Age and gender predict the outcome of treatment for Graves' hyperthyroidism

Azathioprine as an adjuvant therapy in severe Graves' disease: a randomized controlled open-label clinical trial

Introduction

Azathioprine (AZA) interferes with the activation of T and B lymphocytes, which are the main cells involved in the pathogenesis of Graves' disease (GD). The aim of this study was to investigate the effectiveness of AZA as an adjuvant therapy to antithyroid drugs (ATDs) for moderate and severe GD. In addition, we conducted an incremental cost-effectiveness analysis of AZA to determine its cost-effectiveness.

Methods

We conducted a randomized, open-label, and parallel-group clinical trial. We randomized untreated hyperthyroid patients with severe GD into three groups. All patients received 45-mg carbimazole (CM) as the starting dose and propranolol 40-120 mg daily. The first group (AZA1) received an additional 1 mg/kg/day AZA, the second group (AZA2) received an additional 2 mg/kg/day AZA, and the third group (control group) received only CM and propranolol. We measured thyroid-stimulating hormone (TSH) and TSH-receptor antibody (TRAb) levels at baseline and every 3 months, while free triiodothyronine (FT3) and free thyroxine (FT4) levels were measured at the time of diagnosis, 1 month after initiation of therapy, and every 3 months thereafter until 2 years after remission. Thyroid volume (TV) was assessed by ultrasound at baseline and 1 year after remission.

Results

A total of 270 patients were included in this trial. By the end of follow-up, there was higher remission rate in the AZA1 and AZA2 groups compared with controls (87.5% and 87.5% vs. 33.4%, p = 0.002). Throughout the course of follow-up, FT3, FT4, TSH, and TRAb were significantly different between the AZA groups and the control group, but there was no significant difference regarding TV. The decline in the concentrations of FT4, FT3, and TRAb was significantly faster in the AZA2 group than in the AZA1 group. The relapse rate during the 12-month follow-up was insignificantly higher in the control group than in either the AZA1 or AZA2 group (10, 4.4, and 4.4%, p = 0.05, respectively). The median relapse time was 18 months for the control group and 24 months for the AZA1 and AZA2 groups. The incremental cost-effectiveness ratio for the AZA group compared with the conventional group was 27,220.4 Egyptian pounds per remission reduction for patients using AZA as an adjuvant for ATDs.

Conclusion

AZA could be a novel, affordable, cost-effective, and safe drug offering hope for patients with GD to achieve early and long-lasting medical remission.

Trial registry

The trial is registered at the Pan African Clinical Trial Registry (Registration number: PACTR201912487382180).

Influence of biological sex, age and smoking on Graves’ orbitopathy – a ten-year tertiary referral center analysis

Purpose

Severity of Graves’ orbitopathy (GO) shows wide individual differences. For optimal treatment, it is important to be able to predict the natural course of the disease as accurate as possible to counteract with anti-inflammatory and surgical treatment. Therefore, we aimed to further elucidate the impact of sex, age and smoking on GO.

Methods

We collected the clinical and demographic data of all patients of our tertiary referral center from January 2008 till December 2018 and analyzed it with descriptive statistics. Only patients with a complete data set were included in the further analysis. Odds ratio’s for moderate-to-severe and sight-threatening GO in relation to age, sex and smoking were calculated by means of multivariate logistic regression models.

Results

We evaluated the data of 4260 patient with GO and complete data sets. Most of these were women (83%). There were no significant differences between male and female patients regarding smoking habits and thyroid treatment. Men were significantly older at initial manifestation of TED (51.8 vs. 49.9y, p<0.01) and showed significant more often severe stages (61% vs. 53%, p<0.0001). Therefore, they needed significantly more intense treatment with steroids, irradiation, orbital decompression and muscle surgery. In multivariate logistic regression analyses age (OR 0.97, 95% CI:0.97-0.98, p<0.0001), male sex (OR 1.64, 95% CI:1.38-1.9, p<0.0001), smoking (OR 1.19, 95% CI:1.04-1.36, p=0.01), Grave’s disease (OR 1.55, 95% CI:1.26-1.90, p<0.0001) and history of radioiodine treatment (RAI) (OR 2.44, 95% CI:2.10-2.86, p<0.0001) showed an significant association with severe stages of GO.

Discussion

Our retrospective analysis showed once more that women are more often afflicted by GO. In contrast, men seem to be more severely afflicted and in need of anti-inflammatory and surgical treatments. This might be due to a different approach to the health system and resilience to GO specific symptoms, as well as previously described worse thyroid control. Estrogen mediated effects might also play a role as in other autoimmune diseases and should be subject of further trials. Besides the biological sex, smoking could again be confirmed as serious risk factor for severe GO. Of note, RAI was associated with more severe stages of GO, which should be subject to further investigation.

Long-term follow-up result of antithyroid drug treatment of Graves' hyperthyroidism in a large cohort

OBJECTIVE

This study evaluated the efficacy of antithyroid drugs (ATDs) and risk factors associated with the recurrence of Graves' hyperthyroidism using a comprehensive retrospective cohort.

METHODS

We included 1829 patients newly diagnosed with Graves' hyperthyroidism, with sufficient follow-up data. Clinical outcomes of the patients and risk factors associated with recurrence-free survival, including the changes in thyrotropin receptor antibody, were evaluated.

RESULTS

The median age of the patients was 44.5 years, and 69% were female. Among the patients, 1235 had a chance to withdraw ATD after a median of 23 (interquartile range (IQR) 17.0-35.5) months of treatment. The first remission rate was 55.6% during a median of 72.7 months of follow-up. After the first recurrence, 95% of patients underwent the second course of ATD treatment for a median of 21.1 (IQR 14.8-31.7) months, and the remission rate was 54.1%. During a median of 67 months of follow-up, 7.7% of patients underwent surgery, and 10.5% underwent radioactive iodine therapy. Approximately 30% were still on ATD therapy for recurrent disease or prolonged low-dose maintenance. Younger age (<45 years), male sex, and fluctuating or smoldering of TRAb levels were independent risk factors of the first recurrence after ATD treatment.

CONCLUSIONS

ATD treatment is an acceptable option for the initial treatment of Graves' hyperthyroidism as well as for recurrent disease. The optimal treatment period for ATD treatment needs to be determined using the individual risk factors of recurrence.

A systematic review and meta-analysis of the etiology and treatment patterns of thyrotoxicosis in Africa

INTRODUCTION

Thyrotoxicosis is one of the most common endocrine disorders seen in clinical practice. This study aims to determine the etiologies and treatment modalities of thyrotoxicosis in Africa.

AREAS COVERED

The study design is a systematic review with a meta-analysis. Medical databases and the gray literature were systematically searched following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. Studies done in Africa on the etiology and treatment of thyrotoxicosis were selected.

EXPERT OPINION

In Africa, it is still believed that autoimmune diseases, generally, are not as common as what is seen in the western world. The frequency of Graves' disease is reportedly lower in Africa. The treatment of thyrotoxicosis depends on the cause. Therefore, it is of substantial importance to establish the etiology following the diagnosis of the clinical syndrome.

The Mediation Role of Thyrotropin Receptor Antibody in the Relationship Between Age and Severity of Hyperthyroidism in Graves' Disease

Background: The severity of hyperthyroidism in Graves' disease (GD) has been reported to be worse in younger patients and to gradually improve with advancing age, accompanied by declining thyrotropin (TSH) receptor antibody (TRAb) values. This study was conducted to explore the extent to which the declining TRAb production may contribute to a decrease in severe hyperthyroidism with advancing age in patients with GD. Methods: This study was a cross-sectional analysis of retrospectively reviewed data. The medical records of patients newly diagnosed with GD at Ito Hospital, between January 2005 and June 2019, were examined. Patients were divided into age-stratified groups for evaluation. Multivariable logistic regression was performed to estimate the odds ratio (OR) of severe hyperthyroidism by increasing age. Mediation analyses were also conducted to quantify the association between age and declining severity of hyperthyroidism mediated through decreased TRAb productivity. Results: A total of 21,018 patients with newly diagnosed GD (3848 male and 17,170 female) were included. A correlation was observed between TRAb value and thyroid hormone values in each age-stratified group, which became weaker with an increase in age. Patients aged <40 years had a higher risk of severe hyperthyroidism (free thyroxine [fT4] level >7.0 ng/dL [n = 5616], OR [confidence interval, CI] = 1.80 [1.68-1.92]; free triiodothyronine [fT3] level >25 pg/mL [n = 4501], OR [CI] = 2.06 [1.92-2.23]) than those aged ≧40 years. In examining the relationship between age and severe hyperthyroidism, the proportion mediated through TRAb productivity was 8.5% and 8.4% using fT4 and fT3 as an outcome index, respectively. Conclusions: Declining TRAb value mediated only 8.5% of the negative association between age and severity of hyperthyroidism. The presence of other underlying mechanisms, such as the decline in the reactivity of thyrocytes to TSH stimulation, requires further investigation.

