2018 European Thyroid Association Guideline for the Management of Graves' Hyperthyroidism

Management of thyroid eye disease: a Consensus Statement by the American Thyroid Association and the European Thyroid Association

Thyroid eye disease (TED) remains challenging for clinicians to evaluate and manage. Novel therapies have recently emerged, and their specific roles are still being determined. Most patients with TED develop eye manifestations while being treated for hyperthyroidism and under the care of endocrinologists. Endocrinologists, therefore, have a key role in diagnosis, initial management, and selection of patients who require referral to specialist care. Given that the need for guidance to endocrinologists charged with meeting the needs of patients with TED transcends national borders, and to maximize an international exchange of knowledge and practices, the American Thyroid Association and European Thyroid Association joined forces to produce this Consensus Statement.

What we know about the relationship between autoimmune thyroid diseases and gut microbiota: a perspective on the role of probiotics on pediatric endocrinology

INTRODUCTION

Autoimmune diseases account for a cumulative overall prevalence of about 3-5% worldwide. Among them, autoimmune thyroid diseases (ATDs) are the most common and comprise two main entities: Hashimoto's thyroiditis (HT) and Graves-Basedow disease (GD). The pathogenesis of ATDs remains not fully elucidated, however the role of microbioma has been proposed. Gut microbiota exert an important influence on the intestinal barrier, nutrient metabolism and immune system development and functions.

EVIDENCE ACQUISITION

In this review, we describe on the main features of ATDs in pediatrics, focusing on the reciprocal influence between gut microbiota, thyroid hormone metabolism and thyroid autoimmunity and consider the role of probiotics and other microbiota-targeted therapies in thyroid diseases with a perspective on pediatric endocrinology.

EVIDENCE SYNTHESIS

Microbiome affects both endogenous and exogenous thyroid hormone metabolism and influences the absorption of minerals important to the thyroid function, which are iodine, selenium, zinc and iron. The alteration of the gut microbiota, with the consequent modifications in the barrier function and the increased gut permeability, seems involved in the development of autoimmune and chronic inflammatory diseases, including ATDs. The supplementation with probiotics showed beneficial effects on the thyroid hormone and thyroid function because this strategy could restore the intestinal eubiosis and the good strain microorganism proliferation.

CONCLUSIONS

Even though the evidence about the interaction between microbiota and ATDs in pediatric patients is limited, the promising results obtained in the adult population, and in other autoimmune disorders affecting children, highlight the need of for further research in the pediatric field.

A Multicenter, Single-Blind, Case-Control, Immunohistochemical Study of Orbital Tissue in Thyroid Eye Disease

Background: Thyroid eye disease (TED) involves several pathogenic pathways and a battery of infiltrating mononuclear cells, cytokines, and chemokines in the orbit. Revealing the main molecules, which play a major role in the pathogenesis of TED, will help developing novel treatment strategies. Methods: In a multicenter, single-blind, case-control study, 60 tissue samples were collected during orbital decompression (44 TED patients) or non-TED related oculoplastic (16 controls) surgeries. Formalin-fixation and paraffin embedding preserved orbital tissue. Tissue sections were immunostained with 18 antibodies by the micro-polymer labeling technique. Immunostaining slides were scanned by Panoramic Desk and blindly evaluated by a user-independent viewer software. Results: Marked lymphocyte infiltration was observed in orbital tissue specimens of patients with clinically active TED (n = 22) and to a much lesser extent in inactive cases (n = 22), while it was absent in controls. Increased vascularity was noted in all samples, with orbital congestion in specimens of clinically active TED. Tissue fibrosis was present in TED samples but not in controls. Immunohistochemistry of orbital tissue clearly differentiated between TED and controls, as well as between active and inactive TED. In contrast to controls and with the exception of cluster of differentiation 20 (CD20), 17 out of 18 antibodies were highly expressed in orbital connective tissue of TED patients. Especially, thyrotropin receptor (TSH-R), insulin-like growth factor 1 receptor (IGF-1R), CD40, cluster of differentiation 40 ligand (CD40L), CD3, CD68, interleukin-17A (IL-17A), IL-23A, IL-1β, IL-4, regulated on activation, normal T cell expressed and secreted (RANTES), macrophage chemoattractant protein 1 (MCP-1), IL-16, and B cell activating factor (BAFF) were overexpressed in clinically active TED (all p < 0.001). Also, the expression of CD40L, IL-17A, IL-23A, IL-6, IL-1β, RANTES, and BAFF was very high (TED/control ratio >3), moderate (ratio >2), and low in active (p < 0.001), inactive TED and controls, respectively. The expression of TSH-R, IGF-1R, CD40, CD40L, CD3, CD68, CD20, IL-17A, IL-23A, RANTES, MCP-1, and BAFF positively and significantly correlated with both serum TSH-R stimulatory antibody concentrations and clinical activity scores while it negatively correlated with TED duration. Orbital irradiation decreased TSH-R (p < 0.001) and IGF-1R expression (p = 0.012); in contrast, neither smoking, age, nor gender did impact immunohistochemical staining. Conclusions: Adaptive and cell-mediated immunity, overexpression of TSH-R/IGF-1R and CD40/CD40L are the relevant pathomechanisms in TED. Targeting these key players in the active phase of the disease offers specific and novel treatment approaches.

