This document discusses the treatment of thyrotoxicosis. The main goals of treatment are to decrease hyperthyroid symptoms and establish a euthyroid state. The main treatment modalities are antithyroid drugs, radiotherapy, and surgery. Antithyroid drugs like methimazole and propylthiouracil work by inhibiting thyroid hormone production. Radioactive iodine treatment involves administering radioactive iodine which is taken up by the thyroid gland to destroy thyroid tissue. Surgery involves removing part or all of the thyroid gland. Selection of treatment depends on factors like severity of symptoms, comorbidities, risks of each treatment, and patient preferences. Long term follow up is needed to monitor thyroid hormone levels and watch

1. TEACHER: DR SVETLANA VLADIMIROVNA
SHAILEE PATEL,GROUP 39, 6th course,2013
TREATMENT
THYROTOXICOSIS

2. GOALS OF TREATMENT: decrease hyperthyroid symptoms
Establish euthyroid state
Treatment is individualized !!!!! Because each patient has different manifestations.
Main treatment modalities:
(any one as initial therapy, then in combination)
ANTITHYROID
DRUGS
RADIOTHERAPY
SURGERY
•WHICH TREATMENT T BEGIN WITH ????
TO
+++ symptomatic therapy………
•Cardiac decompensation,
Hospitalization
• atrial fibrillation,
/icu
• thyroid storm
Consideration is given to appropriate selection of patients for radioiodine
therapy surgery or ATDs, as well as to the indications and contraindications
for this therapy. Patient input into the treatment choice is important and
must be discussed and considered.

3. SURGERY
RADIOACTIVE IODINE
ANTI THYROID DRUGS
Large goiter >80 gm, with
compessive symptoms.
pts with comorbid conditions,with
surgical risks.
High likelyhood of remissions(mildmoderate disease
High TRAb titer >40IU
Young pts (,have >50%chances of
relapse with ATDs)
Low TRAb titers, moderate to severe
Low uptake of IODINE 131 by the
gland ,low/hypofunctioning nodule
Goiter with good uptake of iodine
old Pts with comorbidities :low life
expectancy
Coexistent hyperparathyroidism
Noncompliant to ATD drugs
Pts with risks of surgery,
pregnancy/lactation,children
,with severe ophthalmopathy
Suspected/documented thyroid
malignancy
Previously surgically treated pts.
Previously operated pts or who need
euthyroid state before surgery.
PATIENT SELECTION
PROS
For prompt control of
hyperthyroidism
CONS
Tx for GD ,avoidance of Sx ,cosmetic
scar,betarays travel 2mm/nt damage
surring tissue.
,can be performed in an outpatient
Patients who cant follow safety rules
of radiations,in nursing homes/outpt.
Avoidance Sx,radiation,
Possibility of remission
setting
Needs lifelong thyroxine
replacement,
Need prior methimisole before Sx
Needs lifelong thyroxine
replacement,
Need prior methimisole before
radiation
Needs constant monitoring and
dose adjustments,
more risk of thyroid storm

5. ANTITYROID DRUGS : thioamides
T3 ,fT4
HOW THEY WORK !
•They are actively transported into the
thyroid gland where they inhibit both the
orgaification of iodine to tyrosine residues in
CARBAMIZOLE
thyroglobulin and the coupling of
iodotyrosines
•Immunosuppressive within the thyroid
gland, where the drugs are concentrated,
decreases thyroid antigen expression and
decreases prostaglandin and cytokine
METHIMAZOLE
release from thyroid cells. also inhibit the
generation of oxygen radicals in T cells, B
cells, decline in antigen presentation. PROPYLTHIOURACIL
methimazole induces the expression of Fas
ligand on the thyroid epithelial cell, thus
inducing apoptosis infiltrating T cells
TSH/THYROTROPIN
BLOODSTREAM
HYPERPLASTIC THYROID
FOLLICLE WITH THYROGLOBULIN
BINDING
OF IODIDE
•DECREASE HYPERTHYROID SYMPTOMS
•MAINTAIN EUTHYROID STATE
•AWAIT SPONTANEOUS REMISSION
MONOIODOTYROSINE
DIIODOTYROSINE
ORGANIFICATION/
IODINATION
COUPLING
T4
DECREASED OUTPUT
OF T3 T4
Tg
T3
T3
AIMED AT:
HYPERPLASTIC
THYROID CELLS

6. CARBAMIZOLE
METHIMAZOLE (MMI,tapazole)
10-20 mg 1t/day PO
ADDED IODIDES
Ten times more potent than PTU,
and once-a-day dose is effective.
Euthyroid state is achieved quickly
Relapse may be observed 1-6 mo
The serum half-life of MMI is four to
six hours,
Cross placental barrier, used
from2nd trimester
MONITOR T3 ,Ft4,
EUTHYROID STATE ESTABLISHED IN 4-6 WEEKS
DOSE REDUCED BY 50%
5-10 mg 1t/day PO
CONTRAINDICATIONS
•allergic
reactions:
antihistamine/RAIU/Sx
•WBC,neutrophil<500/
mm3
•Liver
transaminase
>5 times upper normal
limits
MAINTENANCE Tx CONTINUED FOR
12-24 MO.
TAPER, CONTROL T3 T4, NO SYMPTOMS
STOP Rx.
MONITOR EVERY 3 MO FOR NXT YEAR
Major side effects
• agranulocytosis
•Hepatitis,
•hepatic necrosis
•vasculitis.
MMI
Tx :reduce dose
steroids
JAUNDICE, ACHOLIC
STOOLS ,DARK URINE
PRURITIC RASH PTU
WHEN A PATIENT IS SAID TO BE IN REMISSION ??
Minor side effects:
•Abdominal pains
•Arthalgias
•Bloating
•Nausea
•vomit
PROPYLTHIOURACIL
50-150 mg 3t/day po
Maintenance: 50 mg PO q8-12hr for
up to 12-18 months;
MONITOR T3 ,Ft4,
then taper and
Discontinue if euthyroidism restored
(TSH) is normal
Ptu preffered in pregnancy , 1st
trimester,
reduced
dose
pregnancy proceeds
more protein bound
Half life 75 minutes,
Used
whem
MMI
OR
CARBAMIZOLE not optimal.
•Utricarias
•Hairloss
•Headache,paresthesis
•Fever,change in taste
WHEN s TSH, Ft4 , T3 IS NORMAL FOR 1 YEAR
AFTER DISCONTINUATION OF Rx

