Advantages and Disadvantages of Treatment Choices for Thyrotoxicosis

Description
Thyrotoxicosis is a disorder affecting more women than men. Graves disease (autoimmune
hyperthyroidism) is the most frequent presentation. Treatment choices are anti-thyroid drugs, radioiodine and surgery, each with advantages and disadvantages. Decision on the best choice for
individual patient is based on disease state, risk and benefits and preference.
Specific Instructions for the Students:
Briefly describe treatment choices for thyrotoxicosis, regarding
1.
2.
3.

available choices (anti-thyroid drugs, radio-iodine, surgery)

indications, advantages and disadvantages of the above choices in Graves disease
safety issue regarding anti-thyroid drugs used for thyrotoxicosis in pregnancy

A clinical state, known as thyrotoxicosis happen due to excessive thyroid hormone

production , namely, tri-iodothyronine (T3) and thyroxine (T4), by the thyroid gland
for several reasons such as Graves disease (most common), toxic multinodular goiter,
thyroiditis and more.
As for treatment for Graves disease and also for its subsequent complications, three
choices are available to the patient: antithyroid drugs, surgery and radio-iodine therapy.
The therapy form used will differ based on the cause and disease severity, the patients
age and condition and the resource availability1.
Drugs are used as a primary treatment option in newly diagnosed Graves disease
mostly in children, pregnant ladies, patients with medical and surgery complication.
Basically, these drugs prevent the thyroid gland from producing hormones by inhibiting
thyroperoxidase. Thionamides (Carbimazole or propylthiouracil(PTU))used in patients
for long-term relief and also to prepare them for surgery and RAI. This non-invasive
method is also preferred due to lower cost and risk. Some of the drugs shortcomings are
nausea, hepatitis, goiter, have teratogenic effects, allergic reactions and discontinuation
of drugs can lead to recurrence of the disease. Among all, agranulocytosis is the serious
consequence of antithyroid drug that need medical attention and it manifest earlier as
rash, fever or sore throat2. In pregnancy, PTU is preferred and the drug dose is
minimized to reduce fetal goiter risk. As for the breastfeeding mothers, its not
advisable to take these drugs in large doses (PTU >100 mg or Carbimazole >10 mg) for
the same reason. Propanolol is also useful for symptomatic relief in the absence of
contraindications3,4.

For those who experience relapse after treatment, anti-thyroid medication intolerance,
large goiter and with severe progressive opthalmopathy, partial or total thyroidectomy is
preferred4. Surgery candidates are brought to euthyroid state prior to the surgery by
drug use and Lugols iodine to prevent hypothyroidism and the occurrence of heavy
bleeding during the surgery. Complications such as hypocalcemia, infection, voice
hoarseness are possible with this surgery5. Hypothyroidism is an expected outcome as
thyroid gland is being removed, but, fortunately this can be treated with thyroid
replacement hormone.6,7

As for patients other than children, pregnant women and breastfeeding mothers,
radioiodine therapy is considered safe and appropriate to use in 40 years and above to
treat thyrotoxicosis8. Some also favor this method as it effectively controls
hyperthyroidism and reduce goiter size. For those women, who prefer this method, are
advised to not to conceive for at least 9 months after therapy as this method may cause
destruction of foetals thyroid gland9. RAI lowers thyroid hormone levels by destroying
thyroid tissue cells and sometime, different, repeated doses are needed to ensure enough
thyroid tissue are left for balance hormone production. Long-term follow-up is
emphasized to enable early detection of hypothyroidism due to excessive usage of RAI,
but it is easily treatable with levothyroxine. Studies show, with the administration of
anti-thyroid drug with RAI, hypothyroidism occurrences decline about 10%10.
References :
1. Leslie J. DeGroot, M.D.. Graves Disease and the Manifestations of Thyrotoxicosis.
http://www.thyroidmanager.org/chapter/graves-disease-and-the-manifestations-ofthyrotoxicosis/ (accessed 5 November 2014).
2.

Vaidya B. Diagnosis and management of thyrotoxicosis. Clinical Review 8 June

2006; (): 2-4. http://www.bmj.com/content/332/7554/1369 (accessed 6 November
2014).

3. Jayne A Franklyn MD , Kristien Boelaert MD . Thyrotoxicosis. 24 March 2012 ;

379(9821): 1157-1161. http://www.thelancet.com/journals/lancet/article/PIIS01406736(11)60782-4/abstract (accessed 6 November 2014).
4. James Norman MD. Hyperthyroidism: Overactivity of the Thyroid Gland.
http://www.endocrineweb.com/conditions/hyperthyroidism/hyperthyroidismoveractivity-thyroid-gland (accessed 14 November 2014).
5. Mayo Clinic. Graves Condition- Treatment and Drug.
http://www.mayoclinic.org/diseases-conditions/graves-disease/basics/treatment/con20025811 (accessed 14 November 2014).

6. David T. Derrer, MD. Understanding Graves' Disease -- Diagnosis and Treatment.

http://www.webmd.com/women/understanding-graves-disease-treatment?page=2
(accessed 15 November 2014).
7. Peter S. Bernstein, MD, MPH, FACOG, Karen L. Koscica, DO. Thyrotoxicosis in
Pregnancy. http://www.medscape.com/viewarticle/451718 (accessed 17 November
2014).
8. Kirsten Campbell ,Matthew Doogue. Evaluating and managing patients with
thyrotoxicosis. http://www.racgp.org.au/afp/2012/august/evaluating-and-managingpatients-with-thyrotoxicosis/ (accessed 17 November 2014).
9. Grazia Aleppo MD, FACE, FACP. Thyroid Disease in Pregnancy.
http://www.endocrineweb.com/conditions/thyroid/thyroid-problems-pregnancy
(accessed 18 November 2014).
10. JERI R. REID, M.D., STEPHEN F. WHEELER, M.D.,. Hyperthyroidism: Diagnosis
and Treatment. http://www.aafp.org/afp/2005/0815/p623.html (accessed 16
November 2014).