredo Campennì
- Department of Biomedical and Dental Sciences and Morpho-Functional Imaging, Unit of Nuclear Medicine, University of Messina, Messina, Italy
| | - Anca M Avram
- Departments of Radiology and Medicine, MetroHealth Hospital, Case Western Reserve University, Cleveland, OH, USA
| | - Frederik A Verburg
- Department of Radiology & Nuclear Medicine, Erasmus MC, Rotterdam, The Netherlands.
| | - Ioannis Iakovou
- Academic Department of Nuclear Medicine, University Hospital AHEPA, School of Medicine, Aristotle University of Thessaloniki, Thessaloniki, Greece
- Academic Department of Nuclear Medicine, General Hospital Papageorgiou, Aristotle University of Thessaloniki, Thessaloniki, Greece
| | - Heribert Hänscheid
- Department of Nuclear Medicine, University Hospital Würzburg, Würzburg, Germany
| | - Bart de Keizer
- Department of Radiology and Nuclear Medicine, University Medical Centre Utrecht, Utrecht, The Netherlands
| | - Petra Petranović Ovčariček
- Department of Oncology and Nuclear Medicine, University Hospital Center Sestre Milosrdnice, Zagreb, Croatia
- School of Medicine, University of Zagreb, Zagreb, Croatia
| | - Luca Giovanella
- Clinic for Nuclear Medicine, Ente Ospedaliero Cantonale, Imaging Institute of Southern Switzerland, Bellinzona, Switzerland
- Clinic for Nuclear Medicine, University Hospital and University of Zurich, Zurich, Switzerland
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Azizi F, Abdi H, Amouzegar A, Habibi Moeini AS. Long-term thionamide antithyroid treatment of Graves' disease. Best Pract Res Clin Endocrinol Metab 2023; 37:101631. [PMID: 35440398 DOI: 10.1016/j.beem.2022.101631] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/02/2022]
Abstract
Thionamide antithyroid drugs (ATD) are the treatment of choice for Graves' hyperthyroidism. The major drawback of ATD treatment for 1-2 years is the relapse of hyperthyroidism in about 50% of patients. Recently, it has been shown that ATD treatment for more than five years is accompanied by long-term remission in majority of patients without additional major side effects in both adults and children. Compared to radioactive iodine therapy, long-term ATD results in more favorable outcomes. This review summarizes the evidence on long-term ATD therapy regarding the remission rate of hyperthyroidism, efficacy and safety, indications and mode of therapy in patients with hyperthyroidism.
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Affiliation(s)
- Fereidoun Azizi
- Endocrine Research Center, Research Institute for Endocrine Sciences, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Hengameh Abdi
- Endocrine Research Center, Research Institute for Endocrine Sciences, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Atieh Amouzegar
- Endocrine Research Center, Research Institute for Endocrine Sciences, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Ali Siamak Habibi Moeini
- Endocrine Research Center, Research Institute for Endocrine Sciences, Shahid Beheshti University of Medical Sciences, Tehran, Iran.
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Muhleman MA, Fahim A, Benefield T, Oldan JD, Khandani AH. One institutions' experience with a true standard 15 mCi dose of I-131 for the treatment of Graves' disease. Nucl Med Commun 2023; 44:49-55. [PMID: 36514928 DOI: 10.1097/mnm.0000000000001633] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
INTRODUCTION Currently, there is a lack of consensus on the fixed dosage of RAI to be administered for this purpose between the main guideline frameworks set forth by the American Thyroid Association (ATA), Society of Nuclear Medicine and Molecular Imaging (SNMMI), European Association of Nuclear Medicine (EANM) and the European Thyroid Association (ETA). In this retrospective study, we will investigate the effectiveness of using a standard dose of 15 mCi ±10% of RAI in the treatment of Graves'. METHODS A retrospective chart review was conducted for the period between 1 May 2014 and 2 September 2020, to identify patients diagnosed with hyperthyroidism due to Graves' disease. The patients were grouped based on outcome and assessed for the efficacy of the dosage of 15 mCi ±10% of RAI in a successful treatment. RESULTS Sixty-seven patients were identified that met the inclusion criteria between 1 May 2014 and 2 September 2020. Of the 67 RAI ablations; 60 patients became hypothyroid [60/67, (89.55%)], 2 euthyroid [2/67, (2.99%)] and 5 remained hyperthyroid [5/67, (7.46%)]. CONCLUSIONS For the treatment of Graves' disease, the use of a standard low dose of 15 mCi ±10% has a high success rate without additional measurements or calculations beyond a standard planar image and 24-h uptake %. The adoption of a standard low dose of 15 mCi of I-131 across institutional guidelines would streamline dosage questions and eliminate the need to determine the weight of the thyroid for calculations in all RAI treatments for hyperthyroidism caused by Graves' disease.
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Affiliation(s)
- Mitchel A Muhleman
- Department of Molecular Imaging and Therapeutics, University of North Carolina School of Medicine
| | - Ali Fahim
- Department of Neurology, University of North Carolina
| | - Thad Benefield
- Epidemiology Research Division, University of North Carolina, Chapel Hill, North Carolina, USA
| | - Jorge D Oldan
- Department of Molecular Imaging and Therapeutics, University of North Carolina School of Medicine
| | - Amir H Khandani
- Department of Molecular Imaging and Therapeutics, University of North Carolina School of Medicine
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Pamnani H, Jindal R, Khare J, Sharma M, Siddiqui A, Wangnoo SK. Observational Study on Outcomes after Radioiodine Ablation in Hyperthyroid Patients. Indian J Endocrinol Metab 2022; 26:149-153. [PMID: 35873945 PMCID: PMC9302425 DOI: 10.4103/ijem.ijem_29_22] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/13/2022] [Revised: 02/12/2022] [Accepted: 03/30/2022] [Indexed: 11/21/2022] Open
Abstract
INTRODUCTION Radio-active Iodine (RAI) is a safe, definitive, and cost-effective modality of treatment that is used as the first line of treatment for Graves' hyperthyroidism by most endocrinologists. Very few reports are available from India, observational follow-up data is needed to determine the meaningful prognostic outcomes of RAI ablation in the Indian population. AIMS To study the outcomes in hyperthyroid patients undergoing RAI ablation. MATERIALS AND METHODS This observational cohort study was conducted at Department of Endocrinology at Indraprastha Apollo Hospital, New Delhi. A total of 82 hyperthyroid patients who underwent RAI ablation between June 2014 to June 2018 were enrolled. RAI dose was calculated arbitrarily in most cases; often by an empirical fixed dose based on the goiter size and RAIU. The patients were reviewed at 1, 3 and 6 months post-RAI ablation. During follow-up, along with a detailed clinical examination, free T4, free T3 and TSH were checked. RESULTS The dose of I-131 varied from 6 mCi to 14 mCi. Most of the patients were given RAI in the dose of 7.1-10 mci. About 63.4% of patients achieved hypothyroidism in 6 months, 6.1% in 1 month, 37.8% in 3 months, and 19.5% in 6 months. Gender, age, etiology of hyperthyroidism, baseline thyroid function, goiter, and ophthalmopathy did not affect outcomes after RAI ablation. Those who were not treated with antithyroid drugs prior to RAI therapy were found to have higher rates of conversion to a hypothyroid state. CONCLUSION RAI can be given safely as the first line of treatment in Graves' disease and antithyroid drug naïve patients respond better to therapy.
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Affiliation(s)
- Harsha Pamnani
- Department of Endocrinology, Peoples College of Medical Sciences and Research Centre, Bhopal, Madhya Pradesh, India
| | - Radhika Jindal
- Department of Endocrinology, Safdarjung Hospital, New Delhi, India
| | - Jaideep Khare
- Department of Endocrinology, Peoples College of Medical Sciences and Research Centre, Bhopal, Madhya Pradesh, India
| | - Monika Sharma
- Consultant Endocrinologist, Venkateshwar Hospital, New Delhi, India
| | - Asim Siddiqui
- Senior Consultant Endocrinologist, Indraprastha Apollo Hospital, New Delhi, India
| | - Subhash K. Wangnoo
- Senior Consultant Endocrinologist, Indraprastha Apollo Hospital, New Delhi, India
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Nuclear medicine therapy of thyroid goiter. Nucl Med Mol Imaging 2022. [DOI: 10.1016/b978-0-12-822960-6.00204-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
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9
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Arora S, Bal C. Is There Any Need for Adjusting 131I Activity for the Treatment of High Turnover Graves' Disease Compared to Normal Turnover Patients? Results from a Retrospective Cohort Study Validated by Propensity Score Analysis. Nucl Med Mol Imaging 2021; 55:15-26. [PMID: 33643485 DOI: 10.1007/s13139-020-00674-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/12/2020] [Revised: 11/11/2020] [Accepted: 11/16/2020] [Indexed: 10/22/2022] Open
Abstract
Purpose To compare 131I-therapy outcomes in high turnover and normal turnover Graves' disease patients and predict optimal first 131I activity for high turnover patients. Methods Retrospective cohort design (1:2) validated by propensity score analysis. Cohort 1, high turnover (2-h RAIU/24-h RAIU ≥ 1), n = 104, and cohort 2, normal turnover (ratio < 1), n = 208, patients were compared for post 131I outcome. The cure was defined as a combined euthyroid and stable hypothyroid state following 131I treatment. Logistic regression analysis was used for identifying prognostic factors. The propensity score was applied; 77 matched pairs (1:1 ratio) of high and normal turnover patients were selected as a validation set. Results First 131I cure rates of 28% in high turnover and 66% in normal turnover groups (p = 0.001) were noted. The therapy cycles (median, 2 vs. 1) and cumulative 131I activity (median, 15 vs. 7 mCi) were required to cure hyperthyroidism in cohort 1 and cohort 2, respectively. Age (> 44 years), higher grade of goitre, and 2-h RAIU (> 37%) were associated with 131I therapy failure. The high turnover patients needed a factor of 1.5-2 times more 131I activity to achieve a similar cure rate compared to the normal turnover patients. The first-dose cure rate was 31% vs. 60% by propensity score analysis (n = 154), no way different (28% vs.66%) from the whole group of 312 patients. Conclusion High turnover Graves' disease patients, if administered standard 131I activity, the outcomes shall be poor. To improve the success rate, 131I activity should be increased by 1.5 to 2 times in the high turnover patients. Supplementary Information The online version contains supplementary material available at 10.1007/s13139-020-00674-3.