Time to Euthyroidism and Its Determinants Among Thyrotoxicosis Patients on Anti-Thyroid Drug Who Attend to Medical and Ambulatory Clinics of South Tigrai General Hospitals

Purpose

To determine the time to euthyroidism and its determinants among thyrotoxicosis patients on anti-thyroid drug attending the medical and ambulatory clinics of South Tigrai General Hospitals, Ethiopia, 2015–2020.

Methods

A multi-center retrospective cohort study was conducted from March 30, 2020, to July 30, 2020, among adult thyrotoxicosis patients who received anti-thyroid medications in the medical and chronic ambulatory clinics of South Tigrai General Hospitals, Ethiopia. Epi-data manager version 3.1 software was used for data entry and then exported to STATA version 15 for windows for analysis. Cox proportional hazards regression model was used to determine the determinants of time to euthyroidism and the summary measures of the adjusted hazard ratio with a 95% CI were presented, and P-value < 0.05 used to declare the statistical significance.

Results

One hundred and seventy-five (51.9%) thyrotoxicosis patients become euthyroid with the median time to euthyroidism of 9 months, IQR (6–12) months, with a total of 5542 person-months of observation. Age greater than 40 years (AHR = 0.7; 95% CI 0.54–0.96), toxic multi-nodular goiter (AHR = 0.69; 95% CI 0.60–0.87), World Health Organization goiter size three (AHR = 0.78; 95% CI 0.54–0.82) and baseline free thyroxin (AHR = 0.96; 95% CI 0.80–0.99) were the independent determinants of delayed time to euthyroidism.

Conclusion

The time to euthyroidism was longer than the expected time. High baseline free thyroxin, toxic multinodular goiter, elderly patients, and patients with World Health Organization goiter size three were determinants of delayed time to euthyroidism.

How to use thionamide anti-thyroid drug in the young- what's new?

The excess thyroid hormone secretion that characterises Graves' disease (GD) is generated when stimulatory antibodies bind to the thyroid stimulating hormone receptor on the follicular cell of the thyroid gland.This underlying mechanism cannot easily be abolished and the mainstay of Graves' disease (GD) management in the young remains thionamide anti-thyroid drug (ATD). Unfortunately, GD will usually recur after a 2 or 3 year course of ATD, even when the stimulatory antibody titres have fallen. The diagnosis of GD therefore usually signals the start of a lengthy period of out-patient assessments and associated venepuncture. Careful, more protracted administration of ATD may increase the likelihood of longer-term remission and reduce the likelihood of the patient developing ATD side-effects. An understanding of how best to use ATD and an awareness of the less well-known consequences of GD and its' treatment - such as excessive weight-gain and long-term hypothyroidism - are also of fundamental importance.Recent clinical studies have shed light on how best to manage the young patient with GD and the associated new information will help to answer some of the questions posed by the young person and their family at diagnosis. This new knowledge is the focus of this article about ATD therapy in the young.

Dual attack: targeting the rare co-occurrence of myasthenia gravis and Graves' disease with radioactive iodine therapy

SUMMARY

Occasionally, autoimmune disorders can come in twos. This double trouble creates unique challenges. Myasthenia gravis co-existing with autoimmune thyroid disease occurs in only about 0.14-0.2% of cases. The patient is a 27-year-old man with a 2-month history of bilateral ptosis, diplopia, with episodes of easy fatigability, palpitations, and heat intolerance. On physical exam, the patient had an enlarged thyroid gland. Myasthenia gravis was established based on the presence of ptosis with weakness of the intraocular muscles, abnormal fatigability, and a repetitive nerve stimulation study indicated neuromuscular junction disease. Episodes of fluctuating right shoulder weakness were also noted. He was also found to have elevated FT3, FT4, and a suppressed TSH. Thyroid ultrasound revealed thyromegaly with diffused parenchymal disease. Thyroid scintigraphy showed increased uptake function at 72.4% uptake at 24 h. TRAb was positive at 4.1 U/L. Patient was started on pyridostigmine which led to a significant reduction in the frequency of ocular muscle weakness. Methimazole was also initiated. Radioactive iodine at 14.9 mci was instituted for the definitive management of hyperthyroidism. After RAI, there was abatement of the hyperthyroid symptoms, as well as improvement in the status of the myasthenia gravis, with ptosis, diplopia, and right arm weakness hardly occurring thereafter despite the reduction of the pyridostigmine dose based on a symptom diary and medication intake record. Two distinct autoimmune conditions displayed a markedly improved clinical course with the institution of radioactive iodine therapy for Graves' disease.

LEARNING POINTS

The presence of ptosis, diplopia, and fluctuating muscle weakness are atypical in Graves' disease and should prompt an investigation on the existence of concurrent myasthenia gravis. A prompt diagnosis of both conditions will enable the institution of appropriate management that would target both rare and challenging autoimmune diseases. Selecting the therapeutic options with minimal risk of morbidity and mortality, which could lead to maximal benefit especially in a resource-limited setting is paramount. Targeted non-surgical management can lead to the remission of two autoimmune diseases which can result in patient satisfaction and improved quality of life.

Expert consensus on diagnosis and treatment for elderly with thyroid diseases in China (2021)

In order to improve the diagnosis and treatment of senile thyroid diseases in China and to promote healthy aging, the Endocrine Metabolic Diseases Group of the Chinese Geriatrics Society, and the Thyroid Group of the Chinese Society of Endocrinology jointly drafted the "Expert consensus on diagnosis and treatment for Chinese elderly with thyroid diseases" (referred to as consensus). The Consensus consists of five parts that set 40 recommendations on main clinical issues. The consensus emphasizes clinical focus on the age-related changes of the hypothalamus-pituitary-thyroid axis in the elderly, and it recommends application of comprehensive geriatric assessment to thoroughly evaluate the impact of thyroid diseases and relevant intervention on overall health condition. Meanwhile, it recommends generalization of screening for hypothyroidism during admission to nursing institution or hospital, and routine health check-ups. Furthermore, it develops individualized stratified management on hyperthyroidism, hypothyroidism, thyroid nodules, and differentiated thyroid carcinoma in the elderly distinguished from the youngers, including treatment regimen, control ranges, and flowcharts for diagnosis and treatment. The Consensus will provide the basis for clinical decisions and health management of thyroid diseases in the elderly by geriatrician, endocrinologist, and general practitioners.

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

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.

Gender differences in estimating I-131 thyroid uptake from Tc-99m thyroid uptake for benign thyroid disease

OBJECTIVE

For radioactive Iodine-131 (¹³¹I) treatments of thyroid diseases, increased efficacy has been reported for personalized dosimetry treatments. The measurement of Iodine-131 thyroid uptake (¹³¹IU) is required in these cases. This study aims to investigate whether ^99mTc thyroid uptake (^99mTcU) may be used in place of ¹³¹IU for implementing personalised treatments.

METHODS

A retrospective study of 152 benign thyroid disease ¹³¹I treatments was carried out during 2012-2020; 117 treatments were for female patients while 35 were for male patients diagnosed with either Graves' disease, multinodular goitre or toxic nodules.