Approach to the Patient: Management and the Long-term Consequences of Graves' Disease in Children

In children, Graves' disease (GD) is the most common cause of hyperthyroidism. Most pediatric patients with GD will not go into lasting remission, even following many years of antidrug therapy. Thus, most pediatric patients will require radioactive iodine (RAI) or surgery. When antithyroid drugs are used, methimazole is the drug of choice. When methimazole is used in children, up to 20% will have minor adverse reactions and serious adverse events occur in up to 1%. RAI is an effective form of therapy when the thyroid size is less than 80 g. Because of concerns of whole-body radiation exposure, it is recommended that RAI be avoided in children under 5 years of age, and dosages less than 10 mCi be used between 5 and 10 years of age. Surgery is an effective treatment in children if performed by a high-volume thyroid surgeon. Because of the scarcity of high-volume pediatric thyroid surgeons, a multidisciplinary approach using pediatric surgeons and endocrine surgeons can be considered. Whereas there is a trend toward long-term antithyroid drug therapy in adults, for several reasons, this approach may not be practical for children. Determining the optimal treatment for the pediatric patient with GD, requires consideration of the risks and benefits relating to age and likelihood of remission.

Radioactive iodine in the treatment of Graves' disease: history and modern concept of radionuclide therapy

Radioactive iodine 131I is a theranostic isotope used both for diagnosis and therapy of benign thyroid diseases and thyroid cancer for 85 years. The formation of nuclear medicine is closely linked with the use of 131I. The history of radioiodine therapy began in 1941, when endocrinologist Saul Hertz for the first time used 131I to treat patients with Graves' disease. Since 1946 radioactive iodine 131I became widely available, and its effectiveness became public knowledge after reports on thyrotoxicosis treatment published in the Journal of the American Medical Association by multidisciplinary groups of scientists physicists and endocrinologists. In 1951, isotope 131I became the first Food and Drug Administration approved RP for the treatment of thyroid disorders. Around the same time on the basis of the First Moscow Medical Institute studies on the use of radioiodine isotopes in patients with thyrotoxicosis began. The head of the Soviet group on the studying of radioactive iodine was the physician-scientist Vera Georgievna Spesivtseva. The research works of medical physicists Edith Quimby and Leonidas Marinelli in optimizing therapeutic strategies using radioactive substances in the late 1940s and the wording of the ALARA (As Low As Reasonably Achievable) principle of minimizing exposure of ionizing radiation by the International Commission on Radiological Protection in 1954 contributed to the greater introduction of radionuclides into the medicine.

Long-term management of Graves disease: a narrative review

Graves disease (GD) is the most common cause of hyperthyroidism, accounting for more than 90% of cases in Korea. Patients with GD are treated with any of the following: antithyroid drugs (ATDs), radioactive iodine (RAI) therapy, or thyroidectomy. Most patients begin treatment with ATDs, and clinical guidelines suggest that the appropriate treatment period is 12 to 18 months. While RAI treatment and surgery manage thyrotoxicosis by destroying or removing thyroid tissue, ATDs control thyrotoxicosis by inhibiting thyroid hormone synthesis and preserving the thyroid gland. Although ATDs efficiently control thyrotoxicosis symptoms, they do not correct the main etiology of GD; therefore, frequent relapses can follow. Recently, a large amount of data has been collected on long-term ATDs for GD, and low-dose methimazole (MMZ) is expected to be a good option for remission. For the long-term management of recurrent GD, it is important to induce remission by evaluating the patient's drug response, stopping ATDs at an appropriate time, and actively switching to surgery or RAI therapy, if indicated. Continuing drug treatment for an extended time is now encouraged in patients with a high possibility of remission with low-dose MMZ. It is also important to pay attention to the quality of life of the patients. This review aimed to summarize the appropriate treatment methods and timing of treatment transition in patients who relapsed several times while receiving treatment for GD.

Postradioiodine Graves' management: The PRAGMA study

OBJECTIVE

Thyroid status in the months following radioiodine (RI) treatment for Graves' disease can be unstable. Our objective was to quantify frequency of abnormal thyroid function post-RI and compare effectiveness of common management strategies.

DESIGN

Retrospective, multicentre and observational study.

PATIENTS

Adult patients with Graves' disease treated with RI with 12 months' follow-up.

MEASUREMENTS

Euthyroidism was defined as both serum thyrotropin (thyroid-stimulating hormone [TSH]) and free thyroxine (FT4) within their reference ranges or, when only one was available, it was within its reference range; hypothyroidism as TSH ≥ 10 mU/L, or subnormal FT4 regardless of TSH; hyperthyroidism as TSH below and FT4 above their reference ranges; dysthyroidism as the sum of hypo- and hyperthyroidism; subclinical hypothyroidism as normal FT4 and TSH between the upper limit of normal and <10 mU/L; and subclinical hyperthyroidism as low TSH and normal FT4.

RESULTS

Of 812 patients studied post-RI, hypothyroidism occurred in 80.7% and hyperthyroidism in 48.6% of patients. Three principal post-RI management strategies were employed: (a) antithyroid drugs alone, (b) levothyroxine alone, and (c) combination of the two. Differences among these were small. Adherence to national guidelines regarding monitoring thyroid function in the first 6 months was low (21.4%-28.7%). No negative outcomes (new-onset/exacerbation of Graves' orbitopathy, weight gain, and cardiovascular events) were associated with dysthyroidism. There were significant differences in demographics, clinical practice, and thyroid status postradioiodine between centres.