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Affiliation(s)
- Saurabh Arora
- Department of Nuclear Medicine, All India Institute of Medical Sciences, New Delhi, 110029 India
| | - Chandrasekhar Bal
- Department of Nuclear Medicine, All India Institute of Medical Sciences, New Delhi, 110029 India
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Piccardo A, Ugolini M, Altrinetti V, Righi S, Fiz F, Foppiani L, Giovanella L. Radioiodine therapy of Graves' disease. THE QUARTERLY JOURNAL OF NUCLEAR MEDICINE AND MOLECULAR IMAGING : OFFICIAL PUBLICATION OF THE ITALIAN ASSOCIATION OF NUCLEAR MEDICINE (AIMN) [AND] THE INTERNATIONAL ASSOCIATION OF RADIOPHARMACOLOGY (IAR), [AND] SECTION OF THE SOCIETY OF RADIOPHARMACEUTICAL CHEMISTRY AND BIOLOGY 2021; 65:132-137. [PMID: 33565844 DOI: 10.23736/s1824-4785.21.03337-9] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
Graves' disease (GD), the most common cause of hyperthyroidism, is an autoimmune disease directly caused by circulating autoantibodies that bind and activate the TSH receptor, inducing metabolic activation of the thyroid gland; this may be associated with important cardiac (atrial fibrillation) and ocular (ophthalmopathy) complications. Treating GD with real curative intent implies the full elimination of the functioning thyroid parenchyma using surgery or radioactive iodine therapy (RAI). RAI has been used in humans with hyperthyroidism since 1941, thanks to the pioneering work of a physician (Dr. Saul Hertz) and a physicist (Dr. Arthur Roberts). The rationale of RAI is based on the effect of radiation of 131I on target cells leading to DNA damage, both directly, through breakage of molecular bonds, and indirectly through the formation of free radicals. In particular, irradiation causes a broad spectrum of cellular damage due to the production of reactive oxygen species and lipid peroxidation of the plasma membrane. Thus, RAI-related cellular death takes place through both apoptosis and necrosis. The aim of this review was to summarize indications, efficacy, safety profile, and dosimetric aspects of RAI treatment in patients affected by GD.
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Affiliation(s)
- Arnoldo Piccardo
- Department of Nuclear Medicine, E.O. Ospedali Galliera, Genoa, Italy -
| | - Martina Ugolini
- Department of Nuclear Medicine, E.O. Ospedali Galliera, Genoa, Italy
| | - Vania Altrinetti
- Department of Nuclear Medicine, E.O. Ospedali Galliera, Genoa, Italy
| | - Sergio Righi
- Department of Medical Physics, E.O. Ospedali Galliera, Genoa, Italy
| | - Francesco Fiz
- Humanitas Clinical and Research Center, Rozzano, Milan, Italy
| | - Luca Foppiani
- Department of Internal Medicine, E.O. Ospedali Galliera, Genoa, Italy
| | - Luca Giovanella
- Clinic of Nuclear Medicine and Molecular Imaging, Imaging Institute of Southern Switzerland, Bellinzona, Switzerland
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Abdi H, Zakavi SR, Azizi F. A Clinical Debate: What Is the Therapeutic Choice for Recurrent Graves' Hyperthyroidism? Int J Endocrinol Metab 2020; 18:e108876. [PMID: 33613682 PMCID: PMC7887460 DOI: 10.5812/ijem.108876] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/31/2020] [Revised: 09/26/2020] [Accepted: 09/29/2020] [Indexed: 11/21/2022] Open
Affiliation(s)
- Hengameh Abdi
- Endocrine Research Center, Research Institute for Endocrine Sciences, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Seyed Rasoul Zakavi
- Nuclear Medicine Research Center, Mashhad University of Medical Sciences, Mashhad, Iran
| | - Fereidoun Azizi
- Endocrine Research Center, Research Institute for Endocrine Sciences, Shahid Beheshti University of Medical Sciences, Tehran, Iran
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Francis N, Francis T, Lazarus JH, Okosieme OE. Current controversies in the management of Graves' hyperthyroidism. Expert Rev Endocrinol Metab 2020; 15:159-169. [PMID: 32315207 DOI: 10.1080/17446651.2020.1754192] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/01/2020] [Accepted: 04/07/2020] [Indexed: 12/12/2022]
Abstract
Introduction: The management of Graves' disease centers on the use of effective and well-established therapies, namely thionamide antithyroid drugs, radioactive iodine, and thyroidectomy. Optimal treatment strategies are however controversial and vary significantly across centers.Areas covered: This review addresses specific controversies in Graves' disease management including the choice of primary therapy, the approach to women planning pregnancy, and optimal strategies for antithyroid drug and radioiodine therapy.Expert opinion: Important considerations in choosing therapy include treatment efficacy, adverse effects, patient convenience, and resource settings. Recent data suggest that early and effective control of hyperthyroidism is key to improving cardiovascular morbidity and mortality. Studies addressing cancer risk in radioiodine-treated patients face methodological challenges and require clarification in appropriately designed studies. Remission rates with antithyroid drugs are comparable when thionamides are used alone (titration-regimen) or in combination with levothyroxine (block and replace) and can be optimized by extending treatment for at least 12-18 months. Fixed and calculated radioiodine activity regimens are both effective but entail a trade-off between convenience and precision in the administered activity. Optimal preconception strategies are still evolving but ablative treatment in advance of pregnancy offers the most pragmatic means of reducing adverse effects of hyperthyroidism in subsequent pregnancy.
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Affiliation(s)
- Niroshan Francis
- Endocrinology and Diabetes Department, Prince Charles Hospital, Cwm Taf University Health Board, Merthyr Tydfil, UK
| | - Thanuya Francis
- Endocrinology and Diabetes Department, Prince Charles Hospital, Cwm Taf University Health Board, Merthyr Tydfil, UK
| | - John H Lazarus
- Thyroid Research Group, School of Medicine, Cardiff University, Cardiff, UK
| | - Onyebuchi E Okosieme
- Endocrinology and Diabetes Department, Prince Charles Hospital, Cwm Taf University Health Board, Merthyr Tydfil, UK
- Thyroid Research Group, School of Medicine, Cardiff University, Cardiff, UK
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13
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Radioiodine Therapy for Benign Thyroid Disease. Clin Nucl Med 2020. [DOI: 10.1007/978-3-030-39457-8_28] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/18/2023]
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Thou S, Vinjamuri S. The relationship between thyroid eye disease and radioiodine treatment. Nucl Med Commun 2019; 40:194-198. [DOI: 10.1097/mnm.0000000000000965] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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Kahaly GJ, Bartalena L, Hegedüs L, Leenhardt L, Poppe K, Pearce SH. 2018 European Thyroid Association Guideline for the Management of Graves' Hyperthyroidism. Eur Thyroid J 2018; 7:167-186. [PMID: 30283735 PMCID: PMC6140607 DOI: 10.1159/000490384] [Citation(s) in RCA: 433] [Impact Index Per Article: 72.2] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/26/2018] [Revised: 05/24/2018] [Indexed: 12/12/2022] Open
Abstract
Graves' disease (GD) is a systemic autoimmune disorder characterized by the infiltration of thyroid antigen-specific T cells into thyroid-stimulating hormone receptor (TSH-R)-expressing tissues. Stimulatory autoantibodies (Ab) in GD activate the TSH-R leading to thyroid hyperplasia and unregulated thyroid hormone production and secretion. Diagnosis of GD is straightforward in a patient with biochemically confirmed thyrotoxicosis, positive TSH-R-Ab, a hypervascular and hypoechoic thyroid gland (ultrasound), and associated orbitopathy. In GD, measurement of TSH-R-Ab is recommended for an accurate diagnosis/differential diagnosis, prior to stopping antithyroid drug (ATD) treatment and during pregnancy. Graves' hyperthyroidism is treated by decreasing thyroid hormone synthesis with the use of ATD, or by reducing the amount of thyroid tissue with radioactive iodine (RAI) treatment or total thyroidectomy. Patients with newly diagnosed Graves' hyperthyroidism are usually medically treated for 12-18 months with methimazole (MMI) as the preferred drug. In children with GD, a 24- to 36-month course of MMI is recommended. Patients with persistently high TSH-R-Ab at 12-18 months can continue MMI treatment, repeating the TSH-R-Ab measurement after an additional 12 months, or opt for therapy with RAI or thyroidectomy. Women treated with MMI should be switched to propylthiouracil when planning pregnancy and during the first trimester of pregnancy. If a patient relapses after completing a course of ATD, definitive treatment is recommended; however, continued long-term low-dose MMI can be considered. Thyroidectomy should be performed by an experienced high-volume thyroid surgeon. RAI is contraindicated in Graves' patients with active/severe orbitopathy, and steroid prophylaxis is warranted in Graves' patients with mild/active orbitopathy receiving RAI.