7. RADIOIODINE—(SINGLE SUFFICIENT RADIATION DOSE )
Discontinue ATDs 2 weeks prior to radiotherapy
5-10 mCi calculation based on wt and I131 uptake
(FIXED DOSE 7 mCi/50-100GY)
Can precipitate thyroid storm/aggravate graves ophthalmopathy
DECREASED CLINICAL SYMPTOMS IN 4-6 WKS
Tx: prednisolone 1 mg/kg x2-3mo
FIRST FOLLOWUP IN 2MO
THEN 4-6WK INTERVALS
FOR NXT 6MO
Taper few days before
If MINIMUM RESPONSE radiotherapy
By 3mo
CONSIDER RETREATMENT
When SIGNS OF HYPOTHYROIDISM
Because of destruction of gland appears
THYROID HORMONE REPLACEMENT STARTED
LEVOTHYROXINE
Lifelong ANNUAL FOLLOWUP.
THYROID FUNCTION TESTS
CONTRAINDICATIONS
•Pregnancy,lactation
•Planning pregnancy
•Coexistent/susceptibi
lity of thyroid cancer
•Any metal device in
body,

8. SURGERY : THYROIDECTOMY
Surgery provides rapid treatment of Graves disease and permanent cure of hyperthyroidism in most patients, and it has
"negligible mortality and acceptable morbidity" by experienced surgeons.
PROPERATIVE PREPARATION : render the patient euthyroid is essential in order to prevent thyrotoxic crisis.
CARBAMISOLE/METHIMAZOLE : 6 WEEKS PRIOR , 10-20 MG/D PO
+/+
PROPRANOLOL : 10-40 MG 3T/D
SSKI/LUGOL I2KI SOLUTION : 14 DAYS PRIOR , 50-250 MG(1-5 GTT OF 1G/ML) PO
3T/D
continued postop also!
•Reduce vascularity of gland,blood flow and intraoperative bleeding,
•decrease activity of thyroid gland, action involves decreasing thyroidal iodide uptake, decreasing iodide oxidation and
organification, and blocking release of thyroid hormones
SUBTOTAL/NEAR TOTAL THYROIDECTOMY >>> TOTAL THYROIDECTOMY
intention of leaving enough thyroid remnants behind to avoid hypothyroidism.
MONITOR FOR PERMANENT
HYPOTHYROIDISM ,(if>2mo)
MONITOR SERUM TSH X6-8WKS
fT4 T3
all patients require long-term follow-up.: LIFELONG HORMONE REPLACEMENT BY L-THYROXINE, 1.6-2.3MCG/KG/D

9. •HYPOCALCEMIA (Tx :)
Oral calcium, calcitriol, iv Cagluconate if needed
Prophylaxis : ca-carbonate 1250-2500mg 4t/d , taper to 500mg 1t/d the 1t/2d
calcitriol 0.5 mcg/d …..x2wks
Monitor serum calcium and make changes,
Monitor for transient/permanent hypoparathyroidism.
•DAMAGE TO RECURRENT LARYGEAL NERVE/VOCAL CORDS PARALYSIS,HYPOPARATHYROIDISM
•INTRA N POSTOP BLEEDING,
•COMPLICATIONS OF ANESTHESIA DUE TO SYMPTOMS LIKE HYPERTENSION,ARRYTHMIAS,ECT.

10. SYMPTOMATIC TREATMENT:
usually symptoms receed with decrease of
hyperthyroid state.
BETABLOCKERS
PROPRANOLOL MAX DOSES
GLUCOCORTICOIDS
1)Myxedema/dermatopathy:
topicaltriamcinolone/beclomethaso
ne,topical dressing
2)OPHTHALMOPATHY
a)mild-methycellulose
eyedrops,tainted glasses
b)moderate-severe- high dose
pulsetherapy of
prednisolone,methyprednisolone(12
0-140 mg 1t/wk x5wks iv)
c)Orbit radiotherapy
d)Orbital decompression
(fibrate phase,euthyroid state)
Cardiac arrthmias,palpitations,afib,heart failure
ANTIDEPRRESANTS/SEDATIVES
BENZODIAZEPINE,
LITHIUM
Anxiety
Insomniai
irritability,
DIET LOW IN SALT, HIGH IN CALORIES TO MEET
METABOLIC DEMANDS
SUPPLEMENTS :CALCIUM,VIT D FOR BONE LOSS
ANTIOXIDANTS,ORAL IRON IN SEVERE
ANEMIA
REDUCED PHYSICAL ACTIVITY.
DIGOXIN
EF<40%
DIURETIC-furosemide+
spironolactone
ACEinh-enelapril,
ANTIARHYTHMICS-amiodarone,
useful to normalise thyroid hormones.
in PTUinduced hepatitis also