Hyperthyroidism
Key Points
Key Points
- Thyrotoxicosis is a condition having multiple etiologies, manifestations, and potential therapies.
- The term "thyrotoxicosis" refers to a clinical state that results from inappropriately high thyroid hormone action in tissues due to inappropriately high tissue thyroid hormone levels.
- The term "hyperthyroidism," as used in these guidelines, is a form of thyrotoxicosis due to inappropriately high synthesis and secretion of thyroid hormone(s) by the thyroid.
- Appropriate treatment of thyrotoxicosis requires an accurate diagnosis.
- For example, thyroidectomy is an appropriate treatment for some forms of thyrotoxicosis and not for others.
- Additionally, β-blockers may be used in almost all forms of thyrotoxicosis, whereas antithyroid drugs (ATDs) are useful in only some.
- In the United States, the prevalence of hyperthyroidism is approximately 1.2% (0.5% overt and 0.7% subclinical).
- The most common causes include Graves' disease (GD), toxic multinodular goiter (TMNG), toxic adenoma (TA) and and painless thyroiditis.
Determination of Etiology
...etermination of Etiolog...
...gy of thyrotoxicosis should be determined....
...able 1. Causes of ThyrotoxicosisHaving...
Symptomatic Management
...matic Managemen...
...ergic blockade is recommended in all patien...
...a-Adrenergic Receptor Blockade in the Tr...
Graves' Disease
...' Disease...
...3. Clinical Situations That Favor a Particular...
...Patients with overt Graves' hyperthyroid...
RA...
.... Because RAI treatment of GD can ca...
...dition to β-adrenergic blockade (see Re...
...n patients who are at increased risk for comp...
7. Medical therapy of any comorbid con...
...fficient activity of RAI should be administer...
...y test should be obtained within 48 hours p...
...e physician administering RAI should provide...
...1. Follow-up within the first 1–2 months after R...
...hen hyperthyroidism due to GD persis...
...TDs...
...(MMI) should be used in virtually eve...
14. Patients should be informed of s...
...5. Prior to initiating ATD therapy for GD, the...
...ial white blood cell count should be obtained dur...
...7. There is insufficient evidence to re...
...nction and hepatocellular integrity sh...
.... There is insufficient information to recommen...
20. Minor cutaneous reactions may be managed...
...ent of TRAb levels prior to stopping...
...f MMI is chosen as the primary ther...
...a patient with GD becomes hyperthyroi...
Iodine
...odide may be of benefit in select...
...roidectomy...
...ery is chosen as treatment for GD, patients sho...
...d 25-OH-vitamin D should be assess...
.... In exceptional circumstances, when it is not po...
...8. If surgery is chosen as the prima...
...rgery is chosen as the primary therapy...
...hyroidectomy for GD, alternative st...
...ATD should be stopped at the time of thyroid...
...thyroidectomy for GD, L-thyroxine should...
33. Communication among different membe...
...d Nodules in GD...
...nodule is discovered in a patient...
...oid Storm...
...nosis of thyroid storm should be made...
36. A multimodality treatment appr...
.... Point Scale for the Diagnosis of Thyroid Sto...
...Storm: Drugs and DosesHaving trouble viewin...
...#39; Orbitopathy (GO)...
...6. Assessment of GO: Clinical Acti...
Table 7. GO Severity AssessmentHavi...
...thyroidism should be expeditiously achieved and...
...ommends clinicians advise patients with GD to s...
...king patients with GD without apparent GO, RAI...
...smoking patients with GD without apparent GO, RAI...
...sufficient evidence to recommend for or against th...
.... In patients with Graves’ hyperthyroidis...
...sence of any strong contraindicati...
...In GD patients with mild GO who are tre...
...In patients with active and moderate to severe...
...ents with inactive GO the ATA sugge...
...Oral Glucocorticoids for Prevention...
...Factors for Graves’ OrbitopathyHaving troub...
...ildren and Adolescent...
...eneral...
...Children with GD should be treated with M...
...energic blockade is recommended for children exper...
ATD
...hould be used in children who are treated wi...
.... Pediatric patients and their caretaker...
...initiating ATD therapy, the ATA su...
...TDs should be stopped immediately, and white b...
...eral, PTU should not be used in childr...
.... Persistent minor cutaneous reactions to...
.... If MMI is chosen as the first-line treatment for...
...Cancer Risk See Table 15)...