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Affiliation(s)
- George J. Kahaly
- Department of Medicine I, Johannes Gutenberg University (JGU) Medical Center, Mainz, Germany
- *Prof. George J. Kahaly, JGU Medical Center, DE-55101 Mainz (Germany), E-Mail
| | - Luigi Bartalena
- Department of Medicine and Surgery, University of Insubria, Varese, Italy
| | - Lazlo Hegedüs
- Department of Endocrinology and Metabolism, Odense University Hospital, Odense, Denmark
| | - Laurence Leenhardt
- Thyroid and Endocrine Tumors Unit, Pitié Salpêtrière Hospital, Sorbonne University, Paris, France
| | - Kris Poppe
- Endocrine Unit, CHU Saint-Pierre, Université Libre de Bruxelles (ULB), Brussels, Belgium
| | - Simon H. Pearce
- Department of Endocrinology, Institute of Genetic Medicine, Newcastle University, Newcastle upon Tyne, United Kingdom
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Tabuenca-Dopico O, Boente-Varela R, Lamas-Ferreiro J. Study of factors that influence the outcome of 131 I treatment in hyperthyroidism secondary to nodular goitre. Rev Esp Med Nucl Imagen Mol 2017. [DOI: 10.1016/j.remnie.2017.09.003] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/15/2023]
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Tabuenca-Dopico O, Boente-Varela R, Lamas-Ferreiro JL. Study of factors that influence the outcome of 131I treatment in hyperthyroidism secondary to nodular goitre. Rev Esp Med Nucl Imagen Mol 2017; 36:356-361. [PMID: 28619420 DOI: 10.1016/j.remn.2017.03.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/28/2016] [Revised: 03/08/2017] [Accepted: 03/27/2017] [Indexed: 10/19/2022]
Abstract
OBJECTIVE To assess the outcome after 131I treatment in patients with multinodular (MNG) and nodular toxic goitre (NTG) according to the administered dose and other factors related to the patient, pathology, or previous treatments. MATERIAL AND METHODS A retrospective study was conducted on 108 patients (67 MNG and 41 NTG) treated in our department, with a follow-up period of at least 2 years. Development of hypothyroidism and treatment failure were evaluated along with their relationship with the administered dose and other factors such as age, sex, grade of hyperthyroidism, type of goitre, presence of autoimmunity, or previous antithyroid medication. RESULTS More than one-third (36.9%) of MNG patients, and even higher proportion of NTG patients (51.2%) developed non-transient hypothyroidism, particularly in those receiving 740MBq (66.7%). No relationship was found with any other variable. The development of early hypothyroidism (before one year) was also not related to any variable. Treatment failure was not related to the dose, but in MNG there was a relationship with male gender, presence of autoimmunity, or previous antithyroid drugs use. CONCLUSIONS The high rate of hypothyroidism obtained with high doses of 131I in hyperthyroidism secondary to nodular goitre treatment suggests that lower doses might be sufficient to control the disease without an increase in treatment failures. Only patients with positive autoimmunity, in previous anti-thyroid medication, and perhaps male gender in MNG might be given higher doses, as the failure rate increases, but further studies are required.
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Dietlein M, Grünwald F, Schmidt M, Schneider P, Verburg FA, Luster M. [Radioiodine therapy for benign thyroid diseases (version 5). German Guideline]. Nuklearmedizin 2016; 55:213-220. [PMID: 27922153 DOI: 10.3413/nukmed-0823-16-04] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/30/2016] [Accepted: 05/02/2016] [Indexed: 01/18/2023]
Abstract
The version 5 of the guideline for radioiodine therapy of benign thyroid disorders is an update of the version 4, which was published by the German Society of Nuclear Medicine (Deutsche Gesellschaft für Nuklearmedizin, DGN) in co-ordination with the German Society of Endocrinology (Deutsche Gesellschaft für Endokrinologie, DGE, Sektion Schilddrüse) and the German Society of General- and Visceral-Surgery (Deutsche Gesellschaft für Allgemein- und Viszeralchirurgie, DGAV) in 2007. This guideline was harmonized with the recommendations of the European Association of Nuclear Medicine (EANM). According to the German "Directive on Radiation Protection in Medicine" the physician specialised in nuclear medicine ("Fachkunde in der Therapie mit offenen radioaktiven Stoffen") is responsible for the justfication to treat with radioiodine. Therefore, relevant medical indications for radioiodine therapy and alternative therapeutic options are discussed within the guideline. This procedure guideline is developed in the consensus of a representative expert group. This fulfils the level S1 (first step) within the German classification of Clinical Practice Guidelines.
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Affiliation(s)
- Markus Dietlein
- Prof. Dr. med. Markus Dietlein, Klinik und Poliklinik für Nuklearmedizin, Universitätsklinikum Köln, Kerpener Str. 62, 50937 Köln, Tel. 02 21/478 50 24, Fax 02 21/47 88 90 85, E-Mail:
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Ross DS, Burch HB, Cooper DS, Greenlee MC, Laurberg P, Maia AL, Rivkees SA, Samuels M, Sosa JA, Stan MN, Walter MA. 2016 American Thyroid Association Guidelines for Diagnosis and Management of Hyperthyroidism and Other Causes of Thyrotoxicosis. Thyroid 2016; 26:1343-1421. [PMID: 27521067 DOI: 10.1089/thy.2016.0229] [Citation(s) in RCA: 1338] [Impact Index Per Article: 167.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
BACKGROUND Thyrotoxicosis has multiple etiologies, manifestations, and potential therapies. Appropriate treatment requires an accurate diagnosis and is influenced by coexisting medical conditions and patient preference. This document describes evidence-based clinical guidelines for the management of thyrotoxicosis that would be useful to generalist and subspecialty physicians and others providing care for patients with this condition. METHODS The American Thyroid Association (ATA) previously cosponsored guidelines for the management of thyrotoxicosis that were published in 2011. Considerable new literature has been published since then, and the ATA felt updated evidence-based guidelines were needed. The association assembled a task force of expert clinicians who authored this report. They examined relevant literature using a systematic PubMed search supplemented with additional published materials. An evidence-based medicine approach that incorporated the knowledge and experience of the panel was used to update the 2011 text and recommendations. The strength of the recommendations and the quality of evidence supporting them were rated according to the approach recommended by the Grading of Recommendations, Assessment, Development, and Evaluation Group. RESULTS Clinical topics addressed include the initial evaluation and management of thyrotoxicosis; management of Graves' hyperthyroidism using radioactive iodine, antithyroid drugs, or surgery; management of toxic multinodular goiter or toxic adenoma using radioactive iodine or surgery; Graves' disease in children, adolescents, or pregnant patients; subclinical hyperthyroidism; hyperthyroidism in patients with Graves' orbitopathy; and management of other miscellaneous causes of thyrotoxicosis. New paradigms since publication of the 2011 guidelines are presented for the evaluation of the etiology of thyrotoxicosis, the management of Graves' hyperthyroidism with antithyroid drugs, the management of pregnant hyperthyroid patients, and the preparation of patients for thyroid surgery. The sections on less common causes of thyrotoxicosis have been expanded. CONCLUSIONS One hundred twenty-four evidence-based recommendations were developed to aid in the care of patients with thyrotoxicosis and to share what the task force believes is current, rational, and optimal medical practice.
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Affiliation(s)
- Douglas S Ross
- 1 Massachusetts General Hospital , Boston, Massachusetts
| | - Henry B Burch
- 2 Endocrinology - Metabolic Service, Walter Reed National Military Medical Center , Bethesda, Maryland
| | - David S Cooper
- 3 Division of Endocrinology, Diabetes, and Metabolism, The Johns Hopkins University School of Medicine , Baltimore, Maryland
| | | | - Peter Laurberg
- 5 Departments of Clinical Medicine and Endocrinology, Aalborg University and Aalborg University Hospital , Aalborg, Denmark
| | - Ana Luiza Maia
- 6 Thyroid Section, Hospital de Clinicas de Porto Alegre, Federal University of Rio Grande do Sul , Porto Alegre, Brazil
| | - Scott A Rivkees
- 7 Pediatrics - Chairman's Office, University of Florida College of Medicine , Gainesville, Florida
| | - Mary Samuels
- 8 Division of Endocrinology, Diabetes and Clinical Nutrition, Oregon Health & Science University , Portland, Oregon
| | - Julie Ann Sosa
- 9 Section of Endocrine Surgery, Duke University School of Medicine , Durham, North Carolina
| | - Marius N Stan
- 10 Division of Endocrinology, Mayo Clinic , Rochester, Minnesota
| | - Martin A Walter
- 11 Institute of Nuclear Medicine, University Hospital Bern , Switzerland
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Gharib H, Papini E, Garber JR, Duick DS, Harrell RM, Hegedüs L, Paschke R, Valcavi R, Vitti P. AMERICAN ASSOCIATION OF CLINICAL ENDOCRINOLOGISTS, AMERICAN COLLEGE OF ENDOCRINOLOGY, AND ASSOCIAZIONE MEDICI ENDOCRINOLOGI MEDICAL GUIDELINES FOR CLINICAL PRACTICE FOR THE DIAGNOSIS AND MANAGEMENT OF THYROID NODULES--2016 UPDATE. Endocr Pract 2016; 22:622-39. [PMID: 27167915 DOI: 10.4158/ep161208.gl] [Citation(s) in RCA: 702] [Impact Index Per Article: 87.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
Thyroid nodules are detected in up to 50 to 60% of healthy subjects. Most nodules do not cause clinically significant symptoms, and as a result, the main challenge in their management is to rule out malignancy, with ultrasonography (US) and fine-needle aspiration (FNA) biopsy serving as diagnostic cornerstones. The key issues discussed in these guidelines are as follows: (1) US-based categorization of the malignancy risk and indications for US-guided FNA (henceforth, FNA), (2) cytologic classification of FNA samples, (3) the roles of immunocytochemistry and molecular testing applied to thyroid FNA, (4) therapeutic options, and (5) follow-up strategy. Thyroid nodule management during pregnancy and in children are also addressed. On the basis of US features, thyroid nodules may be categorized into 3 groups: low-, intermediate-and high-malignancy risk. FNA should be considered for nodules ≤10 mm diameter only when suspicious US signs are present, while nodules ≤5 mm should be monitored rather than biopsied. A classification scheme of 5 categories (nondiagnostic, benign, indeterminate, suspicious for malignancy, or malignant) is recommended for the cytologic report. Indeterminate lesions are further subdivided into 2 subclasses to more accurately stratify the risk of malignancy. At present, no single cytochemical or genetic marker can definitely rule out malignancy in indeterminate nodules. Nevertheless, these tools should be considered together with clinical data, US signs, elastographic pattern, or results of other imaging techniques to improve the management of these lesions. Most thyroid nodules do not require any treatment, and levothyroxine (LT4) suppressive therapy is not recommended. Percutaneous ethanol injection (PEI) should be the first-line treatment option for relapsing, benign cystic lesions, while US-guided thermal ablation treatments may be considered for solid or mixed symptomatic benign thyroid nodules. Surgery remains the treatment of choice for malignant or suspicious nodules. The present document updates previous guidelines released in 2006 and 2010 by the American Association of Clinical Endocrinologists (AACE), American College of Endocrinology (ACE) and Associazione Medici Endocrinologi (AME).