RESULTS

A statistically significant correlation was found between ¹³¹IU and ^99mTcU data, with the data more correlated for male than female patients (r = 0.71 vs 0.38, p-value < 0.001). Patient age and time difference between the two respective uptake measurements significantly influenced the uptake correlation in females but not for the male cohort, although there was no significant difference between the parameters across gender. Thyroid diagnosis and hormone levels showed a significant correlation with uptakes in both genders. Estimating ¹³¹IU based on ^99mTcU was shown to be predictive for male but not in female patients (R² = 91% vs 16%).

CONCLUSION

Estimating ¹³¹IU based on ^99mTcU is not recommended for females at our centre. Males reported good correlation, but a larger sample would be needed for validation.

ADVANCES IN KNOWLEDGE

The initial findings showed a significant gender difference in benign thyroid uptake parameters at our centre, highlighting the potential need for gender consideration when planning ¹³¹IU patient management and when reporting studies results.

Age moderates the associations between TRAbs, free T3 and outcomes of Graves' disease patients with radioactive iodine treatment

OBJECTIVE

This study aimed to explore whether age moderates the associations between TSH receptor antibodies (TRAbs) with thyroid hormones and remission in patients with Graves' disease (GD) who undergo radioactive iodine (RAI) treatment.

DESIGN

A single-centre retrospective study.

PATIENTS

A total of 435 eligible consecutive patients diagnosed with GD and treated with RAI therapy were included.

METHODS

TRAbs and thyroid hormones prior to RAI were recorded. Pearson's correlation, t tests and analysis of covariance were conducted to identify the associations between TRAbs, thyroid hormones and remission. Moderation analyses were conducted to test age as a moderator.

RESULTS

Overall, 75.4% of the patients achieved remission with a single dose of iodine-131. TRAb levels before RAI were positively correlated with the circulating thyroid hormones (ps < 0.001). Age moderated the association between TRAbs and free T3 (FT3) (P = .01), but did not moderate the association between TRAbs and free T4 (FT4) (P = .07). TRAb levels before RAI only significantly predicted remission status in young patients (P = .03), but not in middle-aged (P = .36) or older patients (P = .74), after adjusting for covariates. When age was included as a continuous variable, moderation analyses revealed that the association between TRAbs and remission status was stronger in younger patients (P = .03).

CONCLUSIONS

The majority of Graves' disease patients experienced a long-term remission following a single dose of iodine-131. Associations between TRAbs, FT3 and remission are moderated by age. TRAb level prior to RAI is a significant remission in younger patients, but not in middle-aged or older patients.

Serum TSH level as predictor of Graves' disease recurrence following antithyroid drug withdrawal: A systematic review

Graves’ disease (GD) has a high recurrence rate despite various and adequate treatment. Numerous studies have been performed to identify the predictor of disease recurrence. This report aims to investigate the role of thyroid stimulating hormone (TSH) level as a thyrotropin in predicting the recurrence of Graves’ disease within 1 to 2 years following antithyroid drug (ATD) withdrawal. Literature searching was conducted on PubMed, Scopus, Cochrane, Proquest, EBSCO in August 2019 and Google Scholar in October 2020. The study criteria include the study that evaluates TSH level 4 weeks following ATD withdrawal, with subjects ≥18 years old who are retrospectively or prospectively followed up after 1 to 2 years following ATD withdrawal. Four eligible studies were selected based on inclusion/exclusion criteria, all of which measured TSH level at 4 weeks following ATD withdrawal. All studies had 1 to 2 years follow up. One study was an RCT, two studies were done in prospective cohort and another in retrospective cohort. All studies had comparable validity and applicability. Three out of four studies suggested that low TSH level measured 4 weeks following treatment withdrawal was associated with higher risk of disease recurrence. In conclusion, low TSH level obtained 4 weeks after ATD withdrawal was associated with higher rate of recurrence rate in GD.

The prognostic value of thyroid-stimulating immunoglobulin in the management of Graves' disease

BACKGROUND

The bioassay of thyroid-stimulating immunoglobulin was reported to have a similar performance to the commonly used thyroid-stimulating hormone binding inhibition assay, also known as thyroid receptor antibody assay. The normal reference range of thyroid receptor antibody levels indicates the withdrawal of anti-thyroid drugs in the recent clinical guidelines.

METHODS

A prospective, longitudinal observational study was conducted to evaluate the prognostic value of thyroid-stimulating immunoglobulin in patients with Graves' disease.

RESULTS

A total of 77 patients with Graves' disease treated with anti-thyroid drugs were in a continuous follow-up until 1 year after anti-thyroid drugs discontinuation. Commercial kits of thyroid-stimulating immunoglobulin and M22-thyroid-stimulating hormone binding inhibition assay were used and compared. Thyroid-stimulating immunoglobulin was all negative in healthy controls, Hashimoto thyroiditis, and subacute thyroiditis. Thyroid-stimulating immunoglobulin value was highest in untreated patients with Graves' disease (p < 0.001). Under anti-thyroid drugs treatment, thyroid-stimulating immunoglobulin value decreased gradually. A total of 21 patients had positive thyroid-stimulating immunoglobulin at the end of treatment. According to clinical fate of patients with Graves' disease after withdrawal of anti-thyroid drugs, thyroid-stimulating immunoglobulin value and positivity in patients with relapse were significantly higher than that reported in patients with remission (p = 0.001, p < 0.001). After adjustment for age, gender, initial thyroid receptor antibody, initial thyroid-stimulating immunoglobulin, and thyroid receptor antibody at the end of treatment, the odds ratio of positive thyroid-stimulating immunoglobulin for the risk of relapse was 33.271 (95% confidence interval: 4.741-233.458, p < 0.001) and odds ratio of quantitative thyroid-stimulating immunoglobulin was 1.009 (95% confidence interval: 1.002-1.015, p < 0.001).

CONCLUSION

Thyroid-stimulating immunoglobulin is a good predictor of relapse in patients with Graves' disease treated with anti-thyroid drugs. It might be safer to discontinue anti-thyroid drugs when thyroid-stimulating immunoglobulin and thyroid receptor antibody were both negative.

Predictive factors for the outcomes of Graves' disease patients with radioactive iodine (131I) treatment

Although radioactive iodine (¹³¹I) treatment (RIT) is recommended as the preferred option for patients with Graves’ disease (GD), the predictive factors for its clinical outcomes are still unclear. In the present study, we aim to investigate the factors influencing the success rate of RIT treatment on primary GD with a calculated dose approach. The thyroid function (hyperthyroidism, euthyroidism or hypothyroidism) was evaluated at least 1 year after RIT, and its relationship with presenting clinical characteristics and pre-RIT parameters was analyzed in 45 patients retrospectively. After RIT, the remission rate was 62.2%, including 13 euthyroidism cases (28.9%) and 15 hypothyroidism cases (33.3%). We found no significant association between the types of thyroid function and age, gender, the 3-h radioactive iodine uptake (RAIU) prior to RIT, or radioactive iodine (¹³¹I) dosage. However, a variable 24-h RAIU > 46.31% was found associated with the success rate of RIT. The present study implied that a calculated dose approach for GD is effective, but high failure rates are expected in patients presenting poor 24-h RAIU, particularly those with 24-h RAIU below 46.31%.

Predictors of euthyreosis in hyperthyroid patients treated with radioiodine 131I-: a retrospective study

BACKGROUND

Radioiodine (RAI) treatment for hyperthyroidism is a very common modality, chosen by physicians worldwide. The outcome of the therapy, however, is not always predictable. While rendering a patient hypo- or euthyroid is meant as a therapeutic success, the latter does not require lifelong hormonal supplementation. The aim of our study is to determine predictors of euthyreosis in patients who underwent RAI treatment.

METHODS

Medical records of 144 patients who had undergone RAI therapy were examined. Laboratory and clinical data were analyzed statistically. Ultrasonography findings, such as thyroid volume, nodules' size and characteristics had been collected at the beginning of treatment and 6 months after the administration of radioiodine ¹³¹I^-. Moreover, scintigraphy results were taken into account. Multivariate logistic regression analysis model has been used to find predictors of euthyroidism after 12 months of follow-up. The predictors of normal thyroid function have also been analyzed separately for patients with GD (Graves' disease) and TMNG (toxic multinodular goiter).

