Radioiodine ablation of the thyroid to prevent recurrence of amiodarone-induced thyrotoxicosis in patients with resistant tachyarrhythmias

A NEW HYPOTHESIS IN THE TREATMENT OF RECURRENT GLIOBLASTOMA MULTIFORME (GBM). PART 1: INTRODUCTION

Modern treatment of glioblastoma multiforme (GBM) is based on neurosurgical methods combined with radiotherapy and chemotherapy. The prognosis for patients with GBM is extremely poor. Often, complete removal of the tumor is impossible and it often recurs. Therefore, in addition to standard regimens, modern methods such as modulated electrohyperthermia, monoclonal antibodies and individualised multimodal immunotherapy (IMI) based on vaccines and oncolytic viruses are also used in the treatment of GBM. Radioiodine therapy (RIT) also holds out hope for an effective treatment of this extremely aggressive brain tumor. The expression of the sodium iodide symporter (NIS) gene has been proven to have a positive effect on the treatment of selected cancers. Research confirm the presence of expression of this gene in GBM cells, although only in animal studies. Is it possible and therapeutically effective to treat GBM with RIT without the use of an exogenous NIS gene? The safety of therapy is relevant, as the only more serious adverse effect may be hypothyroidism. The use of RIT requires further clinical studies in patients. Perhaps it is worth revolutionizing GBM therapy to give sufferers a "new life".

[Clinical practice guidelines for acute and chronic thyroiditis (excluding autoimmune thyroiditis)]

Острые и хронические заболевания щитовидной железы занимают второе место по выявляемости после сахарного диабета. Всемирная организация здравоохранения отмечает ежегодную тенденцию к увеличению числа заболеваний щитовидной железы. В настоящих клинических рекомендациях будут рассмотрены вопросы этиологии, клинического течения, диагностики и лечения острых и хронических (за исключением аутоиммунного) воспалительных заболеваний щитовидной железы.Клинические рекомендации — это основной рабочий инструмент практикующего врача, как специалиста, так и врача узкой практики. Лаконичность, структурированность сведений об определенной нозологии, методов ее диагностики и лечения, базирующихся на принципах доказательной медицины, позволяют в короткий срок дать тот или иной ответ на интересующий вопрос специалисту, добиваться максимальной эффективности и персонализации лечения.Клинические рекомендации составлены профессиональным сообществом узких специалистов, одобрены экспертным советом Министерства здравоохранения РФ. Представленные рекомендации содержат максимально полную информацию, которая требуется на этапе диагностики острых и хронических тиреоидитов, этапе выбора тактики ведения пациентов с тиреоидитом, а также на этапе лечения пациента.Рабочая группа представляет этот проект в профессиональном журнале, посвященном актуальным проблемам эндокринологии, с целью повышения качества оказываемой медицинской помощи, повышения эффективности лечения острых и хронических тиреоидитов путем ознакомления с полным тестом клинических рекомендаций по острым и хроническим тиреоидитам (исключая аутоиммунный тиреоидит) максимально возможного количества специалистов в области не только эндокринологии, но и медицины общей (семейной) практики.

Management of Amiodarone-Induced Thyrotoxicosis at a Cardiac Transplantation Centre

Background: Amiodarone-induced thyrotoxicosis (AIT) is associated with significant morbidity and mortality, particularly in patients with cardiac failure. The aim of the study was to evaluate the management of AIT at a tertiary hospital specialising in cardiac failure and transplantation. Methods: Retrospective audit of 66 patients treated for AIT by Endocrinology (2007-2016), classified as type 1 (T1) or type 2 (T2) based on radiological criteria. Main outcome measurements were response rate to initial treatment, time to euthyroidism, and frequency/safety of thyroidectomy. Results: Mean age was 60 ± 2 years; 80% were male. Sixty-four patients commenced medical treatment: thionamides (THIO) in 23, glucocorticoids (GC) in 17 and combination (COMB) in 24. Median thyroxine (fT4) was 35.1 (31.2-46.7) in THIO, 43.1 (30.4 -60.7) in GC, and 60.0 (39.0 ->99.9) pmol/L in COMB (p = 0.01). Initial therapy induced euthyroidism in 52%: 70% THIO, 53% GC, and 33% COMB (p = 0.045) by 100 (49-167), 47 (35-61), and 53 (45-99) days, respectively (p = 0.02). A further 11% became euthyroid after transitioning from monotherapy to COMB. Thyroidectomy was undertaken in 33%. Patients who underwent thyroidectomy were younger (54 ± 3 vs. 63 ± 2 years; p = 0.03), with higher prevalence of severely impaired left ventricular function prior to diagnosis of AIT (38 vs. 18%; p = 0.08). Despite median American Society of Anaesthesiologists classification 4, no thyroidectomy patient experienced cardiorespiratory complications/death. Conclusions: Patients with AIT had limited response to medical treatment. The poorest response was observed in COMB group, likely related to greater hyperthyroidism severity. Thyroidectomy is safe in patients with severe cardiac failure if performed in a centre with cardiac anaesthetic expertise. There should be low threshold for proceeding to thyroidectomy in patients with severe AIT and/or cardiac failure.

2016 American Thyroid Association Guidelines for Diagnosis and Management of Hyperthyroidism and Other Causes of Thyrotoxicosis

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.