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Zakavi SR, Khazaei G, Sadeghi R, Ayati N, Davachi B, Bonakdaran S, Jabbari Nooghabi M, Moosavi Z. Methimazole discontinuation before radioiodine therapy in patients with Graves' disease. Nucl Med Commun 2015; 36:1202-7. [PMID: 26426965 DOI: 10.1097/mnm.0000000000000384] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
INTRODUCTION Although radioiodine therapy (RIT) has been used for the treatment of hyperthyroidism for many decades, there is no consensus on the optimal time of methimazole (MMI) discontinuation before RIT. The aim of this clinical trial is to study the effect of three different time points of MMI discontinuation on response to RIT. METHOD AND PATIENTS Overall, 151 patients (18-65 years old), with Graves' disease who were taking MMI and referred to I-131 therapy, were consecutively assigned to one of three groups, and MMI was discontinued for 24-48, 48.1-72, and 72.1-168 h in group, 1, 2, and 3, respectively. Radioiodine uptake was measured in all patients and the radioiodine dose was calculated according to the Quimby formula to deliver 7.4 MBq of I-131 per gram of thyroid weight. Response to RIT was assessed at 1, 3, 6, and 12 months after RIT. RESULTS A total of 102 women and 49 men were included in the study. The mean administered dose of I-131 was 362.9±188.7 MBq (9.8±5.1 mCi) and the mean time to response for radioiodine was 4.1±3.6 months. There was no significant difference between the three groups in age, thyroid weight, anti-TPO level, radioactive iodine uptake level, and radioiodine dose (P>0.1). Response to RIT at 1, 3, 6, and 12 months after administration was also not different between the three groups (P>0.57). CONCLUSION No difference was found in the response to treatment between patients with MMI discontinuation for 24-48, 48.1-72, and 72.1-96 h before RIT. Shorter discontinuation of MMI before RIT may be preferable in most patients. Video Abstract: http://links.lww.com/NMC/A39.
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Affiliation(s)
- Seyed R Zakavi
- aNuclear Medicine Research Center bEndocrine Research Center cRadiology Department, Ghaem Hospital dSurgical Oncology Research Center, Imam Reza Hospital, Faculty of Medicine, Mashhad University of Medical Sciences eDepartment of Statistics, Faculty of Mathematical Sciences, Ferdowsi University of Mashhad, Mashhad, Iran
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Shivaprasad C, Prasanna Kumar KM. Long-term carbimazole pretreatment reduces the efficacy of radioiodine therapy. Indian J Endocrinol Metab 2015; 19:84-88. [PMID: 25593832 PMCID: PMC4287787 DOI: 10.4103/2230-8210.146865] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/28/2022] Open
Abstract
INTRODUCTION Data from several studies suggest that pretreatment with antithyroid drugs (ATD) before (131)I increases the risk of treatment failure. This effect has been demonstrated more consistently with propylthiouracil than with carbimazole (CMZ) or methimazole (MMI). Men with Graves' disease (GD) have a lower rate of remission with (131)I compared to women and the impact of long-term ATD pretreatment on the success of (131)I is unknown. The objective of our study was to compare the efficacy of fixed doses of radioiodine between patients with and without long-term CMZ pretreatment. MATERIALS AND METHODS We performed a retrospective study on 335 male patients with GD treated with (131)I from 1998 to 2008. 148 patients had been pretreated with CMZ, and the remaining 187 patients received (131)I without pretreatment. We compared the success rate of a single dose of (131)I, between patients with and without long-term CMZ pretreatment. RESULTS The success rate of a single dose of (131)I was significantly higher in patients without pretreatment than in patients who were pretreated with CMZ (91.4% vs. 82.3%, P = 0.01). The rate of hypothyroidism in the first 6 months after (131)I therapy was significantly higher in patients without pretreatment (55.1% vs. 44.6%, P = 0.05). There was also a trend for higher cumulative rate of hypothyroidism at last follow-up in nonpretreated patients (78.1% vs. 69.7%). CONCLUSION Male patients with Graves' hyperthyroidism pretreated with CMZ have lower efficacy with 131I therapy compared to nonpretreated patients. CMZ pretreatment given for a prolonged period reduces the efficacy of (131)I therapy.
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Affiliation(s)
- C Shivaprasad
- Department of Endocrinology and Metabolism, Vydehi Institute of Medical Sciences and Research Centre, Bengaluru, Karnataka, India
| | - K M Prasanna Kumar
- Department of Endocrinology and Metabolism, Bangalore Diabetes Hospital, CDEC, Bengaluru, Karnataka, India
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Cepková J, Horáček J, Vižďa J, Doležal J. Radioiodine treatment of Graves' disease - dose/response analysis. ACTA MEDICA (HRADEC KRÁLOVÉ) 2014; 57:49-55. [PMID: 25257150 DOI: 10.14712/18059694.2014.39] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
Abstract
The clinical outcome of 153 Graves' disease patients treated with a wide dose range of radioactive iodine-131 (RAI) was analyzed retrospectively. Six to nine months after the first dose of RAI 60 patients (39%) were hypothyroid (or rather thyroxine-substituted) and 26 (17%) were euthyroid, while 67 patients (44%) did not respond properly: in 32 (21%) their antithyroid drug (ATD) dose could be reduced but not withdrawn (partial response) and 35 (23%) remained hyperthyroid or the same dose of ATD was necessary (no response). The outcome did not correspond significantly to the administered activity of RAI (medians 259, 259, 222, and 259 MBq for hypothyroid, euthyroid, partial, and no response subgroups, respectively), or the activity retained in the gland at 24 h (medians 127, 105, 143, and 152 MBq). The effect was, however, clearly, and in a stepwise pattern, dependent on initial thyroid volume (17, 26, 33 and 35 ml, P < 0.001) or activity per gram tissue retained at 24 h (6.02, 4.95, 4.75, and 4.44 MBq/g, P = 0.002). Also, higher residual level of thyrotoxicosis at the time of RAI treatment was connected with worse outcome. The dose-dependency of outcome was further analyzed. When our sample was divided into tertiles, according to the adjusted dose, the same modest success rates (47%) were seen in the lower and middle tertiles. However, doses higher than 5.88 MBq/g (the upper tertile) resulted in success rate of 75%. Finer division into decils has shown a threshold-like increase in cure rate between the 7th and the 8th decil. In the first 7 decils (doses ≤ 6 MBq/g) the complete response rate was 45 to 50%, in the 8th decil (6.0 to 7.8~MBq/g) it rose to 80% and was not further increased with increasing dose. Direct comparison of higher (> 6 MBq/g, cure rate 80%) and lower (≤ 6 MBq/g, cure rate 46%) doses gave highly significant difference (P < 0.001). With our dosing range we found a dose-dependent clinical outcome that suggests an optimum delivered dose near 6.5 MBq/g, resulting in successful treatment of ca 80% patients.
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Affiliation(s)
- Jitka Cepková
- University Hospital Hradec Králové, Charles University in Prague, Faculty of Medicine in Hradec Králové, Czech Republic: 4th Department of Internal Medicine - Hematology
| | - Jiří Horáček
- University Hospital Hradec Králové, Charles University in Prague, Faculty of Medicine in Hradec Králové, Czech Republic: 4th Department of Internal Medicine - Hematology.
| | - Jaroslav Vižďa
- University Hospital Hradec Králové, Charles University in Prague, Faculty of Medicine in Hradec Králové, Czech Republic: Department of Nuclear Medicine
| | - Jiří Doležal
- University Hospital Hradec Králové, Charles University in Prague, Faculty of Medicine in Hradec Králové, Czech Republic: Department of Nuclear Medicine
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Karyampudi A, Hamide A, Halanaik D, Sahoo JP, Kamalanathan S. Radioiodine therapy in patients with Graves' disease and the effects of prior carbimazole therapy. Indian J Endocrinol Metab 2014; 18:688-693. [PMID: 25285287 PMCID: PMC4171893 DOI: 10.4103/2230-8210.139234] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
UNLABELLED The use of radioiodine as the first line of treatment in Graves' disease is restricted in India because of its limited availability and an unrealistic risk perception associated with it. Additionally, the effectiveness of radioiodine ablation in Graves' disease is influenced by many factors. Prior medical antithyroid therapy is one such important factor. AIMS To analyze the efficacy of low dose radioiodine therapy (5 mCi) in treatment of naive patients of Graves' disease in comparison to that in which it was already primed with an antithyroid drug, carbimazole. SETTINGS AND DESIGN A non-randomized, interventional study conducted in the Department of Medicine and Endocrinology of a tertiary care institute in South India. MATERIALS AND METHODS The study had two groups; Group A (36 treatment naive, uncomplicated Graves' disease patients) and B (34 Graves' disease patients on carbimazole prior to radioiodine therapy). Both groups had baseline clinical, biochemical evaluation and were reassessed at 3 and 6 months for evaluating the clinical status for possible documentation of cure. RESULTS The cure rate was 61.1% in drug naive group and 58.8% in pretreated group at 6 months following radioiodine (P = 0.845). Higher baseline 999m technicium (99m Tc) uptake, male gender, BMI and higher baseline free thyroxine (fT4) level predicted treatment failure following radioiodine therapy. CONCLUSIONS Administration of carbimazole prior to low dose radioiodine therapy does not alter the efficacy of radioiodine. Low fixed dose (5 mCi) of radioactive iodine may be a safe and effective primary therapeutic option in Graves' disease patients pretreated with antithyroid drugs.