CONCLUSIONS

Dysthyroidism in the 12 months post-RI was common. Differences between post-RI strategies were small, suggesting these interventions alone are unlikely to address the high frequency of dysthyroidism.

Estimating Incidence and Case Fatality of Thyroid Storm in Germany Between 2007 and 2017: A Claims Data Analysis

Background: Given the paucity of epidemiological studies on thyroid storm, we aimed to estimate the incidence rate and case fatality of thyroid storm in Germany based on a large claims database. Methods: Using the German Pharmacoepidemiological Research Database (GePaRD) we identified patients with at least one inpatient discharge diagnosis of thyroid storm (International Statistical Classification of Diseases and Related Health Problems, 10th revision, German modification; ICD-10-GM E05.5) between 2007 and 2017 and calculated age-standardized and age-specific incidence rates in males and females (no age restriction). We defined deaths occurring within 30 days of the diagnosis as thyroid storm-associated and determined case fatality by sex and age group. Point estimates were reported with confidence intervals [CIs]. Results: We identified 1690 patients with an incident diagnosis of thyroid storm. Of these, 72% were females (n = 1212). The mean age was 60 years (standard deviation: 18.6 years). The age-standardized incidence rate per 100,000 persons per year was 1.4 [CI 1.2-1.7] in females and 0.7 [CI 0.5-0.9] in males. In females ≤60 and >60 years of age, the incidence rate was 0.9 [CI 0.9-1.0] (males: 0.4 [CI 0.3-0.4]) and 2.7 [CI 2.5-2.9] (males: 1.7 [CI 1.5-1.9]), respectively. The case fatality of thyroid storm was 1.4% [CI 0.6-2.8] in females ≤60 years and 10.9% [CI 8.6-13.7] in females >60 years. In males, the case fatality was 1.0% [CI 0.2-4.0] in those aged ≤60 years and 16.7% [CI 12.6-21.7] in those >60 years. Conclusions: Incidence rates of thyroid storm were markedly higher in females than in males and were three times higher in persons >60 years compared with younger age groups. The case fatality was below 2% in persons aged ≤60 years and markedly higher in older persons (males: 17 times and females: 8 times).

Notes for the general paediatrician: managing thyrotoxicosis in children and young people

Thyrotoxicosis due to hyperthyroidism is a serious disorder in childhood often presenting to general paediatricians with a range of clinical manifestations. The commonest cause is Graves' disease, an autoimmune disorder resulting from thyrotropin receptor stimulation by autoantibodies. Early recognition and accurate interpretation of investigations are essential to achieve and maintain a euthyroid state. This will not only optimise growth, development and transition from childhood to young adult life but also avoid the potentially severe and life-threatening complications of acute thyrotoxicosis. In this review, we have focussed on the general paediatrician's perspective of the presentation and management of thyrotoxicosis and the need to network with specialist paediatric endocrine centres to optimise patient care. We have discussed nuances of therapy, side effects and long-term outcomes, while recognising that limited remission rates in this age group often necessitate more definitive management. While carbimazole is usually used as first-line medical therapy, we have provided useful information to guide paediatricians in the discussion of individualised safe and effective treatment plans for both short-term and long-term management.

Current concepts regarding Graves' orbitopathy

Graves' orbitopathy (GO) is an orbital autoimmune disorder and the main extrathyroidal manifestation of Graves' disease, the most common cause of hyperthyroidism. GO affects about 30% of Graves' patients, although fewer than 10% have severe forms requiring immunosuppressive treatments. Management of GO requires a multidisciplinary approach. Medical therapies for active moderate-to-severe forms of GO (traditionally, high-dose glucocorticoids) often provide unsatisfactory results, and subsequently surgeries are often needed to cure residual manifestations. The aim of this review is to provide an updated overview of current concepts regarding the epidemiology, pathogenesis, assessment, and treatment of GO, and to present emerging targeted therapies and therapeutic perspectives. Original articles, clinical trials, systematic reviews, and meta-analyses from 1980 to 2021 were searched using the following terms: Graves' disease, Graves' orbitopathy, thyroid eye disease, glucocorticoids, orbital radiotherapy, rituximab, cyclosporine, azathioprine, teprotumumab, TSH-receptor antibody, smoking, hyperthyroidism, hypothyroidism, thyroidectomy, radioactive iodine, and antithyroid drugs. Recent studies suggest a secular trend toward a milder phenotype of GO. Standardized assessment at a thyroid eye clinic allows for a better general management plan. Treatment of active moderate-to-severe forms of GO still relies in most cases on high-dose systemic-mainly intravenous-glucocorticoids as monotherapy or in combination with other therapies-such as mycophenolate, cyclosporine, azathioprine, or orbital radiotherapy-but novel biological agents-including teprotumumab, rituximab, and tocilizumab-have achieved encouraging results.

The relationship between atherosclerotic disease and relapse during ATD treatment

Background

Clinical relapse is a potential risk for traditional antithyroid drug (ATD) treatment in hyperthyroid patients. Evidence suggests that atherosclerotic disease is closely associated with hyperthyroidism, while the relationship between atherosclerosis and relapse remains unclear.