RESULTS

The analysis showed that age (OR 1,06; 95%CI 1.025-1.096, p = 0,001), thyroid gland volume (OR 1,04; 95%CI 1,02-1,06; p < 0.001) and iodine uptake level (OR 0,952; 95%CI 0,91-0,98; p = 0,004) were significant factors of achieving normal thyroid function after RAI therapy. According to multivariate logistic regression analysis, in GD patients only age has been shown to be a significant factor (OR 1,06; 95%CI 1,001-1,13; p = 0.047), while in TMNG patients' age (OR 1,04; 95%CI 1-1,09; p = 0.048), thyroid gland volume (OR 1.038; 95%CI 1.009-1.068; p = 0.009) and iodine uptake level (OR 0.95; 95%CI 0.9-0.99; p = 0.02) all have been proven to be significant predictors of achieving euthyroidism.

CONCLUSIONS

The more advanced age, larger volume of thyroid gland and lower iodine uptake level are predictors of euthyreosis after RAI treatment.

Candidate gene associations reveal sex-specific Graves' disease risk alleles among Chinese Han populations

BACKGROUND

With several susceptibility single nucleotide polymorphisms identified by case-control association studies, Graves' disease is one of the most common forms of autoimmune thyroid disease. In this study, we aimed to determine whether any observed differences in genetic associations are influenced by sex in Chinese Han populations.

METHODS

A total of 8,835 patients with Graves' disease and 9,936 sex-matched healthy controls were enrolled in the study. Confirmed by a two-staged association analysis, sex-specific analyses among 20 Graves' disease susceptibility loci were conducted.

RESULTS

A significant sex-gene interaction was detected primarily at rs5912838 on Xq21.1 between the GPR174 and ITM2A genes, whereby male Graves' disease patients possessed a significantly higher frequency of risk alleles than their female counterparts. Interestingly, compared to women, male patients with Graves' disease had a higher cumulative genetic risk and higher persistent thyroid stimulating hormone receptor antibody-positive rate after receiving antithyroid drug therapy for at least 1 year.

CONCLUSION

The findings of this study suggest the existence of one potential sex-specific Graves' disease variant on Xq21.1. This could increase our understanding of the pivotal mechanism behind Graves' disease and ultimately aid in identifying possible therapeutic targets.

Retrospective Study of Tc-99m Thyroid Scan in Patients with Graves' Disease: Is There Significant Difference in Lobar Activity?

PURPOSE

Graves' disease (GD) is the most common cause of hyperthyroidism. It was reported that the right thyroid lobe is generally larger, and it is more likely to be affected by thyroid disorders. The aim of the current study is to verify preferential affection of one of the thyroid lobes and incidence of higher activity of either thyroid lobe in patients with GD through analysis of quantitative data of Tc-99m thyroid scan and possible relation of different thyroid lobar activity to gender, age, and total thyroid uptake (TTU) level.

MATERIALS AND METHODS

Retrospective analysis of quantitative data of Tc-99m thyroid scan in patients with GD was done. Total and lobar thyroid uptake levels were analyzed and correlated with age, gender, and TTU.

RESULTS

GD was reported in 222 patients, representing 76.6% of those with hyperthyroidism, women represent 70.3% of patients. The right thyroid lobe uptake (RLU) figures were significantly higher compared to the left in the whole group as well as in women and in young patients (<40 years). This significance was lost in men and in old patients. Equal lobar uptake was found in 11 patients. 138 patients (62.2%) had higher RLU, while the remaining 73 patients (32.8%) had higher left thyroid lobe uptake, with statistically significant difference. This significant difference was found in women and in young patients and was absent in men and old patients. There is an increase in the incidence of patients with higher RLU in association with an increase in TTU. All women with TTU >30% had higher RLU figures.

CONCLUSION

There is significant preferential thyroid lobar affection in favor of the right thyroid lobe in patients with GD, with significantly higher RLU figures and significantly more incidence of patients with higher right lobar activity. This significance is maintained in women and in young patients and lost in men and old patients. The incidence of higher right thyroid lobe activity also increases in association with increase in TTU. Our results emphasize the value of Tc99m thyroid scan in patients with GD, especially when surgery is the treatment of choice, helping to tailor suitable surgical procedure for each individual patient.

High neutrophil-to-lymphocyte ratio is associated with relapse in Graves' disease after antithyroid drug therapy

PURPOSE

Antithyroid drugs (ATDs) are effective in controlling hyperthyroidism due to Graves' disease (GD); however, long-term remission rates are low. The neutrophil-to-lymphocyte ratio (NLR) is a useful prognostic marker in many inflammatory diseases. We aimed to evaluate whether NLR can be used as a prognostic marker for relapse in patients with GD after ATD therapy.

METHODS

This retrospective cohort study included 108 patients with newly diagnosed GD who achieved remission after ATD therapy and were followed-up for >12 months after ATD discontinuation. The primary outcome was relapse-free survival (RFS).

RESULTS

Patients were classified into two groups according to baseline NLR: low NLR group with NLR < 1.14 (n = 59; 55%) and high NLR group with NLR ≥ 1.14 (n = 49; 45%). During the median follow-up of 6.5 years, disease relapse after a year of ATD withdrawal occurred in 23 (21%) patients. The patients with high NLR had poorer RFS than those with low NLR, and RFS curves were significantly different between the two groups (p = 0.002). In multivariate analysis, a high NLR (OR = 4.22, p = 0.016) was an independent prognostic factor for relapse in patients with GD after adjusting for age, sex, goiter, orbitopathy, thyroid hormone levels, thyrotropin binding inhibiting immunoglobulin titer, and the duration of ATD therapy.

CONCLUSIONS

This study showed that NLR can be an early and cost-effective prognostic biomarker for relapse in patients with GD after ATD therapy. Further studies are needed to validate the prognostic role of NLR in GD.

Benign Thyroid Diseases: Are There Gender-Specific Differences for Diagnosis and Treatment of Nontoxic Thyroid Nodules? Results from a 4-Year Retrospective Analysis of an Endocrine Tumor Board

Introduction

Benign nodular goiters are endemic in Germany and diagnostic thyroidectomy is one of the most frequent surgical procedures. Less than 10% result in a malignant finding which is a poor ratio in comparison to other European countries. There is a female preponderance in almost all thyroid pathologies according to the current literature but not much is known concerning gender-specific differences in thyroid nodules.

Objective

We aimed at finding gender-specific differences in diagnosis and treatment of nontoxic thyroid nodules and focused on preoperative workup as well as cytological and histological findings of patients with solitary and multinodular nontoxic goiters.

Methods

We retrospectively analyzed 392 cases out of 693 thyroid cases managed interdisciplinarily by the endocrine board of a university center between January 2015 and December 2018 (4 years).

Results

The combination of fine needle biopsy and interdisciplinary case discussion resulted in a rate of malignancy of 28.9% in patients undergoing surgery for solitary and multinodular nontoxic goiter. Although there was no significant gender-specific difference in the distributions and malignancy rates of Bethesda categories, male patients had a significantly higher malignancy rate of 40% in our collective (p = 0.04).

Conclusions

Surgical treatment for male patients with suspicious hypofunctioning thyroid nodules should be favored. However, well-designed prospective studies are required to investigate gender-specific recommendations for the treatment of benign thyroid diseases in the future.