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Affiliation(s)
- Arun Karyampudi
- Department of Medicine, Jawaharlal Institute of Post-graduate Medical Education and Research, Puducherry, India
| | - Abdoul Hamide
- Department of Medicine, Jawaharlal Institute of Post-graduate Medical Education and Research, Puducherry, India
| | - Dhanapathi Halanaik
- Department of Nuclear Medicine, Jawaharlal Institute of Post-graduate Medical Education and Research, Puducherry, India
| | - Jaya Prakash Sahoo
- Department of Endocrinology, Jawaharlal Institute of Post-graduate Medical Education and Research, Puducherry, India
| | - Sadishkumar Kamalanathan
- Department of Endocrinology, Jawaharlal Institute of Post-graduate Medical Education and Research, Puducherry, India
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Abstract
For treatment of benign nodular goitre the choice usually stands between surgery and (131)I therapy. (131)I therapy, used for 30 years for this condition, leads to a goitre volume reduction of 35-50% within 1-2 years. However, this treatment has limited efficacy if the thyroid (131)I uptake is low or if the goitre is large. Recombinant human TSH (rhTSH)-stimulated (131)I therapy significantly improves goitre reduction, as compared with conventional (131)I therapy without pre-stimulation, and adverse effects are few with rhTSH doses of 0.1 mg or lower. RhTSH-stimulated (131)I therapy reduces the need for additional therapy due to insufficient goitre reduction, but the price is a higher rate of hypothyroidism. Another approach with rhTSH-stimulation is to reduce the administered (131)I activity by a factor that equals the increase in the thyroid (131)I uptake. Using this approach, radiation exposure is considerably reduced while the goitre reduction is similar to that obtained with conventional (131)I therapy.
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Affiliation(s)
- Steen Joop Bonnema
- Department of Endocrinology, Odense University Hospital, DK-5000 Odense C, Denmark.
| | - Søren Fast
- Department of ENT Head & Neck Surgery, Hospital Lillebaelt, DK-7000 Vejle, Denmark.
| | - Laszlo Hegedüs
- Department of Endocrinology, Odense University Hospital, DK-5000 Odense C, Denmark.
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Bonnema SJ, Hegedüs L. Radioiodine therapy in benign thyroid diseases: effects, side effects, and factors affecting therapeutic outcome. Endocr Rev 2012; 33:920-80. [PMID: 22961916 DOI: 10.1210/er.2012-1030] [Citation(s) in RCA: 160] [Impact Index Per Article: 13.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/18/2023]
Abstract
Radioiodine ((131)I) therapy of benign thyroid diseases was introduced 70 yr ago, and the patients treated since then are probably numbered in the millions. Fifty to 90% of hyperthyroid patients are cured within 1 yr after (131)I therapy. With longer follow-up, permanent hypothyroidism seems inevitable in Graves' disease, whereas this risk is much lower when treating toxic nodular goiter. The side effect causing most concern is the potential induction of ophthalmopathy in predisposed individuals. The response to (131)I therapy is to some extent related to the radiation dose. However, calculation of an exact thyroid dose is error-prone due to imprecise measurement of the (131)I biokinetics, and the importance of internal dosimetric factors, such as the thyroid follicle size, is probably underestimated. Besides these obstacles, several potential confounders interfere with the efficacy of (131)I therapy, and they may even interact mutually and counteract each other. Numerous studies have evaluated the effect of (131)I therapy, but results have been conflicting due to differences in design, sample size, patient selection, and dose calculation. It seems clear that no single factor reliably predicts the outcome from (131)I therapy. The individual radiosensitivity, still poorly defined and impossible to quantify, may be a major determinant of the outcome from (131)I therapy. Above all, the impact of (131)I therapy relies on the iodine-concentrating ability of the thyroid gland. The thyroid (131)I uptake (or retention) can be stimulated in several ways, including dietary iodine restriction and use of lithium. In particular, recombinant human thyrotropin has gained interest because this compound significantly amplifies the effect of (131)I therapy in patients with nontoxic nodular goiter.
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Affiliation(s)
- Steen Joop Bonnema
- Department of Endocrinology, Odense University Hospital, DK-5000 Odense C, Denmark.
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Abstract
All forms of thyroid diseases are much more frequently observed in women than men, although the reasons are still not completely elucidated.Hyperthyroidism is defined by elevated circulating free thyroid hormones. The prevalence is about 2 % in women and 0.2 % in men. The most frequent causes are various forms of thyroid autonomy in elderly women and Graves' disease, which occurs mostly in younger women.Hypothyroidism is defined by a lack of thyroid hormones. It is a common endocrine disorder caused by autoimmune thyroiditis (Hashimoto thyroiditis), iodine deficiency or following surgery or radioiodine therapy. Thyroxine requirements depend on fat-free mass and are, therefore, somewhat higher in males who are more often undersubstituted. In pregnancy lower TSH-reference ranges have to be considered and thyroid function should be monitored throughout pregnancy to avoid harm to the foetus caused by maternal thyroid dysfunctions. If overtreated women more often feature fractures, whereas males more often develop atrial fibrillation.
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Affiliation(s)
- Alois Gessl
- Department of Internal Medicine III, Medical University Of Vienna, Vienna, Austria
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Bonnema SJ, Grupe P, Boel-Jørgensen H, Brix TH, Hegedüs L. A randomized trial evaluating a block-replacement regimen during radioiodine therapy. Eur J Clin Invest 2011; 41:693-702. [PMID: 21175612 DOI: 10.1111/j.1365-2362.2010.02452.x] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
BACKGROUND Lack of consensus regarding the antithyroid drug regimen in relation to radioiodine ((131) I) therapy of hyperthyroidism prompted this randomized trial comparing two strategies. DESIGN Patients with Graves' disease (GD, n = 51) or toxic nodular goitre (TNG, n = 49) were randomized to (131) I either 8 days following discontinuation of methimazole (-BRT, n = 52, median dose: 5 mg) or while on a continuous block-replacement regimen (+BRT, n = 48, median dose 15 mg methimazole and 100 μg levothyroxine). results: Patients in the +BRT group required more radioactivity. In this group, thyroid function did not change in the early post (131) I period, while serum-free T3 index was higher in the -BRT group (P < 0·05). One year posttherapy, the fraction of cured patients (euthyroid or hypothyroid) was 48% and 61% in the +BRT and -BRT group, respectively (P = 0·014 unadjusted; P = 0·004 adjusted), but the outcome depended on the type of disease. In GD, treatment failure in the +BRT group correlated positively with the 24-h thyroid (131) I uptake (P = 0·017), while no correlations existed in the -BRT group. In addition to +BRT allocation, patients with TNG were at higher risk of treatment failure with lower thyroid radiation doses (P = 0·048), higher doses of methimazole (P = 0·026) and lower levels of serum TSH (P = 0·009). CONCLUSIONS A continuous block-replacement regimen results in a stable thyroid function during (131) I therapy but is hampered by the higher amounts of radioactivity required. The study demonstrates that the outcome in GD is highly unpredictable, while treatment failure in patients with TNG is correlated with a number of factors.
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Affiliation(s)
- Steen J Bonnema
- Department of Endocrinology, Odense University Hospital, Denmark.
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Kahaly GJ, Bartalena L, Hegedüs L. The American Thyroid Association/American Association of Clinical Endocrinologists guidelines for hyperthyroidism and other causes of thyrotoxicosis: a European perspective. Thyroid 2011; 21:585-91. [PMID: 21663420 DOI: 10.1089/thy.2011.2106.ed3] [Citation(s) in RCA: 46] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
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Gharib H, Papini E, Paschke R, Duick DS, Valcavi R, Hegedüs L, Vitti P. American Association of Clinical Endocrinologists, Associazione Medici Endocrinologi, and EuropeanThyroid Association Medical Guidelines for Clinical Practice for the Diagnosis and Management of Thyroid Nodules. Endocr Pract 2010; 16 Suppl 1:1-43. [PMID: 20497938 DOI: 10.4158/10024.gl] [Citation(s) in RCA: 362] [Impact Index Per Article: 25.9] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/27/2023]
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Stokkel MPM, Handkiewicz Junak D, Lassmann M, Dietlein M, Luster M. EANM procedure guidelines for therapy of benign thyroid disease. Eur J Nucl Med Mol Imaging 2010; 37:2218-28. [DOI: 10.1007/s00259-010-1536-8] [Citation(s) in RCA: 131] [Impact Index Per Article: 9.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/16/2010] [Accepted: 06/17/2010] [Indexed: 01/18/2023]
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Oszukowska L, Knapska-Kucharska M, Lewiński A. Effects of drugs on the efficacy of radioiodine (|) therapy in hyperthyroid patients. Arch Med Sci 2010; 6:4-10. [PMID: 22371713 PMCID: PMC3278936 DOI: 10.5114/aoms.2010.13499] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/19/2008] [Revised: 01/08/2009] [Accepted: 02/08/2009] [Indexed: 11/30/2022] Open
Abstract
The treatment of hyperthyroidism is targeted at reducing the production of thyroid hormones by inhibiting their synthesis or suppressing their release, as well as by controlling their influence on peripheral tissue (conservative therapy, medical treatment). Radical treatment includes surgical intervention to reduce the volume of thyroid tissue or damage of the mechanisms of thyroid hormone synthesis by radioiodine ((131)|) administration. Radioiodine ((131)|) is a reactor radionuclide, produced as a result of uranium decomposition and emission of β and γ radiation. The therapeutic effects of the isotope are obtained by the emission of β radiation. In the paper, the effects of administered drugs (antithyroid, glucocorticosteroids, lithium carbonate, inorganic iodine, β-blockers) on the final outcome of radioiodine therapy in patients with hyperthyroidism are discussed.