Methods

Two hundred and twenty-five patients with GD who underwent ATD as their first treatment were studied; 88 and 137 patients were categorized as drug reduction relapse and drug reduction remission, respectively. Logistic regression was used to analyze risk factors of drug reduction relapse in patients with GD.

Results

During a median of 48 months followed up 88 patients who relapsed. According to multivariate analyses, atherosclerosis related diseases, FT4, goiter, and anxiety rating scores are independent risk factors for drug reduction. According to K-M survival analysis, patients with atherosclerosis related diseases, FT4 &gt; 18.82 pmol/L, anxiety rating scores &gt; 23, and gradation of goiter ≥ Grade II had a higher risk of relapse than those with lower levels. ROC analysis shown atherosclerosis related diseases significantly improved the predictive accuracy of relapse.

Conclusions

Atherosclerotic disease is closely related to the relapse of hyperthyroidism, ATD treatment in hyperthyroid patients with atherosclerosis should be given more attention.

Treatment of post-radioactive iodine relapse of hyperthyroidism: comparison of long-term methimazole and radioactive iodine treatment

BACKGROUND

This study aimed to compare the time to achieve euthyroidism and sustained control of hyperthyroidism after treatment with radioactive iodine (RAI) or long-term methimazole (LT-MMI) in patients with post-RAI relapsed hyperthyroidism.

METHODS

Sixty four patients with recurrence of hyperthyroidism after RAI treatment were randomly assigned to either RAI or LT-MMI treatment. Both groups were followed every 1-3 months in the first year and then every 6 months for a total of 60 months.

RESULTS

In RAI and LT-MMI groups, mean age was 49.0 ± 12.1 and 50.1 ± 14.6 years and time of relapse of hyperthyroidism after previous RAI treatment was 23.2 ± 18.8 and 20.8 ± 17.1 months, respectively. At the end of study, in the LT-MMI group, 31 (97%) and 1 (3%) were euthyroid and hypothyroid, respectively; in the RAI group, 8 (25%) patients were euthyroid, whereas 18 (56%), 3 (9.5%) and 3 (9.5%) had overt hypothyroidism, subclinical hypothyroidism and hyperthyroidism, respectively. Mean time to euthyroidism was 9.4 ± 5.0 months in the RAI group and 3.5 ± 2.8 months in the LT-MMI group (p < 0.001). Patients in the RAI group spent 77.7 ± 14.0 percent and those in the LT-MMI group spent 95.2 ± 5.9 percent of 60 months in the euthyroid state (p < 0.001).

CONCLUSION

In patients with post-RAI relapse of hyperthyroidism, LT-MMI treatment was superior to radioiodine because of faster achievement of euthyroidism and more sustained control of hyperthyroidism during 60 months of follow-up.

Interplay between cardiovascular and thyroid dysfunctions: A review of clinical implications and management strategies

Cardiovascular diseases (CVD) and thyroid dysfunction are two of the most prevailing disorders in the world that are closely interlinked. Actions of thyroid hormones are mediated via thyroid receptors present in the myocardium and the vascular tissue. Primary mechanism that links thyroid dysfunction with CVD is the modification of cardiovascular risk factors (dyslipidemia, blood pressure, coagulation parameters, etc.) resulting in endothelial and left ventricular systolic and diastolic dysfunction.

Both overt and subclinical hyperthyroidism and hypothyroidism may cause adverse alterations in cardiac function. Hyperthyroidism gives rise to palpitation, atrial fibrillation, systolic hypertension, and heart failure, whereas hypothyroidism increases diastolic hypertension, pericardial effusion, and the risk of ischemic heart disease via altering lipid and coagulation parameters. Early recognition and treatment of thyroid dysfunction may prevent adverse cardiovascular events in patients with or without pre-existing CVD.

Certain cardiac conditions and medications can cause alterations in thyroid function that may predispose an individual to higher morbidity and mortality. In certain situations, thyroid dysfunction treatment may have cardiovascular benefits. This study deals with the interplay between cardiovascular and thyroid dysfunctions associated with clinical implications and management strategies.

High levels of thyroid hormones promote recurrence of Graves' disease via overexpression of B-cell-activating factor

Background

Elevated thyroid hormone (TH) levels have been suggested to be associated with the pathological progression of Graves' disease (GD). However, direct evidence from clinical studies remains unclear.

Methods

Peripheral blood samples were collected from patients with or without the recurrence of Graves' hyperthyroidism (GH) and healthy donors. Thyroid tissue samples were obtained from patients with benign thyroid nodules. To assess the differentiation of autoreactive B cells, the expression of B‐cell‐activating factor (BAFF) and the proportion of CD11c+/–IgG+/− subsets of B cells stimulated by high levels of triiodothyronine (T3) in vivo and in vitro were examined by ELISA, flow cytometry, western blotting, and qRT‐PCR.

Results

Serum BAFF levels in patients with GD were significantly and positively correlated with FT3, FT4, and TRAb levels. Furthermore, the ratio of abnormally differentiated CD11c+ autoreactive B cells positively correlated with BAFF and TRAb. High levels of triiodothyronine (T3) induced BAFF overexpression in thyroid follicular cells and mononuclear cells of the normal thyroid in vitro, thereby promoting the differentiation of CD11c+IgG+ autoreactive secretory B cells (ASCs). However, the precise knockdown of BAFF expression significantly inhibited the abnormal differentiation of ASCs.