Pharmacodynamic Response to Anti-thyroid Drugs in Graves' Hyperthyroidism

Objective: Graves' disease is the commonest cause of hyperthyroidism in populations with sufficient dietary iodine intake. Anti-thyroid drugs (ATD) are often used as the initial treatment for Graves' hyperthyroidism, however there is a paucity of data relating the dose of ATD therapy to the effect on thyroid hormone levels, increasing the risk of both over- and under-treatment. We aimed to determine the pharmacodynamic response to the ATD carbimazole. Design: Retrospective cohort study. Methods: Participants were patients (n = 441) diagnosed with Graves' disease at Imperial College Healthcare NHS Trust between 2009 and 2018. The main outcome measure was change in thyroid hormone levels in response to ATD. Results: Baseline thyroid hormone levels were positively associated with TSH receptor antibody titres (P < 0.0001). Baseline free triiodothyronine (fT3) were linearly related to free thyroxine (fT4) levels in the hyperthyroid state (fT3 = fT4^*0.97-11), and fell proportionately with carbimazole. The percentage falls in fT4 and fT3 per day were associated with carbimazole dose (P < 0.0001). The magnitude of fall in thyroid hormones after the same dose of carbimazole was lower during follow up than at the initiation visit. The fall in thyroid hormone levels approximated to a linear response if assessed at least 3 weeks after commencement of carbimazole. Following withdrawal of antithyroid drug treatment, the risk of relapse was greater in patients with higher initial fT4, initial TSH receptor antibody titre, males, smokers, and British Caucasian ethnicity. Conclusion: We identify a dose-response relationship for fall in thyroid hormones in response to carbimazole to aid in the selection of dose for Graves' hyperthyroidism.

Corticosteroid Pulse Therapy for Graves' Ophthalmopathy Reduces the Relapse Rate of Graves' Hyperthyroidism

Background: A course of anti-thyroid drugs (ATD) is the most common first line treatment for Graves' hyperthyroidism. However, hyperthyroidism relapse is frequent (30-70%). Due to the autoimmune nature of Graves' disease, the immunosuppressive treatment used for active Graves' orbitopathy (GO) may reduce the relapses after ATD discontinuation. Objective: To evaluate the recurrence rate in Graves' patients who, in addition to standard ATD, were treated or not treated with parenteral methylprednisolone (MPDS) for GO. Methods: Single-center retrospective study in a continuous series of 162 newly diagnosed Graves' patients, with or without GO, all gone into remission and followed-up until hyperthyroidism recurrence or at least 4 years after ATD discontinuation. Patients with moderate-severe active GO underwent middle dose MPDS treatment according to the EuGoGo guidelines. Cox proportional-hazard model was used to comparatively evaluate the risk of recurrence and the predictive factors in patients treated or not treated with MPDS pulse therapy. Results: MPDS treatment was the most significant factor that independently correlated with a reduced risk of hyperthyroidism relapse (HR = 0.53, 95% C.I. = 0.31-0.89). FT3 and female sex were also independent protective factors, while age almost reached the significance level, p = 0.062. The efficacy of MPDS was very high in patients aged <40 years (42.1% decrease in relapses, p < 0.01) but it was not significant in older patients. Discussion: Our study found that after ATD discontinuation the frequency of Graves' hyperthyroidism relapse was reduced in patients treated with MPDS pulse therapy for GO. This effect was more marked in young patients.

When should antithyroid drug therapy to reduce the relapse rate of hyperthyroidism in Graves' disease be discontinued?

OBJECTIVE

The use of antithyroid drug (ATD) therapy in patients with Graves' disease (GD) hyperthyroidism has been increasing, but ATD therapy is associated with a higher relapse rate. We aimed to evaluate clinical factors for predicting relapse of GD after ATD therapy.

METHODS

Patients (n = 149) with newly diagnosed GD who achieved remission of hyperthyroidism after ATD therapy (≥6 months) were followed up for >18 months after ATD withdrawal. We evaluated the predictive factors of relapse during a median of 6.9 years of follow-up.

RESULTS

Disease relapse occurred in 52 patients (34.9%). By multivariate analyses, a duration of the minimum maintenance dose therapy (MMDT) of <6 months was a significant factor in disease relapse (hazard ratio [HR], 2.58; 95% confidence interval [CI], 1.47-4.52; p < 0.001), and a T3/free T4 (fT4) ratio > 120 at ATD withdrawal was significantly more frequent in patients with relapse (HR 2.43; 95% CI, 1.36-4.34; p = 0.002). In the prediction-of-relapse model, the likelihood of relapse was greater in the high-risk group, which had a short MMDT duration and a T3/fT4 ratio ≥120 (HR, 5.81; 95% CI, 2.52-13.39; p < 0.001) and the intermediate-risk group, which had a short MMDT duration or a T3/fT4 ratio < 120 (HR, 2.77; 95% CI, 1.26-6.13; p < 0.001), than in the low-risk group, which had a long MMDT duration and a T3/fT4 ratio < 120.

CONCLUSION

An MMDT longer than 6 months and a high T3/fT4 ratio at ATD withdrawal were independent predictors of relapse in patients who achieved initial remission after ATD for GD. These factors could be used to determine the optimal time to withdraw ATD during the treatment of GD hyperthyroidism.

The Influence of Juvenile Graves' Ophthalmopathy on Graves' Disease Course

Purpose

To investigate juvenile Graves' ophthalmopathy (GO) signs and compare Graves' disease (GD) course in patients with or without GO.

Patients and Methods

There were analyzed data (visual acuity, proptosis, palpebral fissure measurements, clinical activity score (CAS), and the course of GD) of 67 children who have been newly diagnosed with GD. 26.9% of patients with GD had signs of ophthalmopathy (GO+), and 73.1% were without ophthalmopathy (GO−).

Results

Upper eyelid retraction (72.3%), proptosis (66.7%), and soft tissue changes (27.8−38.9%) were in GO+ patients. The palpebral fissure, CAS, and proptosis values were greater in the GO+ group than in the GO− group (p < 0.001). GD course in GO+ patients was longer than that in GO− patients (p < 0.001). The duration of the first remission was longer in GO− than in GO+ patients (p < 0.001). The duration of first remission was longer than one year for 61.2% in GO− and 33.3% in GO+ patients (p < 0.02).

Conclusion

The common manifestations of juvenile GO patients were upper eyelid retraction, proptosis, and soft tissue involvement. The study demonstrates that pediatric patients with GO are more likely to have a severe course of autoimmune thyroid disease.

Antithyroid Drug Therapy for Graves' Disease and Implications for Recurrence

Graves' disease (GD) is the most common cause of hyperthyroidism worldwide. Current therapeutic options for GD include antithyroid drugs (ATD), radioactive iodine, and thyroidectomy. ATD treatment is generally well accepted by patients and clinicians due to some advantages including normalizing thyroid function in a short time, hardly causing hypothyroidism, and ameliorating immune disorder while avoiding radiation exposure and invasive procedures. However, the relatively high recurrence rate is a major concern for ATD treatment, which is associated with multiple influencing factors like clinical characteristics, treatment strategies, and genetic and environmental factors. Of these influencing factors, some are modifiable but some are nonmodifiable. The recurrence risk can be reduced by adjusting the modifiable factors as much as possible. The titration regimen for 12-18 months is the optimal strategy of ATD. Levothyroxine administration after successful ATD treatment was not recommended. The addition of immunosuppressive drugs might be helpful to decrease the recurrence rate of GD patients after ATD withdrawal, whereas further studies are needed to address the safety and efficacy. This paper reviewed the current knowledge of ATD treatment and mainly focused on influencing factors for recurrence in GD patients with ATD treatment.

Novel Application of Quantitative Single-Photon Emission Computed Tomography/Computed Tomography to Predict Early Response to Methimazole in Graves' Disease

Objective

Since Graves' disease (GD) is resistant to antithyroid drugs (ATDs), an accurate quantitative thyroid function measurement is required for the prediction of early responses to ATD. Quantitative parameters derived from the novel technology, single-photon emission computed tomography/computed tomography (SPECT/CT), were investigated for the prediction of achievement of euthyroidism after methimazole (MMI) treatment in GD.

Materials and Methods

A total of 36 GD patients (10 males, 26 females; mean age, 45.3 ± 13.8 years) were enrolled for this study, from April 2015 to January 2016. They underwent quantitative thyroid SPECT/CT 20 minutes post-injection of ^99mTc-pertechnetate (5 mCi). Association between the time to biochemical euthyroidism after MMI treatment and %uptake, standardized uptake value (SUV), functional thyroid mass (SUVmean × thyroid volume) from the SPECT/CT, and clinical/biochemical variables, were investigated.