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Affiliation(s)
- Lidia Oszukowska
- Department of Nuclear Medicine and Oncological Endocrinology, Medical University of Lodz, Poland
| | | | - Andrzej Lewiński
- Department of Endocrinology and Metabolic Diseases, Medical University of Lodz, Poland
- Polish Mother's Memorial Hospital – Research Institute, Lodz, Poland
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Giusti M, Caputo M, Calamia I, Bagnara M, Ceresola E, Schiavo M, Mussap M, Ferone D, Minuto F, Bagnasco M. Long-term outcome of low-activity radioiodine administration preceded by adjuvant recombinant human TSH pretreatment in elderly subjects with multinodular goiter. Thyroid Res 2009; 2:6. [PMID: 19566933 PMCID: PMC2713215 DOI: 10.1186/1756-6614-2-6] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/14/2009] [Accepted: 06/30/2009] [Indexed: 11/13/2022] Open
Abstract
Background Large multinodular goiter (MNG) in elderly people is a common finding which can require intervention. The long-term effect of radioiodine therapy on thyroid volume (TV) and function after recombinant human (rh) TSH pre-treatment was evaluated. Methods After baseline evaluation, 40 subjects over 60 years old with a large MNG were treated with 131I up to the activity of 600 MBq. Nineteen patients were pretreated with rhTSH (0.1 mg on 2 consecutive days; group 1) while 21 subjects underwent treatment without rhTSH pretreatment (group 2). TV was monitored every 6–12 months by ultrasonography. The median follow-up period was 36 months. Results At the baseline, the groups matched in terms of TV, 24-h radioiodine uptake (RAIU), urinary iodine and neck complaints. The number of subjects pretreated with anti-thyroid drugs was significantly (P = 0.01) greater in group 2 than in group 1; TSH was more suppressed (P = 0.003) and f-T3 was more elevated (P = 0.005) in group 2 than in group 1 patients. RhTSH increased 24-h RAIU in group 1 up to the baseline level observed in group 2. The 131I activity administered was similar in both groups. Adverse events were slight and similar in both groups. A permanent post-radioiodine toxic condition was reported only in 2 patients in group 2. After radioiodine therapy, hypothyroidism was observed in significantly more group 1 patients than group 2 patients (P = 0.002). While TV was reduced in both groups, the percentage TV reduction recorded at the last examination was significantly higher (P = 0.03) in group 1 than in group 2. MNG-related complaints were significantly reduced in both group 1 (P = 0.0001 vs baseline) and group 2 (P = 0.001) patients. Conclusion Low radioiodine activities after pretreatment with low-dosage rhTSH are able to reduce TV and improve MNG-related symptoms in elderly subjects.
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Affiliation(s)
- Massimo Giusti
- Clinica Endocrinologica, Azienda Ospedaliera Universitaria "San Martino", Genoa, Italy.
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Hegedüs L. Treatment of Graves' hyperthyroidism: evidence-based and emerging modalities. Endocrinol Metab Clin North Am 2009; 38:355-71, ix. [PMID: 19328416 DOI: 10.1016/j.ecl.2009.01.009] [Citation(s) in RCA: 59] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
Currently there are three well-established treatment options for hyperthyroid Graves' disease (GD): antithyroid drug therapy with thionamides (ATD), radioactive iodine treatment with (131)I, and thyroid surgery. This article reviews the current evidence so the reader can evaluate advantages and disadvantages of these treatment modalities. Surgery is rarely used, except for patients who have a large goiter or ophthalmopathy. Fewer than 50% of patients treated with ATD remain in long-term remission. Therefore, radioactive iodine is used increasingly. No data as yet support the routine use of biologic therapies (eg, rituximab). Prospective, randomized studies comparing available and any novel therapeutic options for GD are needed. The focus of these studies should include, but not be limited to, cost and quality of life.
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Affiliation(s)
- Laszlo Hegedüs
- Department of Endocrinology and Metabolism, Odense University Hospital, University of Southern Denmark, Odense, Denmark.
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Fast S, Nielsen VE, Grupe P, Bonnema SJ, Hegedüs L. Optimizing 131I Uptake After rhTSH Stimulation in Patients with Nontoxic Multinodular Goiter: Evidence from a Prospective, Randomized, Double-Blind Study. J Nucl Med 2009; 50:732-7. [DOI: 10.2967/jnumed.108.060152] [Citation(s) in RCA: 30] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/01/2023] Open
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Fast S, Nielsen VE, Bonnema SJ, Hegedüs L. Time to reconsider nonsurgical therapy of benign non-toxic multinodular goitre: focus on recombinant human TSH augmented radioiodine therapy. Eur J Endocrinol 2009; 160:517-28. [PMID: 19106244 DOI: 10.1530/eje-08-0779] [Citation(s) in RCA: 57] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
The treatment of benign multinodular goitre (MNG) is controversial, but surgery is recommended in large compressive goitres. While some patients decline surgery others may have contraindications due to comorbidity, since MNG is prevalent in the elderly. Therefore, non-surgical treatment alternatives are needed. Until recently, levothyroxine therapy was the preferred non-surgical alternative, but due to low efficacy and potential side-effects, it is not recommended for routine use in recent international guidelines. Conventional radioiodine ((131)I) therapy has been used for two decades as an effective and safe alternative to surgery in the treatment of symptomatic non-toxic MNG. Since much higher activities of (131)I are employed when treating non-toxic rather than toxic MNG, there has been reluctance in many countries to use this treatment modality. Frequently, the (131)I -uptake in a non-toxic MNG is low, which makes (131)I therapy less feasible. Another challenge is the negative correlation between the initial goitre size and goitre volume reduction (GVR). With its ability to more than double the thyroid (131)I-uptake, recombinant human TSH (rhTSH) increases the absorbed radiation dose and thus enhances the GVR by 35-56% at the expense of up to fivefold higher rate of permanent hypothyroidism. An alternative strategy is to reduce the administered (131)I-activity with a factor corresponding to the rhTSH induced increase in (131)I-uptake. Hereby, the extrathyroidal irradiation can be reduced without compromising efficacy. Thus, although in its infancy, and still experimental, rhTSH-augmented (131)I therapy may profoundly alter the non-surgical treatment of benign non-toxic MNG.
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Affiliation(s)
- Søren Fast
- Department of Endocrinology and Metabolism, Odense University Hospital, DK-5000 Odense C, Denmark.
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Souza MVLD, Souza HFD, Buescu A, Vaisman M. Mudanças evolutivas no tratamento da doença de Graves com iodo radioativo: 12 anos de experiência em um hospital universitário. Radiol Bras 2009. [DOI: 10.1590/s0100-39842009000200007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
Abstract
OBJETIVO: Avaliar a mudança no perfil e abordagem dos pacientes com doença de Graves submetidos a dose terapêutica de radioiodo. MATERIAIS E MÉTODOS: Avaliamos, retrospectivamente, 226 pacientes portadores de doença de Graves submetidos a dose terapêutica de radioiodo entre janeiro de 1990 e dezembro de 2001. O período de 12 anos foi dividido em três períodos de 4 anos para fins de análise estatística, sendo comparadas variáveis clínicas e laboratoriais nos períodos descritos. RESULTADOS: Constatamos que o número de pacientes encaminhados para a dose terapêutica, assim como o percentual de pacientes do sexo feminino (de 62% para 86%; p = 0,005), tiveram incremento significativo. Houve aumento significativo no percentual de pacientes em uso de metimazol previamente à dose terapêutica (de 9,1% para 35,6%; p = 0,03). A dose média de iodo administrada também teve incremento significativo (de 7,6 mCi para 12,7 mCi; p = 0,000003), com reflexo direto em um maior percentual de pacientes curados (de 55,6% para 83,7%; p = 0,004) um ano pós-dose terapêutica. CONCLUSÃO: A dose terapêutica de radioiodo tem sido um método cada vez mais aceito nos pacientes com doença de Graves e a dose administrada tem sido cada vez maior, no intuito de cura permanente e diminuição das chances de recidiva.
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Shi GM, Xu Q, Zhu CY, Yang YL. Influence of Propylthiouracil and Methimazole Pre-treatment on the Outcome of Iodine-131 Therapy in Hyperthyroid Patients with Graves' Disease. J Int Med Res 2009; 37:576-82. [PMID: 19383254 DOI: 10.1177/147323000903700235] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022] Open
Abstract
There is ongoing controversy about potential differences in the influence of the anti-thyroid drugs propylthiouracil (PTU) and methimazole (MMI) on radioiodine treatment of Graves' hyperthyroidism. This retrospective study investigated the influence of PTU and MMI pre-treatment, individually or sequentially, on the outcome of iodine-131 (131I) therapy in 199 patients with Graves' disease who had been treated with 131I for the first time and followed up at 3 and 6 months after treatment. Pre-treatment with PTU, or sequential PTU and MMI pre-treatment, increased the failure rate of 131I therapy and reduced the rate of hypothyroidism. MMI pre-treatment alone had no significant influence on the results of 131I therapy. Logistic regression analyses indicated that PTU pre-treatment and having a thyroid gland of > 60 g were both significantly related to 131I therapy failure.