Conclusion

The pathological progression of GD was prolonged and exacerbated by autoimmune positive feedback modulation caused by high TH levels. BAFF could be considered a potential target for localized thyroid immunosuppressive treatment of Graves' hyperthyroidism recurrence.

Perioperative management of the thyrotoxic patients: A systematic review

Background

Thyrotoxicosis is a clinical syndrome produced by a multitude of disorders. Thyrotoxicosis is a serious medical condition that, if left untreated, can lead to a fatal illness. This review of recent evidences give additional input for perioperative management of thyrotoxic patients.

Methods

The literatures were found with Boolean operators in the form of thyrotoxicosis AND anesthesia, antithyroid medications AND perioperative optimization AND beta blockers OR calcium channel blockers in electronic data base sources such as the Cochrane library, PubMed, and Google scholar. This review was carried out in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) 2020 statement.

Conclusions

and recommendations: Before surgery and anesthesia, manifestation of thyrotoxicosis including palpitation, irritability etc should be ruled out.

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Thyrotoxicosis is a clinical syndrome produced by a multitude of disorders.

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Hyperthyroidism is a prevalent clinical condition that raises the risk of complications.

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Surgery and anesthesia should be postponed in elective thyrotoxicosis patients.

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Patients with thyrotoxicosis symptoms and elevated thyroid function tests should be optimized for 12–18 months.

The role of PET/CT in thyroid autoimmune diseases

Autoimmune thyroid diseases (AITD) are a heterogeneous group of disorders. They include, in particular, Graves' disease and Hashimoto's thyroiditis with a wide range of different functional status ranging from subclinical biochemical abnormalities to severe hyperthyroidism or severe hypothyroidism respectively. Furthermore, other conditions more frequently infectious or drug related can cause an immune reaction in the thyroid tissue. In AITDs, positron emission tomography/computed tomography (PET/CT) does not play a primary role for disease diagnosis or management, but accidental findings can occur in both symptomatic and asymptomatic patients, and they should be recognized and well interpreted. A comprehensive literature search of the PubMed databases was conducted to identify papers (systematic review, prospective and retrospective study, case report) evaluating the role of PET/CT in thyroid autoimmune diseases. Thyroid diffuse uptake of 18F-fluoro-2-deoxy-2-d-glucose ([18F]FDG) has been shown to be frequently associated with AITDs, but also with immune-induced thyroid disorders related to SARS-CoV-2 or immunotherapy, while malignant lesions more often have a focal aspect. Other radiopharmaceuticals as [68Ga]-DOTA-peptides, [68Ga]-fibroblast activation protein inhibitors (FAPIs) and [68Ga]-prostate specific membrane antigen ([68Ga]-PSMA) showed similar findings. In conclusion, PET/CT scan in AITDs does not play a primary role in the diagnosis, but the occasional finding of a thyroid uptake must always be described in the report and possibly investigated for a better patient's management.

Clinical evaluation of an automated TSI bridge immunoassay in the diagnosis of Graves' disease and its relationship to the degree of hyperthyroidism

BACKGROUND

The rapid and accurate detection of thyroid-stimulating hormone (TSH) receptor antibodies has always been an urgent need for the clinical diagnosis and management of Graves' disease (GD). We aimed to evaluate the use of an automated thyroid-stimulating immunoglobulin (TSI) bridge immunoassay in the diagnosis of GD and to analyze the relationship between TSI and the degree of hyperthyroidism.

METHODS

A total of 227 new-onset GD patients, 29 Hashimoto thyroiditis, 43 non-autoimmune thyroid diseases and 37 euthyroid controls were consecutively recruited. All participants accepted the measurement of their serum thyroid function and thyroid-associated antibodies, including TSI being measured by an Immulite 2000 bridge immunoassay and TSH receptor autoantibodies (TRAb) being measured by a third-generation Roche electrochemiluminescence immunoassay. The quantitative consistency between the TSI and TRAb detection methods was analyzed by using Passing-Bablok regression and Bland-Altman plots. The diagnostic performance for GD was assessed by receiver operating characteristic (ROC) curve analysis.

RESULTS

Among 227 GD patients (174 females and 53 males, with a mean age of 39 years), the quantitative TSI was positively correlated with TRAb (r = 0.8099). According to the cut-off values proposed by the manufacturers (TSI: 0.55 IU/L, TRAb: 1.75 IU/L), the positive rates of TSI and TRAb in new-onset GD patients were 96.92% and 95.15%, respectively. Both TSI and TRAb levels positively correlated with FT₄ levels (TSI: r = 0.243, TRAb: r = 0.317; all P < 0.001) and FT₃ levels (TSI: r = 0.288, TRAb: r = 0.360; all P < 0.001) in new-onset GD patients. The ROC analysis showed that the optimal TSI cut-off value was 0.577 IU/L for GD diagnosis in this Chinese population, with a sensitivity of 96.92% and a specificity of 97.25%, respectively. The optimal TRAb cut-off value of was 1.38 IU/L, with a sensitivity of 96.92% and a specificity of 99.08%. There were no significant differences between the cut-off values obtained through the ROC analysis and those provided by the manufacturer for both TSI and TRAb when calculating their sensitivity and specificity in diagnosing GD. Among the 8 newly diagnosed GD cases with discordant qualitative antibody results, TSI was more likely than TRAb to match the clinical diagnosis of GD (6 TSI-positive vs. 2 TRAb-positive patients).