Results

GD patients had a significantly greater %uptake (6.9 ± 6.4%) than historical control euthyroid patients (n = 20, 0.8 ± 0.5%, p < 0.001) from the same quantitative SPECT/CT protocol. Euthyroidism was achieved in 14 patients at 156 ± 62 days post-MMI treatment, but 22 patients had still not achieved euthyroidism by the last follow-up time-point (208 ± 80 days). In the univariate Cox regression analysis, the initial MMI dose (p = 0.014), %uptake (p = 0.015), and functional thyroid mass (p = 0.016) were significant predictors of euthyroidism in response to MMI treatment. However, only %uptake remained significant in a multivariate Cox regression analysis (p = 0.034). A %uptake cutoff of 5.0% dichotomized the faster responding versus the slower responding GD patients (p = 0.006).

Conclusion

A novel parameter of thyroid %uptake from quantitative SPECT/CT is a predictive indicator of an early response to MMI in GD patients.

Predictive Value of Gene Polymorphisms on Recurrence after the Withdrawal of Antithyroid Drugs in Patients with Graves' Disease

Graves' disease (GD) is one of the most common endocrine diseases. Antithyroid drugs (ATDs) treatment is frequently used as the first-choice therapy for GD patients in most countries due to the superiority in safety and tolerance. However, GD patients treated with ATD have a relatively high recurrence rate after drug withdrawal, which is a main limitation for ATD treatment. It is of great importance to identify some predictors of the higher recurrence risk for GD patients, which may facilitate an appropriate therapeutic approach for a given patient at the time of GD diagnosis. The genetic factor was widely believed to be an important pathogenesis for GD. Increasing studies were conducted to investigate the relationship between gene polymorphisms and the recurrence risk in GD patients. In this article, we updated the current literatures to highlight the predictive value of gene polymorphisms on recurrence risk in GD patients after ATD withdrawal. Some gene polymorphisms, such as CTLA4 rs231775, human leukocyte antigen polymorphisms (DRB1*03, DQA1*05, and DQB1*02) might be associated with the high recurrence risk in GD patients. Further prospective studies on patients of different ethnicities, especially studies with large sample sizes, and long-term follow-up, should be conducted to confirm the predictive roles of gene polymorphism.

Predictive factors for early response to methimazole in children and adolescents with Graves disease: a single-institute study between 1993 and 2013

PURPOSE

We aimed to investigate the predictive factors for early response to methimazole (MMI) in pediatric patients with Graves disease (GD).

METHODS

Our study included 44 pediatric patients who were diagnosed with GD between January 1, 1993, and December 31, 2013, and were available for follow-up, achieving a normalization of thyroid functions (TFs) at the Chonbuk National University Hospital Pediatric Department. We retrospectively analyzed TFs such as tri-iodothyronine (T3), free thyroxine (fT4), thyroid-stimulating hormone (TSH), and thyroid antibody levels at diagnosis. We also examined their family history of thyroid disease, symptoms at presentation, and normalization time for TF after treatment. We divided our clinical series of patients into the following 4 age groups: <7 years old, 7-12 years old, 13-15 years old, and 16-18 years old.

RESULTS

At diagnosis, the time of normalization of T3 was significantly shorter in the higher antimicrosomal antibody (AMA) group compared with the lower AMA group (2.53 months vs. 6.18 months) (P<0.05). However, the time of normalization of T3/fT4/TSH had no significant correlations with other variables such as age, sex, a family history of thyroid diseases, thyroglobulin, thyroid-stimulating immunoglobulin, or antithyroglobulin antibody (ATA).

CONCLUSION

Higher serological titers of AMA at diagnosis may have prognostic value in the response to initial MMI treatment in pediatric hyperthyroid GD patients.

Transient Hypothyroidism after Radioiodine for Graves' Disease: Challenges in Interpreting Thyroid Function Tests

Graves' disease is the most common cause of hyperthyroidism and is often managed with radioactive iodine (RAI) therapy. With current dosing schemes, the vast majority of patients develop permanent post-RAI hypothyroidism and are placed on life-long levothyroxine therapy. This hypothyroidism typically occurs within the first 3 to 6 months after RAI therapy is administered. Indeed, patients are typically told to expect life-long thyroid hormone replacement therapy to be required within this timeframe and many providers expect this post-RAI hypothyroidism to be complete and permanent. There is, however, a small subset of patients in whom a transient post-RAI hypothyroidism develops which, initially, presents exactly as the typical permanent hypothyroidism. In some cases the transient hypothyroidism leads to a period of euthyroidism of variable duration eventually progressing to permanent hypothyroidism. In others, persistent hyperthyroidism requires a second dose of RAI. Failure to appreciate and recognize the possibility of transient post-RAI hypothyroidism can delay optimal and appropriate treatment of the patient. We herein describe five cases of transient post-RAI hypothyroidism which highlight this unusual sequence of events. Increased awareness of this possible outcome after RAI for Graves' disease will help in the timely management of patients.

Technetium uptake predicts remission and relapse in Grave's disease patients on antithyroid drugs for at least 1 year in South Indian subjects

CONTEXT

Most of the information on remission related factors in Grave's disease are derived from Western literature. It is likely that there may be additional prognostic factors and differences in the postdrug treatment course of Grave's disease in India.

AIM

To study factors which predict remission/relapse in Grave's disease patients from South India. Also to establish if technetium (Tc) uptake has a role in predicting remission.

SUBJECTS AND METHODS

Records of 174 patients with clinical, biochemical, and scintigraphic criteria consistent with Grave's disease, seen in our Institution between January 2006 and 2014 were analyzed. Patient factors, drug-related factors, Tc-99m uptake and other clinical factors were compared between the remission and nonremission groups.

STATISTICAL ANALYSIS USED

Mann-Whitney U-test and Chi-square tests were used when appropriate to compare the groups.

RESULTS

Fifty-seven (32.7%) patients attained remission after at least 1 year of thionamide therapy. Of these, 11 (19.2%) patients relapsed within 1 year. Age, gender, goiter, and presence of extrathyroidal manifestations were not associated with remission. Higher values of Tc uptake were positively associated with remission (P- 0.02). Time to achievement of normal thyroid function and composite dose: Time scores were significantly associated with remission (P - 0.05 and P - 0.01, respectively). Patients with lower FT4 at presentation had a higher chance of remission (P - 0.01). The relapse rates were lower than previously reported in the literature. A higher Tc uptake was found to be significantly associated with relapse also (P - 0.009).

CONCLUSION

The prognostic factors associated with remission in Graves's disease in this South Indian study are not the same as that reported in Western literature. Tc scintigraphy may have an additional role in identifying people who are likely to undergo remission and thus predict the outcome of Grave's disease.

Outcome of Radioiodine Therapy in a West African Population

Hyperthyroidism continues to be a pressing public health concern in West Africa. Its prevalence in Africa has been quoted as 1.2%-9.9%, with Graves' disease as its most common cause. Radioiodine-131 (RAI) therapy of hyperthyroidism recently commenced in two government hospitals in Ghana and Nigeria. This is a retrospective analysis of consecutive patients treated with RAI for primary hyperthyroidism at the National Centre for Radiotherapy and Nuclear Medicine (NCRNM) from 2008-2013, and in the University College Hospital (UCH) from 2006-2013. Cure was defined as euthyroidism or hypothyroidism occurring at 6 months post-RAI. Data were analysed using SPSS version 21 and Epi Info version, categorical data were evaluated with the Chi-square test and Fisher's exact test. 94 patients were studied, aged 20-74 years; 78 were females, and 16 were males. 38 were Ghanaian and 56 Nigerian. The presence of thyroid-associated ophthalmopathy (TAO) made cure less likely (χ(2) P = 0.006, odds ratio = 0.118; 95% confidence interval, 0.027-0.518). Other factors assessed proved to be insignificant. Our findings suggest that hyperthyroid patients with TAO will benefit from a higher RAI dose than their counterparts without TAO.