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Affiliation(s)
- G-M Shi
- Department of Chemotherapy, The First Affiliated Hospital, College of Medicine, Zhejiang University, Zhejiang, China
| | - Q Xu
- Department of Nuclear Medicine, The First Affiliated Hospital, College of Medicine, Zhejiang University, Zhejiang, China
| | - C-Y Zhu
- Department of Nuclear Medicine, The First Affiliated Hospital, College of Medicine, Zhejiang University, Zhejiang, China
| | - Y-L Yang
- Department of Nuclear Medicine, The First Affiliated Hospital, College of Medicine, Zhejiang University, Zhejiang, China
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Boelaert K, Syed AA, Manji N, Sheppard MC, Holder RL, Gough SC, Franklyn JA. Prediction of cure and risk of hypothyroidism in patients receiving 131I for hyperthyroidism. Clin Endocrinol (Oxf) 2009; 70:129-38. [PMID: 18462261 DOI: 10.1111/j.1365-2265.2008.03291.x] [Citation(s) in RCA: 56] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
CONTEXT There is little consensus regarding the most appropriate dose of radioiodine ((131)I) to be administered to patients with hyperthyroidism. OBJECTIVE To compare the efficacy of fixed dose regimens of (131)I in curing hyperthyroidism and to define simple clinical and biochemical factors that predict outcome in individual patients. DESIGN Consecutive series of hyperthyroid subjects treated with (131)I. SETTING Single Secondary/Tertiary Care Hospital Clinic. PARTICIPANTS A total of 1278 patients (1013 females and 262 males, mean age 49.7 years) presenting with hyperthyroidism between 1984 and 2006. INTERVENTION Treatment with (131)I using a fixed dose regimen. MAIN OUTCOME MEASURES Probability of cure and risk of development of hypothyroidism following a single dose of (131)I. RESULTS Patients given a single dose of (131)I of 600 MBq (n = 485) had a higher cure rate (84.1%) compared with those receiving either 370 MBq (74.9%, P < 0.001) or those given 185 Bq (63%, P < 0.001). An increased incidence of hypothyroidism by 1 year was evident with higher doses (600 MBq: 60.4%; 370 MBq: 49.2%, P = 0.001; 185 Bq: 38.1%, P < 0.001). Binary logistic regression analysis identified a 600 Bq dose of (131)I [adjusted odds ratio, AOR 3.33 (2.28-4.85), P < 0.001], female gender [AOR 1.75 (1.23-2.47), P = 0.002], lower presenting serum free T4 concentration [AOR 1.01 (1.01-1.02), P < 0.001] and absence of a palpable goitre [AOR 3.33 (2.00-5.56), P < 0.001] to be independent predictors of cure. Similarly, a 600 MBq dose [AOR 3.79 (2.66-5.38), P < 0.001], female gender [AOR 1.46 (1.05-2.02), P = 0.02], younger age [AOR 1.03 (1.02-1.04), P < 0.001], absence of a palpable goitre [AOR 3.85 (2.38-5.88), P < 0.001] and presence of ophthalmopathy [AOR 1.57 (1.06-2.31), P = 0.02] were identified as independent factors predicting the probability of development of hypothyroidism at one year. Based on these findings, formulae to indicate probability of cure and risk of hypothyroidism for application to individual patients were derived. CONCLUSIONS Simple clinical/biochemical criteria can be used to predict outcome after (131)I treatment. These factors determine that males, those with severe biochemical hyperthyroidism, and those with a palpable goitre require larger doses (600 MBq) in order to achieve cure.
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Affiliation(s)
- K Boelaert
- Division of Medical Sciences, University Hospital Birmingham, NHS Foundation Trust, Edgbaston, Birmingham, UK.
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40
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Long-term carbimazole intake does not affect success rate of radioactive 131Iodine in treatment of Graves' hyperthyroidism. Nucl Med Commun 2008; 29:642-8. [DOI: 10.1097/mnm.0b013e3282fda205] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
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41
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Vaidya B, Williams GR, Abraham P, Pearce SHS. Radioiodine treatment for benign thyroid disorders: results of a nationwide survey of UK endocrinologists. Clin Endocrinol (Oxf) 2008; 68:814-20. [PMID: 17973939 DOI: 10.1111/j.1365-2265.2007.03097.x] [Citation(s) in RCA: 53] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
Abstract
BACKGROUND A survey of physicians' practice relating to radioiodine administration for hyperthyroidism was carried out in the UK over 15 years ago and showed wide variations in patient management. This led to the development of national guidelines for the use of radioiodine in hyperthyroidism. As there have been significant advances in the field since that survey, we carried out another survey to study the prevalent practices relating to radioiodine therapy for benign thyroid disorders across the UK. SUBJECTS AND METHODS We mailed 698 UK consultant endocrinologists a questionnaire on radioiodine treatment based on three patient scenarios: hyperthyroid Graves' disease, subclinical hyperthyroidism and nontoxic goitre. RESULTS The response rate was 40%. For the scenario of an initial presentation of Graves' disease, 80%, 19% and 0.4% of respondents preferred thionamide, radioiodine or thyroidectomy, respectively. There were inconsistencies in respondents' recommendations on radioiodine dose, the use of pre- and post-radioiodine supplementary treatments, timing of a repeat dose, and the use of radioiodine in thyroid eye disease. For the case of subclinical hyperthyroidism, one-third of respondents would generally initiate treatment. The majority were more likely to treat subclinical hyperthyroidism in the presence of paroxysmal atrial fibrillation or osteoporosis. If a decision were made to treat subclinical hyperthyroidism, 63%, 35%, 1% and 0.4% would recommend radioiodine, thionamide, beta-blocker and thyroidectomy, respectively. For the scenario of nontoxic goitre, 62%, 21%, 13% and 5% favoured observation, thyroidectomy, radioiodine and thyroxine, respectively. CONCLUSIONS There remain significant differences in several aspects of clinical practice relating to the use of radioiodine treatment for benign thyroid disorders in the UK.
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Affiliation(s)
- Bijay Vaidya
- Department of Endocrinology, Royal Devon and Exeter Hospital, Exeter, UK.
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Abstract
Thyrotoxicosis is a condition resulting from elevated levels of thyroid hormone. In this article, the authors review the presentation, diagnosis, and management of various causes of thyrotoxicosis.
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Affiliation(s)
- Bindu Nayak
- Division of Endocrinology and Metabolism, Georgetown University Hospital, 4000 Reservoir Road, Building D, Suite 232, Washington, DC 20007, USA.
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Bonnema SJ, Nielsen VE, Boel-Jørgensen H, Grupe P, Andersen PB, Bastholt L, Hegedüs L. Improvement of goiter volume reduction after 0.3 mg recombinant human thyrotropin-stimulated radioiodine therapy in patients with a very large goiter: a double-blinded, randomized trial. J Clin Endocrinol Metab 2007; 92:3424-8. [PMID: 17566091 DOI: 10.1210/jc.2007-0501] [Citation(s) in RCA: 66] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
INTRODUCTION The effect of (131)I therapy amplification by recombinant human (rh) TSH prestimulation in very large goiters has not been evaluated in a double-blinded, placebo-controlled study. METHODS Twenty-nine patients (22 females; age range 37-87 yr) with a large multinodular goiter (median 160 ml, range 99-440 ml) were randomized to receive placebo (n = 15) or 0.3 mg rhTSH (n = 14) 24 h before (131)I administration. Goiter volume was monitored by magnetic resonance imaging. RESULTS On average, the goiter volume was unchanged 1 wk after therapy in both groups, but the largest deviations from baseline were observed in the rhTSH group. After 12 months the median goiter volume was reduced from 170 to 121 ml in the placebo group and from 151 to 72 ml in the rhTSH group, respectively (within group: P = 0.001; between group: P = 0.019). This corresponds to reductions of 34.1 +/- 3.2 and 53.3 +/- 3.3%, respectively (between group: P < 0.001). In the placebo group, the goiter reduction correlated positively with the retained thyroid (131)I dose, whereas such a relationship was absent in the rhTSH group. Adverse effects, mainly related to thyroid pain and cervical compression, were more frequent in the rhTSH group. At 12 months, goiter-related complaints were significantly reduced in both groups without any between-group difference. One and three patients in the placebo and the rhTSH group, respectively, developed hypothyroidism. CONCLUSION rhTSH-stimulated (131)I therapy improves the reduction of very large goiters by more than 50%, compared with (131)I therapy alone, but at the expense of more adverse effects after therapy. Our data suggest that rhTSH stimulation may work through mechanisms that go beyond the increase in thyroid (131)I uptake.
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Affiliation(s)
- Steen J Bonnema
- Department of Endocrinology and Metabolism, Odense University Hospital, DK-5000 Odense C, Denmark.
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Razvi S, Pearce SHS. Do antithyroid drugs influence outcome after radioiodine therapy for hyperthyroidism? ACTA ACUST UNITED AC 2007; 3:628-9. [PMID: 17637723 DOI: 10.1038/ncpendmet0584] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/09/2007] [Accepted: 05/23/2007] [Indexed: 11/08/2022]
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Adamali HI, Gibney J, O'Shea D, Casey M, McKenna TJ. The occurrence of hypothyroidism following radioactive iodine treatment of toxic nodular goiter is related to the TSH level. Ir J Med Sci 2007; 176:199-203. [PMID: 17632747 DOI: 10.1007/s11845-007-0059-1] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/16/2007] [Accepted: 06/07/2007] [Indexed: 10/23/2022]
Abstract
BACKGROUND Strategies to increase frequency of euthyroidism following radioactive (RAI) treatment of hyperthyroidism are required. AIMS To examine the role of TSH in development of hypothyroidism post RAI treatment in patients with Graves' disease (N = 98) or toxic nodular goiter, TNG (N = 88). DESIGN This retrospective study examined thyroid status over a mean of 3.7 years post-RAI. RESULTS Although RAI dose was significantly higher in TNG group, hypothyroidism occurred more frequently in Graves' disease (71.4 and 22.7%) P < 0.001. The TSH levels at the time of RAI treatment were lower in TNG patients who remained euthyroid, (0.4+/-0.1 vs. 1.2+/-0.5 mU/l, P < 0.0022). CONCLUSIONS A higher frequency of euthyroidism occurs in patients with TNG than with Graves' disease following RAI, particularly when suppressed TSH levels were suppressed at time of RAI-treatment.