CONCLUSION

The automated TSI bridge immunoassay was positively correlated with thyroxine levels in new-onset GD patients and was more likely to be consistent with the clinical diagnosis of GD than with that of TRAb. The positive Immulite 2000 TSI cut-off value of 0.577 IU/L for GD diagnosis in the Chinese population were close to the value recommended by the manufacturer.

Generalized gingival necrosis in a patient under methimazole use

Hyperthyroidism is a common disease, with a prevalence between 0.2% and 0.5%, characterized by an increase in the synthesis and release of thyroid hormones. Management of this condition requires medical intervention to correct the hormonal imbalance and control its clinical manifestations. Methimazole is a thionamide derivative considered among the first-choice treatment options for hyperthyroidism. However, it may cause serious side effects such as neutropenia or agranulocytosis, which, although rare, can lead to death. The clinical manifestations of this complication range from fever, ulcerations in the oral and pharyngeal mucosa, tonsillitis, and lymphadenopathy to hemorrhagic necrosis and septicemia. This report describes the case of a patient with generalized gingival necrosis that was related to the use of methimazole for the treatment of hyperthyroidism.

Thyrotropin Receptor Antibodies in Early Pregnancy

CONTEXT

Thyrotropin (TSH) receptor antibodies (TRAb) are important when distinguishing between Graves' and gestational hyperthyroidism, but sparse evidence exists on the recommended cutoff during pregnancy.

OBJECTIVE

This work aimed to establish a method- and pregnancy-specific cutoff for TRAb, to describe the frequency of TRAb positivity in early pregnancy, and to follow up the women in the years after pregnancy.

METHODS

This cohort study used the North Denmark Region Pregnancy Cohort and Danish nationwide registers of women in the North Denmark Region who had a blood sample drawn in early pregnancy, 2011 to 2015, that was stored in a biobank for assessment of thyroid function and thyroid autoantibodies. A cutoff value for TRAb was established in a reference cohort (n = 524) and used to identify TRAb-positive and TRAb-negative hyperthyroidism in early pregnancy for evaluation of frequency and follow-up.

RESULTS

The method- and cohort-specific cutoff for TRAb in early pregnancy was 0.98 IU/L (95% CI, 0.96-0.99 IU/L). Among women with low TSH in early pregnancy and no known thyroid disease (n = 414), 21 women (5.1%) were TRAb positive and 393 (94.9%) were TRAb negative. Follow-up in the years following the pregnancy (median 8.1 years) revealed that 52.4% of women with TRAb-positive hyperthyroidism and 8.4% of the women with TRAb-negative hyperthyroidism were diagnosed with hyperthyroidism.

CONCLUSION

This is the first study to measure TRAb in a large group of women in early pregnancy and to establish a pregnancy-specific cutoff. Results reveal that TRAb-negative hyperthyroidism is predominant in early pregnancy and rarely associated with later development of hyperthyroidism.

Identification of patients with Graves' disease who benefit from high-dose radioactive iodine therapy

OBJECTIVE

Radioactive iodine (RAI) therapy is a useful treatment for Graves' disease (GD). Most RAI sessions administer ≤ 500 MBq of iodine (I)-131. Sometimes patients require repeated RAI, often for longer periods of remission. We investigated the characteristics of patients for whom high dose (mostly 1110 MBq of I-131) RAI was effective as RAI therapy for GD.

METHODS

We retrospectively analyzed the cases of 79 patients who underwent RAI for GD in a multicenter setting. We divided the patients into two groups based on the I-131 dose administered: the low dose (LD) group who received ≤ 500 MBq (n = 44) and the high dose (HD) group who received > 500 MBq (n = 35). The therapeutic effect was defined as achieving remission and reaching the point of participating in thyroid hormone replacement therapy within 1 year after RAI. We compared the LD and HD groups' remission rates and conducted a multivariate logistic regression analysis of predictive factors for remission. In a simulation, using the formula for predicting the probability of remission obtained from the analysis results, we estimated how much the remission rate would change if the I-131 dose is increased from 500 to 1110 MBq.

RESULTS

The mean ± standard deviation I-131 dose administered in the LD group was 480 ± 6 MBq, and that of the HD group was 1054 ± 265 MBq. Thirty-five patients (80%) in the LD group and 26 patients (74%) in the HD group achieved remission; this difference in the remission rate was not significant. The multivariate analysis results demonstrated that the absorbed dose and thyroid-stimulating antibody (TSAb) were independent predictors of remission. Seven patients (8.9%) showed an increased probability of remission from < 50% to > 50% when the higher RAI dose was applied (1110 MBq instead of 500 MBq). The thyroid volume and TSAb values in these patients were relatively large at 54.7 ± 34.2 mL and 1378.4 ± 586.3%, respectively.

CONCLUSION

Although the overall remission rate was not significantly different between the patients who received high- or low-dose I-131, treatment with high-dose RAI may improve the probability of remission in patients with a massive thyroid volume and/or high-TSAb Graves' disease.

TPO antibody status prior to first radioactive iodine therapy as a predictive parameter for hypothyroidism in Graves' disease

Objective

We investigated whether a positive thyroid peroxidase antibody (TPO Ab) status before radioactive iodine (RAI) therapy in patients with Graves' hyperthyroidism is a predictive factor for developing hypothyroidism post RAI.