Response to Radioiodine Therapy for Thyrotoxicosis: Disparate Outcomes for an Indigenous Population

Despite 70 years of experience treating thyrotoxic patients with radioiodine not all patients are successfully treated by a single dose. Multiple factors predicting radioiodine efficacy have been reported. The aim of this study was to assess whether ethnicity was associated with radioiodine response. A retrospective review was performed of patients who received radioiodine therapy for thyrotoxicosis from 1 January 2008 to 31 December 2010 and had follow-up available of a minimum of 12 months. 224 patients were included, 82.4% female, and 63.7% had Graves's disease. Radioiodine failed in 21.5% of patients overall, with a higher failure rate in the indigenous population (35.2%). When controlling for other influencing factors by logistic regression, there continued to be an increased risk for the indigenous group (OR 2.82) and those treated with antithyroid drugs following radioiodine (OR 2.04). Younger age was also associated with an increased risk of failing radioiodine therapy (OR 0.97 for each year of age). Cure rates following radioiodine were lower for indigenes independent of factors known to affect radioiodine outcome. This is the first report demonstrating ethnicity as a possible independent variable for radioiodine efficacy. Further work is needed to investigate the cause of this difference.

Effectiveness of Radioiodine Treatment for Toxic Nodular Goiter

OBJECTIVE

The aim of this retrospective study is to evaluate the treatment outcomes in patients with toxic nodular goiter (TNG) that received radioiodine treatment (RAIT) and to determine the influence of age, gender, nodule size, I-131 dose, underlying etiology and antithyroid drugs on the outcomes of RAIT.

METHODS

Two hundred thirty three patients (mean 64±10 years old) with TNG that received RAIT were included in the study. Treatment success was analyzed according to demographic (age and gender) and clinical data (thyroid function tests before and after RAIT, thyroid sonography and scintigraphy, I-131 dose, antithyroid drugs). A fixed dose of 555 MBq was administered to patients with nodules smaller than 2 cm in diameter and of 740 MBq to patients with nodules larger than 2 cm. Hyperthyroidism treatment success was defined as achieving hypothyroidism or euthyroidism six months after RAIT.

RESULTS

In our study, the cure rate was 93.9% six months after RAIT. Hypothyroidism was observed in 74 (31.7%) patients, and euthyroidism was achieved in 145 (62.2%) patients while 14 (6%) patients remained in hyperthyroid state. Age and gender did not affect treatment outcomes. No correlation was found between underlying etiology or antithyroid drugs and therapeutic effectiveness. The effectiveness of RAIT was better in patients with nodules smaller than 2 cm.

CONCLUSION

We observed that high cure rates were obtained in patients with TNG with 555 MBq and 740 MBq doses of I-131. While nodule diameter and RAI dose are important factors for treatment efficacy; age, gender, underlying etiology and antithyroid drugs do not affect the outcome of RAIT.

Stress triggers the onset and the recurrences of hyperthyroidism in patients with Graves' disease

The aim of this study was to evaluate the relationship of stressful events (SE) with the onset and outcome of Graves' disease (GD). Over a period of 21 years, we enrolled 58 consecutive patients in whom at least one SE had occurred ≤12 months before the onset of GD. Patients were treated with antithyroid drugs (ATD) for ≥12 months and followed up for ≥5 years after ATD withdrawal. We divided patients in three groups: REM (who reached remission; 25.9%); EXA (who experienced ≥1 exacerbation during ATD; 10.3%); and REL (who experienced ≥1 relapse after ATD withdrawal; 63.8%). The average age at onset was similar in the three groups. All males aged ≤25 years at GD onset relapsed at least once; no patient aged ≥51 years at GD onset relapsed ≥2 times. All patients who exacerbated or relapsed had at least one SE preceding each exacerbation or relapse. The time lag between SE and onset of GD (19.3±11.9 weeks) correlated with the age at onset (r=0.292, P=0.0002), particularly in the REL group (r=0.346, P=0.001). Overall, EXA and REL patients experienced more SE than REM patients (P=0.0002 and P=0.003, respectively). In the REL group, the overall number of SE was correlated with the number of relapses (r=0.486, P<0.0001). There exist GD patients who are prone to develop hyperthyroidism and its recurrences when exposed to SE. They are relatively young; the younger these patients are, the shorter is the time lag between SE and the onset of hyperthyroidism.

The relationship between sex and symmetry in thyroid eye disease

Purpose

To examine the relationships between sex and symmetry in the context of disease activity, severity, and thyroid status in thyroid eye disease.

Methods

Retrospective chart review of 31 men and 31 women with untreated thyroid eye disease. Subjective complaints, smoking status, thyroid status, and objective findings pertinent to the clinical activity score (CAS) and “NO SPECS” classification were recorded. Overall disease asymmetry was defined as having simultaneous asymmetry of both more than one symptom and more than one external finding. Asymmetry was compared across sex and thyroid status. CAS and NO SPECS severity were compared across sex, symmetry, and thyroid status.

Results

Asymmetric appearance was reported by 58% of men and 19% of women. Asymmetric proptosis (>2 mm difference) was seen in 45% of men and 23% of women (P=0.036). Overall asymmetry was seen in 55% of men and 19% of women (P=0.017). Thyroid status and sex had a combined effect on symmetry, as 15 of 16 hyperthyroid females (94%) demonstrated symmetric disease. Average NO SPECS severity was 3.5 (standard deviation [SD] 1.4) in men and 3.3 (SD 1.1) in women (P=0.51), and was 3.8 (SD 1.4) in asymmetric patients versus 3.2 (SD 1.3) in symmetric patients (P=0.08). The CAS was higher in asymmetric than symmetric patients (1.84 versus 0.97; P=0.012).

Conclusion

Men demonstrated more asymmetric disease (proptosis and overall asymmetry) than women, while hyperthyroid females demonstrated more symmetry than euthyroid and hypothyroid males and females. NO SPECS severity score was unaffected by sex, thyroid status, or symmetry. Asymmetric patients demonstrated higher clinical activity scores.

Failure of radioactive iodine in the treatment of hyperthyroidism

BACKGROUND

Persistent or recurrent hyperthyroidism after treatment with radioactive iodine (RAI) is common and many patients require either additional doses or surgery before they are cured. The purpose of this study was to identify patterns and predictors of failure of RAI in patients with hyperthyroidism.

METHODS

We conducted a retrospective review of patients treated with RAI from 2007 to 2010. Failure of RAI was defined as receipt of additional dose(s) and/or total thyroidectomy. Using a Cox proportional hazards model, we conducted univariate analysis to identify factors associated with failure of RAI. A final multivariate model was then constructed with significant (p < 0.05) variables from the univariate analysis.

RESULTS

Of the 325 patients analyzed, 74 patients (22.8 %) failed initial RAI treatment, 53 (71.6 %) received additional RAI, 13 (17.6 %) received additional RAI followed by surgery, and the remaining 8 (10.8 %) were cured after thyroidectomy. The percentage of patients who failed decreased in a stepwise fashion as RAI dose increased. Similarly, the incidence of failure increased as the presenting T3 level increased. Sensitivity analysis revealed that RAI doses <12.5 mCi were associated with failure while initial T3 and free T4 levels of at least 4.5 pg/mL and 2.3 ng/dL, respectively, were associated with failure. In the final multivariate analysis, higher T4 (hazard ratio [HR] 1.13; 95 % confidence interval [CI] 1.02-1.26; p = 0.02) and methimazole treatment (HR 2.55; 95 % CI 1.22-5.33; p = 0.01) were associated with failure.

CONCLUSIONS

Laboratory values at presentation can predict which patients with hyperthyroidism are at risk for failing RAI treatment. Higher doses of RAI or surgical referral may prevent the need for repeat RAI in selected patients.

Diagnosis and management of Graves disease: a global overview

Graves disease is an autoimmune disorder characterized by goitre, hyperthyroidism and, in 25% of patients, Graves ophthalmopathy. The hyperthyroidism is caused by thyroid hypertrophy and stimulation of function, resulting from interaction of anti-TSH-receptor antibodies (TRAb) with the TSH receptor on thyroid follicular cells. Measurements of serum levels of TRAb and thyroid ultrasonography represent the most important diagnostic tests for Graves disease. Management of the condition currently relies on antithyroid drugs, which mainly inhibit thyroid hormone synthesis, or ablative treatments ((131)I-radiotherapy or thyroidectomy) that remove or decrease thyroid tissue. None of these treatments targets the disease process, and patients with treated Graves disease consequently experience either a high rate of recurrence, if receiving antithyroid drugs, or lifelong hypothyroidism, after ablative therapy. Geographical differences in the use of these therapies exist, partially owing to the availability of skilled thyroid surgeons and suitable nuclear medicine units. Novel agents that might act on the disease process are currently under evaluation in preclinical or clinical studies, but evidence of their efficacy and safety is lacking.