Dysfunction of the thyroid gland during amiodarone therapy: a study of 297 cases

AIM

This study aims to explore and compare the efficacy of radioiodine treatment (RIT) in hyperthyroid and euthyroid patients who have been treated with amiodarone (AM) in the past or are currently undergoing AM treatment. Clinical observation of a group of patients with amiodarone-induced hypothyroidism during a 12-month follow-up period was used for comparison.

DESIGN

This was a observational, two-centered study. Patients were assessed at baseline and at 2 months, 6 months, 8 months, and 12 months after RIT.

PATIENTS

Group A: At baseline (61 males [M] and 17 females [F], mean age 50±19 years), there were 78 euthyroid patients with cardiac arrhythmias, who were treated with AM and developed amiodarone-induced thyrotoxicosis, and currently require retreatment with AM. Group B: Hyperthyroid patients (92 M and 26 F, mean age 72±11.8 years) after AM therapy in the past. Group C: Hyperthyroid patients (66 M and 13 F, mean age 63.9±13.2 years) currently treated by AM. Group D: Hypothyroid patients (6 M and 16 F, mean age 61.4±10.4 years) after AM therapy. The patients from Groups A, B, and C were retreated with AM after ~3-6 weeks of RIT.

RESULTS

In Group A, after 12 months of RIT therapy, recurrent thyrotoxicosis was observed in six (7.7%) cases, and persistent hypothyroidism was diagnosed in 42 (53.8%) cases. In Group B, hyperthyroidism occurring during treatment with AM was found in 40 (33.9%) patients, and permanent hypothyroidism was observed in eleven (12.5%) cases. After annual follow-up in Group C, nine (11.4%) patients were diagnosed with hypothyroidism, while 27 (34.1%) patients were diagnosed with hyperthyroidism. In Group D, all patients had permanent hypothyroidism and when the concentration of serum thyroid-stimulating hormone was >10 µIU/mL, l-thyroxine was applied.

CONCLUSION

Our study showed that radioiodine administration is advisable in certain circumstances, even in euthyroid patients. It allows for continuation of further long-term AM treatment. Additionally, RIT allows for the reintroduction of AM therapy that was previously terminated. Hence, it can help control life-threatening tachyarrhythmias and decrease episodes of thyrotoxicosis.

Radioactive iodine in the treatment of type-2 amiodarone-induced thyrotoxicosis

OBJECTIVE

Amiodarone-induced thyrotoxicosis (AIT) is usually classified into two types: type 1, in which a high iodine content triggers the autonomous production of thyroid hormone; and type 2, in which destructive thyroiditis causes the release of preformed thyroid hormone. AIT is a difficult management problem that sometimes requires ablative thyroid therapy. The use of radioactive iodine (RAI) therapy in patients with type-1 AIT who had a 24-hour radioactive iodine uptake (RAIU) value of >10% has been previously reported. Despite its documented efficacy at usual doses (10-30 mCi) in patients with type-1 AIT, the efficacy of RAI in those with type-2 AIT has never been questioned, because type-2 patients usually have low RAIU. We thought that high adjusted-dose RAI might be an attractive alternative to thyroid gland ablation in patients with type-2 AIT.

PATIENTS AND METHODS

Four patients with type-2 AIT who required thyroid ablation were included in the study. These individuals were either poor candidates for surgery or had refused surgery. The size of the thyroid gland in all subjects was within normal limits, and each thyroid was characterized by a homogenous echotexture on ultrasonography, the absence of vascularity on Doppler sonography, a low (<4%) 24-hour RAIU value and the absence of thyroid autoantibodies-all of which are characteristic of type-2 AIT.

RESULTS

The patients were initially treated with thionamides and glucocorticoids. All patients except one achieved euthyroidism before RAI therapy. All four patients received one dose of RAI (range 29-80 mCi) and followed up for 12 months. No exacerbation of thyrotoxicosis was noted after RAI therapy. Hypothyroidism (in three patients) or euthyroidism (in one patient) was achieved in first six months.

CONCLUSIONS

In patients with type-2 AIT, RAI treatment may be the therapy of choice for thyroid gland ablation.

[Thyroid and treatment with amiodarone diagnosis, therapy and clinical management]

Amiodarone is a frequently used antiarrhythmic drug with a high antiarrhythmic potency. However, beside its antiarrhythmic effects Amiodarone also reveals a variety of adverse effects and drug-related complications. The affected organs include the eyes, skin, lungs, nervous system, liver, gastrointestinal tract and the thyroid. The thyroid is one of the most frequently affected organs by Amiodarone. An altered hormone equilibrium always occurs and has to be distinguished from Amiodarone induced hyperthyroidism and hypothyroidism. The differentiation of these states frequently causes problems and may even be a diagnostic and therapeutic challenge in certain cases. The article gives an overview on the interactions between Amiodarone and the thyroid, the diagnostic and therapeutic options and management strategies of patient on Amiodarone therapy in the view of thyroid function.

A practical guide for clinicians who treat patients with amiodarone: 2007

Amiodarone is commonly used to treat supraventricular and ventricular arrhythmias in various inpatient and outpatient settings. Over- and under-use of amiodarone is common, and data regarding patterns of use are sparse and largely anecdotal. Because of adverse drug reactions, proper use is essential to deriving optimal benefits from the drug with the least risk. This guide updates an earlier version published in 2000, reviews indications for use of amiodarone and recommends strategies to minimize adverse effects. The recommendations included herein are based on the best available data and the collective experience of the member of the writing committee.