Methods

We performed a retrospective study of patients with Graves' hyperthyroidism with known TPO Ab status, receiving the first administration of RAI. Patients from four thyroid outpatient centres in Belgium receiving their first RAI therapy between the years 2011 and 2019 were studied. Clinical, laboratory, imaging, and treatment data were recorded from medical charts. Hypothyroidism and cure (defined as combined hypo- and euthyroidism) were evaluated in period 1 (≥2 and ≤9 months, closest to 6 months post RAI) and period 2 (>9 months and ≤24 months post RAI, closest to 12 months post RAI).

Results

A total of 152 patients were included of which 105 (69%) were TPO Ab-positive. Compared to TPO Ab-negative patients, TPO Ab-positive patients were younger, had a larger thyroid gland, and had more previous episodes of hyperthyroidism. In period 1, 89% of the TPO Ab-positive group developed hypothyroidism and 72% in the TPO Ab-negative group (P = 0.007). In period 2, the observation was similar: 88% vs 72% (P = 0.019). In the multivariate logistic regression analysis, a positive TPO Ab status was associated with hypothyroidism in period 2 (adjusted OR: 4.78; 95% CI: 1.27-20.18; P = 0.024). In period 1, the aOR was 4.16 (95% CI: 1.0-18.83; P = 0.052).

Conclusion

A positive TPO Ab status in patients with Graves' hyperthyroidism receiving the first administration of RAI is associated with a higher risk of early hypothyroidism.

Outcomes of Early-Pregnancy Antithyroid Drug Withdrawal in Graves' Disease: A Preliminary Prospective Follow-Up Study

Objective: The use of antithyroid drugs (ATDs) carries potential risk for teratogenic effects. For women with well-controlled hyperthyroidism on a low dose of ATDs, drug withdrawal upon pregnancy is recommended by international medical guidelines. Therefore, it is necessary to determine the characteristics of patients suitable for ATD withdrawal, subsequent changes in thyroid function after ATD discontinuation, and its impact on pregnancy and offspring outcomes. Methods: This prospective study recruited 63 pregnant women with well-controlled Graves' hyperthyroidism who had stopped ATDs during early pregnancy. Patients were followed up until the end of pregnancy and data on pregnancy outcomes were collected. Results: Overall, 20 patients (31.7%) had rebound of hyperthyroidism. Patients with either subnormal thyrotropin (TSH) levels (TSH <0.35 mIU/L, odds ratio [OR] = 5.12, confidence interval [CI = 1.29-20.34], p = 0.03) or positive thyrotropin receptor antibody (TRAb) (TRAb >1.75 IU/L, OR = 3.79, [CI = 1.17-12.30], p = 0.02) at the time of ATDs withdrawal presented a higher risk of rebound than those with either normal TSH levels or negative TRAb. Patients with both subnormal TSH and positive TRAb at the time of ATD withdrawal were more likely to experience rebound (83.3%, 5/6) than those with both normal TSH and negative TRAb (13%, 3/23, OR = 33.33, [CI = 2.83-392.60], p = 0.003). The prevalence of adverse pregnancy outcomes was significantly higher in patients who experienced rebound compared with those who did not (55.0% vs. 9.3%, OR = 11.92, [CI = 3.08-46.18], p = 0.0002). Conclusions: Subnormal TSH levels and TRAb positivity at the time of ATD withdrawal in early pregnancy may be associated with rebound of Graves' hyperthyroidism. Rebound of hyperthyroidism during pregnancy may increase the risk of adverse pregnancy outcomes. Larger prospective studies are needed to confirm these findings.

An update on thyroid disorders in the postpartum period

PURPOSE

To review the pathophysiology, diagnosis and management of postpartum thyroid dysfunction, and related management of thyroid disorders during lactation.

METHODS

We reviewed the literature on postpartum thyroid dysfunction and management of thyroid disorders during lactation.

RESULTS

The postpartum period is characterized by a rebound from the immunotolerance induced by pregnancy. Routine thyroid function screening is not recommended for asymptomatic women in the postpartum period. Testing thyroid function should be considered at 6-12-week postpartum for high-risk populations, including women with a previous episode of postpartum thyroiditis, Graves' disease, or those with Hashimoto's thyroiditis on thyroid hormone replacement, known thyroid peroxidase antibody positivity, type 1 diabetes mellitus, other nonthyroidal autoimmune disease, or chronic hepatitis C. A serum TSH should also be checked in the setting of postpartum depression or difficulty lactating. If patients have thyrotoxicosis, new-onset or recurrent Graves' disease must be differentiated from postpartum thyroiditis, because the management differs. Periodic thyroid function testing is recommended following recovery from postpartum thyroiditis due to high lifetime risk of developing permanent hypothyroidism. Levothyroxine, and the lowest effective dose of antithyroid drugs, (propylthiouracil, methimazole, and carbimazole) can be safely used in lactating women. The use of radiopharmaceutical scanning is avoided during lactation and radioactive iodine treatment is contraindicated.

CONCLUSIONS

Diagnosing postpartum thyroid dysfunction is challenging, because symptoms may be subtle. A team approach involving primary care providers, endocrinologists, and obstetricians is essential for transitioning thyroid care from the gestational to the postpartum setting.