Prevalence and risk factors for thyroid eye disease among Korean dysthyroid patients

Purpose

To determine the prevalence of thyroid eye disease among dysthyroid Korean patients and to analyze the relationship between demographic data, lifestyle risk factors, and status of thyroid disease and thyroid eye disease.

Methods

All dysthyroid patients who visited endocrinology clinics in 24 general hospitals in Korea during a chosen one-week period were enrolled in this cross-sectional study. Data were collected during an interviewer-administered questionnaire and chart review. Demographic data, lifestyle risk factors, and status of thyroid disease variables were analyzed as risk factors using multivariable regression models to identify independent associations with thyroid eye disease.

Results

A total of 1,632 dysthyroid patients were included (1,301 females [79.7%] and 331 males [20.3%]). Two hundred eighty-three of these patients (17.3%) had thyroid eye disease. Multiple logistic regression analyses revealed that female gender, young age, Graves' disease, dermopathy, anti-thyroid medication treatment, and radioiodine treatment were independent risk factors for thyroid eye disease.

Conclusions

The lower prevalence of thyroid eye disease in dysthyroid Korean patients and the influence of gender on risk factors in this study are novel findings compared to studies performed involving Europeans. Although the risk factors for thyroid eye disease are understood in part, a more in-depth comparative study of gender and ethnic groups is needed to fully understand the biological significance of the demographic factors.

Predictors of long-term remission in patients with Graves' disease: a single center experience

Antithyroid drugs (ATDs) remain the first-line therapy in patients with Graves' disease (GD), despite a high relapse rate. The purpose of this study was to identify the predictors of remission in patients with GD treated with ATDs-retrospective study at an endocrine referral service in Northern Greece. Two-hundred and eleven patients met the study's criteria. Females (p = 0.049), non-smokers (p = 0.017), patients without ophthalmopathy (p = 0.033), and those developing pharmaceutical hypothyroidism (p = 0.018) experienced longer duration of remission. Duration of remission was positively associated with therapy duration (r s = 0.151, p = 0.030), maximum TSH levels during (r s = 0.241, p = 0.001), at the end (r s = 0.280, p < 0.001) and 3 months after therapy (r s = 0.341, p = 0.003). There was a negative association with free T4 (FT4) (r s = -0.426, p < 0.001) and free triiodothyronine (FT3) (r s = -0.467, p = 0.038) levels at 6 months after ATDs discontinuation. In multiple-regression analysis, only duration of the first ATDs course for more than 24 months independently predicted duration of remission. Female gender, non-smoking, the absence of orbitopathy, treatment duration, pharmaceutical hypothyroidism, higher TSH levels during, at the end and 3 months after ATDs discontinuation, and lower FT4 and FT3 levels 6 months after therapy were associated with longer duration of remission. However, only duration of ATDs therapy for more than 24 months independently predicted predict long-term remission in GD.

Clinical experience with radioactive iodine in the treatment of childhood and adolescent Graves' disease

BACKGROUND/AIMS

Treatments for Graves' disease (GD) in children and adolescents include oral antithyroid drugs (ATDs), near total thyroidectomy, and radioactive iodine (RAI). ATDs remain the preferred choice in this age group, but because persistent remission occurs in 30% of cases, RAI is becoming a common option for definitive therapy.

METHODS

We performed a review of 65 medical records of GD patients under age 19 years who were followed between 1985 and 2005.

RESULTS

The prevalence of GD was higher in females (3:1) and during puberty (for both genders). If no remission was detected during ATD treatment, RAI was indicated when the following criteria were present: non-compliance, relapse, or side effects that were related to ATDs, large goiter, and long-term use of ATDs. The majority of patients developed hypothyroidism within 6 months after RAI. A progressive higher dose regimen was implemented in the last 10 years of the study period. A second RAI dose was necessary in eight cases. During the follow-up period, three pregnancies occurred. One patient with a thyroid nodule and benign cytology was detected.

CONCLUSIONS

RAI therapy is effective and safe in the treatment of GD in children and adolescents.

Hyperthyroidism in childhood: causes, when and how to treat

Graves' disease (GD) is the most common cause of hyperthyroidism in children. This review gives an overview and update of management of GD. Antithyroid drugs (ATD) are recommended as the initial treatment, but the major problem is the high relapse rate (30%) as remission is achieved after a first course of ATD. More prolonged medical treatment may increase the remission rate up to 50%. Alternative treatments, such as radioactive iodine or thyroidectomy, are considered in cases of relapse, lack of compliance, or ATD toxicity. Therefore, clinicians have sought prognostic indicators of remission. Relapse risk decreases with longer duration of the first course of ATD treatment, highlighting the positive impact of a long period of primary ATD treatment on outcome. The identification of other predictive factors such as severe biochemical hyperthyroidism at diagnosis, young age, and absence of other autoimmune conditions has made it possible to stratify patients according to the risk of relapse after ATD treatment, leading to improvement in patient management by facilitating the identification of patients requiring long-term ATD or early alternative therapy. Neonatal autoimmune hyperthyroidism is generally transient, occurring in only about 2% of the offspring of mothers with GD. Cardiac insufficiency, intrauterine growth retardation, craniostenosis, microcephaly and psychomotor disabilities are the major risks in these infants and highlight the importance of thyroid hormone receptor antibody determination throughout pregnancy in women with GD, as well as highlighting the need for early diagnosis and treatment of hyperthyroidism.

Toll-like receptor gene polymorphisms are associated with susceptibility to Graves' ophthalmopathy in Taiwan males

BACKGROUND

Toll-like receptors (TLRs) are a family of pattern-recognition receptors, which plays a role in eliciting innate/adaptive immune responses and developing chronic inflammation. The polymorphisms of TLRs have been associated with the risk of various autoimmune diseases, including systemic lupus erythematosus (SLE), multiple sclerosis and rheumatorid arthritis. The aim of this study was to evaluate whether TLR genes could be used as genetic markers for the development of Graves' ophthalmopathy (GO).

METHODS

6 TLR-4 and 2 TLR-9 gene polymorphisms in 471 GD patients (200 patients with GO and 271 patients without GO) from a Taiwan Chinese population were evaluated.

RESULTS

No statistically significant difference was observed in the genotypic and allelic frequencies of TLR-4 and TLR-9 gene polymorphisms between the GD patients with and without GO. However, sex-stratified analyses showed that the association between TLR-9 gene polymorphism and GO phenotype was more pronounced in the male patients. The odds ratios (ORs) was 2.11 (95% confidence interval [CI] = 1.14-3.91) for rs187084 AàG polymorphism and 1.97 (95% CI = 1.07-3.62) for rs352140 AàG polymorphism among the male patients. Increasing one G allele of rs287084 and one A allele of rs352140 increased the risk of GO (p values for trend tests were 0.0195 and 0.0345, respectively). Further, in haplotype analyses, the male patients carrying the GA haplotype had a higher risk of GO (odds ratio [OR] = 2.02, 95% confidence interval [CI] = 1.09-3.73) than those not carrying the GA haplotype.

CONCLUSION

The present data suggest that TLR-9 gene polymorphisms were significantly associated with increased susceptibility of ophthalmopathy in male GD patients.

Juvenile thyrotoxicosis; can we do better?

Thyrotoxicosis remains a frustrating condition for the young person, family, and health professionals involved. The associated symptoms do not always suggest thyroid disease and patients can be unwell for many months before the diagnosis is made. The antithyroid drug regimen used to treat children and adolescents with thyrotoxicosis varies from one unit to another and yet the potentially life threatening side effects and remission rates post-treatment may be related to the regimen used. Most patients with thyrotoxicosis will need many years of drug therapy if the thyroid gland is not removed surgically or destroyed by radioiodine. Even "definitive" treatment will typically necessitate thyroxine replacement for life.