...6. Pediatric patients with GD who are not in remi...
...ATA suggests that children with GD having total T...
.... If RAI therapy is chosen as treat...
...rgery...
...ith GD undergoing thyroidectomy sh...
...ery is chosen as therapy for GD in children, tot...
...y in children should be performed by...
TMNG or TA
...NG or TA
.... The ATA suggests that patients with overtly TMN...
...able 10. Clinical Situations That Favor a...
...AI...
...AI treatment of TMNG or TA can cause a transie...
...4. In addition to β-adrenergic blo...
...In patients who are at increased risk fo...
...oning nodules on radionuclide scintigraphy o...
...ctivity of RAI should be administere...
...8. Sufficient activity of RAI should b...
69. Follow-up within the first 1–2 month...
...yperthyroidism persists beyond 6 months following...
...rgery...
...1. If surgery is chosen as treatment for TMNG or...
...is chosen as treatment for TMNG, near-total or to...
...r TMNG should be performed by a high-...
...surgery is chosen as the treatment for TA, a t...
.... The ATA suggests that surgery for TA be performe...
...Following thyroidectomy for TMNG, serum calcium...
...ld be stopped at the time of surgery for TMNG o...
...yroidectomy for TMNG, thyroid hormone replacement...
...ing lobectomy for TA, TSH and estimated free T4 le...
...RAI therapy should be used for retreatment of pers...
...TDs...
...g-term MMI treatment of TMNG or TA...
...anol or Radiofrequency Ablation...
...therapies such as ethanol or radiofrequency...
Subclinical Hyperthyroidism and Pregnancy
...bclinical Hyperthyroidism and P...
...nical Hyperthyroidism (SH)...
...3. When TSH is persistentl...
...When TSH is persistent...
...persistently below the lower limit of normal but...
...n TSH is persistently below the lower lim...
...o be treated, the treatment should be bas...
Table 11. Subclinical Hyperthyroidis...
...egnancy...
...The diagnosis of hyperthyroidism in pregnanc...
89. Transient hCG-mediated TSH suppress...
...should be used for overt hyperthyroidism due to...
...ho develop hyperthyroidism during their reprodu...
...ATA suggests that women with hyper...
...with hyperthyroidism caused by GD who are we...
...ATA suggests that women who are treate...
...The ATA suggests that a woman who tests positi...
...A suggests that the physician contact...
...ATA suggests that women in early pregnancy who...
98. Women taking PTU during the 1st trimeste...
...9. GD during pregnancy should be treat...
...cy is a relative contraindication to thyroidec...
...1. When thyroidectomy is necessary f...
...2. When thyroidectomy is necessary for the tre...
...03. Patients who were treated with...
...Patients receiving ATD for GD when...
...Patients with elevated TRAb levels at 18–...
...stpartum Thyroid...
.... In women developing thyrotoxicosis after deliver...
...n women with symptomatic thyrotoxicosis from p...
...pregnant women diagnosed with hyperthyr...
...le 12. Summary of Recommendations Concerning M...
Other Conditions
...er Condition...
...-Associated Thyrotox...
...Causes of Drug-Associated Thyrotoxicosis...
...ts taking medications known to cause thyrotoxicos...
...uced Hyperthyroidism...
...outine administration of ATDs before iodi...
...-adrenergic blocking agents alone...
...duced Thyrotoxicosis (AIT)...
...TA suggests monitoring thyroid functi...
...cision to stop amiodarone in the setting...
...nically stable patients with AIT, the ATA...
.... MMI should be used to treat overt thyrotox...
.... Combined ATD and corticosteroid therapy should...
...Patients with AIT who are unrespon...
...uggested Approach to the Management of...
...uctive Thyroiditis...
...bacute Thyroid...
...Patients with mild symptomatic subacute thyro...
Painless Thyroiditi...
.... Patients with symptomatic thyrotoxicosis due t...
...e Thyroiditis...
...Acute thyroiditis should be treated with...
...Causes of Thyrotoxicosis...
...14. Unusual Causes of Thyrotoxico...
TSH-Secreting Pituitary Tumo...
.... The diagnosis of a TSH-secreting pituitar...
...th TSH-secreting pituitary adenomas should under...
Struma Ova...
...nts with struma ovarii should be treated i...
...riocarcino...
...tment of hyperthyroidism due to ch...
Appendix
...pendix
...e 15. Theoretical Projections of Cance...