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
...Dete...
...y of thyrotoxicosis should be determined....
Table 1. Causes of Thyrotoxicosis...
Symptomatic Management
...Symptomatic Ma...
.... β-adrenergic blockade is recomm...
...renergic Receptor Blockade in the Tr...
Graves' Disease
...Graves...
...linical Situations That Favor a Particula...
.... Patients with overt Graves' hyper...
...RAI...
...AI treatment of GD can cause a tran...
...n addition to β-adrenergic blockade (se...
...nts who are at increased risk for complications du...
...cal therapy of any comorbid conditio...
8. Sufficient activity of RAI should be adm...
.... A pregnancy test should be obtained within...
...The physician administering RAI shou...
...llow-up within the first 1–2 month...
...hyperthyroidism due to GD persists a...
...ATD...
...azole (MMI) should be used in virtually...
...should be informed of side effects of ATDs a...
...initiating ATD therapy for GD, the A...
...al white blood cell count should be obtained durin...
...s insufficient evidence to recommen...
.... Liver function and hepatocellula...
...sufficient information to recommend for or against...
...r cutaneous reactions may be managed with concurr...
21. Measurement of TRAb levels prior to stopping A...
...s chosen as the primary therapy for G...
...a patient with GD becomes hyperthy...
...tassium iodide may be of benefit in...
...Thyroidectomy...
.... If surgery is chosen as treatment for G...
...ium and 25-OH-vitamin D should be asse...
...exceptional circumstances, when it is not possibl...
.... If surgery is chosen as the primary therapy for...
...y is chosen as the primary therapy for GD,...
...Following thyroidectomy for GD, alternative strat...
...ATD should be stopped at the time o...
...llowing thyroidectomy for GD, L-thyroxine sh...
...nication among different members of...
...Thyroid...
...4. If a thyroid nodule is discovered in a patient...
...Thyroid Storm...
...s of thyroid storm should be made clinically in a...
36. A multimodality treatment approach...
Table 4. Point Scale for the Diagnosis of Th...
...e 5. Thyroid Storm: Drugs and Doses...
...Graves'...
...ble 6. Assessment of GO: Clinical Activity Sco...
...able 7. GO Severity Assessment...
...oidism should be expeditiously achiev...
...ommends clinicians advise patients wit...
...nsmoking patients with GD without app...
...smoking patients with GD without apparent GO, RA...
...s insufficient evidence to recommend for or agai...
.... In patients with Graves’ hyperthyr...
...bsence of any strong contraindication to GC...
...D patients with mild GO who are treated...
...with active and moderate to severe or sight-...
...with inactive GO the ATA suggests RAI the...
...le 8. Use of Oral Glucocorticoids fo...
...le 9. Risk Factors for Graves’ Orbitopat...
...Children and Adolescents...
...Genera...
.... Children with GD should be treated with...
...renergic blockade is recommended for children ex...
...ATD...
...e used in children who are treated...
...tric patients and their caretakers should be...
...Prior to initiating ATD therapy, the ATA sugge...
.... ATDs should be stopped immediately...
...al, PTU should not be used in children....
...inor cutaneous reactions to MMI therapy in c...
...f MMI is chosen as the first-line treatment fo...
...RAI (Fo...
...patients with GD who are not in rem...
...ests that children with GD having to...
...RAI therapy is chosen as treatment for GD in chi...
...Surge...
...9. Children with GD undergoing thyroidectomy...
...s chosen as therapy for GD in children,...
...my in children should be performed by high-vol...
TMNG or TA
...TMNG o...
.... The ATA suggests that patients with overtl...
...able 10. Clinical Situations That Fa...
...use RAI treatment of TMNG or TA can ca...
...addition to β-adrenergic blockade...
...In patients who are at increased risk for co...
...nctioning nodules on radionuclide scint...
...cient activity of RAI should be adminis...
...activity of RAI should be administered in a sing...
...ollow-up within the first 1–2 month...
...roidism persists beyond 6 months fol...
...Surgery...
...If surgery is chosen as treatment for...
...If surgery is chosen as treatment for TMNG, near-t...
...ery for TMNG should be performed by a...
...ry is chosen as the treatment for TA, a thyroid ul...
...ATA suggests that surgery for TA be performed by...
...thyroidectomy for TMNG, serum calcium ± iPTH leve...
...uld be stopped at the time of surgery for...
...hyroidectomy for TMNG, thyroid hormone repl...
...lowing lobectomy for TA, TSH and estimated f...
...I therapy should be used for retrea...
...A...
...MI treatment of TMNG or TA might be indicated...
...Ethanol or Ra...
...e therapies such as ethanol or radiofrequen...
Subclinical Hyperthyroidism and Pregnancy
...Subclinical...
...Subclinical...
...TSH is persistently...
...4. When TSH is persistentl...
...SH is persistently below the lower limit of...
...n TSH is persistently below the lower lim...
...be treated, the treatment should be based o...
...linical Hyperthyroidism: When to Treat...
...Pregnancy...
...e diagnosis of hyperthyroidism in pr...
...t hCG-mediated TSH suppression in early pregna...
...py should be used for overt hypert...
91. In women who develop hyperthyroidi...
...e ATA suggests that women with hyperthyroidi...
...omen with hyperthyroidism caused by GD who ar...
...ests that women who are treated with ATD an...
...TA suggests that a woman who tests posit...
96. The ATA suggests that the physician con...
...TA suggests that women in early pregnancy wh...
...en taking PTU during the 1st trimester of...
...ing pregnancy should be treated wit...
...ancy is a relative contraindication to thyroid...
101. When thyroidectomy is necessary for the tre...
...roidectomy is necessary for the treatment of hyp...
...ts who were treated with RAI or thyroidectom...
...ts receiving ATD for GD when becoming pregnant or...
...Patients with elevated TRAb levels at 1...
...Postpar...
...In women developing thyrotoxicosis after del...
...women with symptomatic thyrotoxicosis from p...
...egnant women diagnosed with hyperth...
...y of Recommendations Concerning Management of G...
Other Conditions
...Other Conditions...
...Drug-Associated...
...es of Drug-Associated Thyrotoxicosis...
...ients taking medications known to cause t...
...Iodin...
.... Routine administration of ATDs before iod...
...Beta-adrenergic blocking agents al...
...Amiodarone-i...
.... The ATA suggests monitoring thyroid functi...
...3. The decision to stop amiodarone...
...clinically stable patients with AIT, the ATA sugge...
...should be used to treat overt thyro...
...6. Combined ATD and corticosteroid therapy...
.... Patients with AIT who are unresponsive to aggre...
...Suggested Approach to the Management of AIT...
...Destructiv...
...Subacute Thyr...
...with mild symptomatic subacute thyroi...
...Painless Thyroiditis...
...ients with symptomatic thyrotoxicosis due to...
...Acute Thyroiditis...
...Acute thyroiditis should be treated with anti...
...Unusual Cause...
...ble 14. Unusual Causes of Thyrotoxicosis...
...TSH-Secreting...
...gnosis of a TSH-secreting pituitary adenoma...
...Patients with TSH-secreting pituitary adenoma...
...Struma Ovarii...
...ents with struma ovarii should be treated ini...
...Choriocarcinoma...
...4. Treatment of hyperthyroidism due to chorioc...
Appendix
...Appe...
...Theoretical Projections of Cancer In...