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Affiliation(s)
- H I Adamali
- Department of Endocrinology and Diabetes Mellitus, St. Vincent's University Hospital, Elm Park, Dublin 4, Ireland.
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Abstract
Radioiodine has been in use for over 60 years as a treatment for hyperthyroidism. Major changes in clinical practice have occurred with the realization that accurate dosimetry is incapable of avoiding the risks of hypothyroidism, while more accurate assessment of the risks of other adverse effects of radioiodine such as ophthalmopathy and carcinogenesis have become available. More is also known of the potential for pretreatment with an antithyroid drug to affect the outcome of radioiodine treatment. However, we are still uncertain of the benefits of radioiodine treatment in subclinical hyperthyroidism. During the last two decades there has been wider acceptance of radioiodine as a safe and effective therapy for benign, nontoxic goitre, coupled with waning enthusiasm for the use of levothyroxine, as the risks and benefits of this option have become more apparent. The use of recombinant TSH offers the prospect that radioiodine treatment of nontoxic goitre can be simplified and improved, although more studies of this strategy are urgently required.
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Abstract
Nuclear medicine is directly involved in both the diagnosis and treatment of benign thyroid disease, which requires an understanding of the pathophysiology and management of thyroid disorders in addition to expertise in nuclear methodology. Thyroid uptake and imaging, the principal nuclear tests in thyroid disease, may be used as follows: (1) Differential diagnosis of hyperthyroidism: A very low thyroid uptake suggests destructive ("subacute") thyroiditis, a self-limited disorder, whereas a normal or elevated uptake is consistent with toxic nodular goiter and Graves' disease. Scintigraphic characteristics also help differentiate between nodular and Graves' disease. (2) Function of thyroid nodules: Fine-needle aspiration biopsy with cytological examination (FNAB) is used routinely to assess for malignancy in thyroid nodules. Scintigraphy may be of assistance before FNAB. "Hot" nodules are generally benign and do not require FNAB, while "cold" nodules may be malignant. (3) Differential diagnosis of congenital hypothyroidism: Scintigraphy combined with ultrasound examination may be used to identify such conditions as thyroid agenesis, dyshormonogenesis, and incomplete thyroid descent. Treatment of Graves' disease and toxic nodular disease with (131)I may require greater clinical involvement and decision analysis compared with thyroid uptake and imaging. The following aspects of treatment are particularly important: (1) Risk: Radioiodine treatment may occasionally aggravate hyperthyroidism, Graves' ophthalmopathy, and airway obstruction caused by large, nodular goiters. Alternative treatments, including the temporary use of antithyroid drugs, and surgery for nodular goiters, may be considered. (2) Radioiodine dose: Cure of hyperthyroidism with a single (131)I treatment is desirable, though not always possible. Such factors as a large goiter, severe hyperthyroidism, and prior propylthiouracil therapy, may contribute to treatment failure. (3) Informed consent: A detailed discussion with the patient regarding the clinical risks, outcomes, and side effects of (131)I is a critical component of successful management.
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Affiliation(s)
- Salil D Sarkar
- Nuclear Medicine, Jacobi Medical Center, North Bronx Health Network, NY 10461, USA.
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48
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de Souza MVL, Buescu A, Vaisman M, de Souza HF, Luiz RR. Efeito do propiltiouracil sobre a eficácia da dose terapêutica de iodo radioativo (I-131) no hipertiroidismo por doença de graves. ACTA ACUST UNITED AC 2006; 50:1088-95. [PMID: 17221116 DOI: 10.1590/s0004-27302006000600016] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/20/2006] [Accepted: 07/14/2006] [Indexed: 11/22/2022]
Abstract
Com objetivo de avaliar a influência das drogas antitiroidianas (AT) sobre a eficácia da dose terapêutica de iodo radioativo (DT), avaliamos retrospectivamente 226 prontuários de pacientes portadores de doença de Graves submetidos à DT no período entre 1990 e 2001: 58 pacientes sem antitiroidiano (AT), 119 em uso de propiltiouracil (PTU) e 49 em uso de metimazol (MMI). O estado funcional tiroidiano 9-12 meses pós-DT dividia os pacientes entre curados e não curados. Níveis elevados de T4 livre, captação de 131I em 24 h tiveram influência negativa sobre a taxa de cura, assim como menor dose de iodo administrada e maior volume do bócio (p< 0,05). O percentual de pacientes curados em uso de PTU previamente à DT foi de 70,2% (84/119), enquanto nos pacientes em uso de MMI foi de 85,7% (42/49), e de 84,5% (49/58) nos pacientes sem AT pré-DT (p= 0,034). Em modelo de regressão multivariado, T4 livre > 4 ng/dl, maior volume do bócio, dose terapêutica < 10 mCi e o uso prévio de PTU tiveram relação com menores taxas de cura. Quando comparado ao grupo sem AT, concluímos que PTU implica em maior risco de falência pós-DT (OR= 3,13), o mesmo não ocorrendo com MMI (OR= 1,28).
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Affiliation(s)
- Marcus V L de Souza
- Serviço de Endocrinologia, Departamento de Ciências Médicas, Universidade Federal do Rio de Janeiro.
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Dunkelmann S, Kuenstner H, Nabavi E, Rohde B, Groth P, Schuemichen C. Change in the intrathyroidal kinetics of radioiodine under continued and discontinued antithyroid medication in Graves’ disease. Eur J Nucl Med Mol Imaging 2006; 34:228-36. [PMID: 17021811 DOI: 10.1007/s00259-006-0234-z] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2006] [Accepted: 06/25/2006] [Indexed: 11/26/2022]
Abstract
PURPOSE This study evaluated the thyroidal kinetics of radioiodine in Graves' disease under continued thiamazole medication and after discontinuation of thiamazole for 1-2 days, with a view to keeping the period of discontinuation as short as possible and to exploring the underlying mechanism of a postulated radioprotective effect of antithyroid drugs. METHODS In 316 patients, diagnostic and therapeutic radioiodine kinetics were followed up for 2 days by ten uptake measurements each and were defined mathematically by a two-compartment model. RESULTS Without thiamazole or when thiamazole was discontinued for at least 2 days, all uptake curves could be fitted perfectly by a simple in- and output function; the mean square error (mse) was 0.38 (test) and 0.28 (therapy). Under continued thiamazole medication (11.0+/-7.0 mg/day), the energy dose delivered to the thyroid was lowered by factor of 2.5. Uptake curves were deformed (mse: 1.06, test and 0.86, therapy) and appeared two peaked, suggesting coexistence of follicles with blocked and follicles with intact hormone synthesis and hence heterogeneous radioiodine uptake in the thyroid. In patients with maximally altered uptake curves, the success rate was as low as 31%. One day after discontinuation of thiamazole, mse was still increased (0.78, test), while 2 days afterwards it had normalised (0.36, test) and 3 days afterwards (mse: 0.24, therapy) the success rate was 87%. CONCLUSION Efficacy of radioiodine therapy under continued thiamazole medication is reduced not only by a lower uptake and shorter half-life of radioiodine, but also by a heterogeneous energy dose distribution in the thyroid. Discontinuation of thiamazole (but probably not of propylthiouracil) for at least 2 days is required to restore the efficacy of radioiodine.
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Affiliation(s)
- Simone Dunkelmann
- Clinic of Nuclear Medicine, University of Rostock, Gertrudenplatz 1, 18057 Rostock, Germany.
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Bonnema SJ, Bennedbaek FN, Veje A, Marving J, Hegedüs L. Continuous methimazole therapy and its effect on the cure rate of hyperthyroidism using radioactive iodine: an evaluation by a randomized trial. J Clin Endocrinol Metab 2006; 91:2946-51. [PMID: 16735487 DOI: 10.1210/jc.2006-0226] [Citation(s) in RCA: 36] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
BACKGROUND A randomized clinical trial was performed to clarify whether continuous use of methimazole (MTZ) during radioiodine ((131)I) therapy influences the final outcome of this therapy. DESIGN Consecutive patients with Graves' disease (n = 30) or a toxic nodular goiter (n = 45) were rendered euthyroid by MTZ and randomized to stop MTZ 8 d before (131)I (-MTZ; n = 36) or to continue MTZ until 4 wk after (131)I (+MTZ; n = 39). Calculation of the (131)I activity included an assessment of the (131)I half-life and the thyroid volume. RESULTS The 24-h thyroid (131)I uptake was lower in the +MTZ group than in the -MTZ group (44.8 +/- 15.6% vs. 62.1 +/- 9.9%, respectively; P < 0.001). At 3 wk after therapy, no significant change in serum free T(4) index was observed in the +MTZ group (109 +/- 106 vs. 83 +/- 28 nmol/liter at baseline; P = 0.26), contrasting an increase in the -MTZ group (180 +/- 110 vs. 82 +/- 26 nmol/liter; P < 0.001). The number of cured patients was 17 (44%) and 22 (61%) in the +MTZ and -MTZ groups, respectively (P = 0.17). Cured patients tended to have a lower 24-h thyroid (131)I uptake (50.1 +/- 13.8% vs. 56.4 +/- 17.1%; P = 0.09). By adjusting for a possible interfactorial relationship through a regression analysis (variables: randomization, 24- and 96-h thyroid (131)I uptake, type and duration of disease, age, gender, presence of antithyroid peroxidase antibodies, thyroid volume, dose of MTZ), only the continuous use of MTZ correlated with treatment failure (P = 0.006), whereas a low 24-h thyroid (131)I uptake predicted a better outcome (P = 0.006). CONCLUSION Continuous use of MTZ hinders an excessive increase of the thyroid hormones during (131)I therapy of hyperthyroid diseases. However, such a strategy seems to reduce the final cure rate, although this adverse effect paradoxically is attenuated by the concomitant reduction of the thyroid (131)I uptake.
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Affiliation(s)
- Steen Joop Bonnema
- Department of Endocrinology and Metabolism, Odense University Hospital, DK-5000 Odense C, Denmark.
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