Anti-TSH receptor antibodies (TRAb): Comparison of two third generation automated immunoassays broadly used in clinical laboratories and results interpretation

Graves’ disease (GD) is the most common cause of hyperthyroidism in iodine-replete populations. It is an autoimmune disease caused by autoantibodies to the TSHR (TRAb). Although the diagnostic is mainly clinical, measuring TRAb improves accuracy and provides valuable prognostic information. The aim of this study was to compare the performance of two of the most widely used immunoassays i.e., EliA™ anti-TSH-R and Elecsys^® anti-TSH-R. We have carried out a comparative study measuring TRAb by the two immunoassays in consecutive sera samples referred to the laboratory for TRAb measurement. Autoantibodies were measured in all samples in parallel by the two techniques. The two techniques were highly concordant as demonstrated by a Cohen’s kappa of 0.82. At the manufacturer recommended cut-off, sensitivity of Elecsys^® TRAb test was higher (100% vs. 96.6%), while specificity of the EliA™ TRAb test was higher (99.4% vs. 95.3%). In most patients TRAb are detected by any of two tests which are both well suited for Clinical Laboratories use. However, a higher specificity may constitute an advantage for measurement used not for screening but for diagnostic purposes, as anti-TSH-R is.

Changes in Th9 and Th17 lymphocytes and functional cytokines and their relationship with thyroid-stimulating hormone receptor antibodies at different stages of graves’ disease

Objective

Graves’ disease (GD) is an organ-specific autoimmune disease characterized by the production of thyroid-stimulating antibodies (TSAb). The newly discovered CD4⁺ T helper cells, Th9 and Th17 lymphocytes, have been confirmed to be closely associated with a variety of immune diseases. However, relationships with the onset and development of GD remain unclear. The purpose of this study was to investigate the roles of Th9 and Th17 in the pathogenesis and prognosis of GD.

Patients

We recruited 26 patients with newly diagnosed GD, 45 patients with GD in remission, and 20 healthy individuals.

Measurements

Thyroid function and autoantibodies were evaluated using chemiluminescence immunoassays. Th9 and Th17 cells were analyzed using flow cytometry. The expression of Foxo1, IRF-4, RORc, IL-9, and IL-17 mRNA was examined using real-time PCR, and IL-9 and IL-17 protein levels were measured using enzyme-linked immunosorbent assay.

Results

Th9, Th17, and characteristic cytokines IL-9 and IL-17 in the GD-untreated group were significantly higher than those in the control and remission groups. The above indexes significantly decreased in the remission group, with the levels in the TRAb⁻ remission group being similar to those in the normal group, while in the TRAb⁺ remission group, levels were differentially increased. TRAb titer was positively correlated with the levels of Th9, Th17, and their functional cytokines.

Conclusions

Th9 and Th17 cells may be involved in the pathogenesis and disease outcome of GD, which could provide a new direction for developing immunotherapy for patients with GD.

Late endocrine effects after hematopoietic stem cell transplantation in children with nonmalignant diseases

The number of children undergoing hematopoietic stem cell transplantation (HSCT) for nonmalignant diseases has increased in recent years. Endocrine complications are common after HSCT for malignant diseases, while little is known about long-term prevalence and risk factors in children transplanted for nonmalignant diseases. We retrospectively evaluated gonadal function, near adult height and thyroid function in 197 survivors of pediatric HSCT for hemoglobinopathies (n = 66), inborn errors of immunity/metabolism (n = 74) and bone marrow failure disorders (n = 57); median follow-up was 6.2 years (range 3.0-10.5). Gonadal dysfunction occurred in 55% of (post)pubertal females, was still present at last assessment in 43% and was more common after busulfan- than treosulfan-based conditioning (HR 10.6, CI 2.2-52.7; adjusted for HSCT indication). Gonadal dysfunction occurred in 39% of (post)pubertal males, was still present at last assessment in 32% and was less common in those who were prepubertal compared to (post)pubertal at HSCT (HR 0.11; CI 0.05-0.21). Near adult height was more than 2 SDS below mean parental height in 21% of males and 8% of females. Hypothyroidism occurred in 16% of patients; 4% received thyroxin treatment. In conclusion, endocrine complications, especially gonadal dysfunction, are common after pediatric HSCT for nonmalignant conditions. In females, treosulfan seems less gonadotoxic than busulfan. Careful long-term endocrine follow-up is indicated.

Empiric radioiodine for hyperthyroidism: Outcomes, prescribing patterns, and its place in the modern era of theranostics

BACKGROUND

The modern era of radioiodine (I-131) theranostics for metastatic differentiated thyroid cancer requires us to rationalize the role of traditional empiric prescription in nonmalignant thyroid disease. We currently practice empiric I-131 prescription for treatment of hyperthyroidism. This study aims to assess outcomes after treatment of hyperthyroidism by empiric I-131 prescription at our centre, evaluate factors that impact on outcomes and prescribing practice, and gain insight into whether there is a place for theranostically-guided prescription in hyperthyroidism.

PATIENTS AND METHODS

A retrospective review was undertaken of all patients with Graves' disease, toxic multinodular goitre (MNG) and toxic adenoma treated with I-131 between 2016 and 2021. Associations between clinical or scintigraphic variables and remission (euthyroid or hypothyroid) or persistence of hyperthyroidism at follow-up were performed using standard t test as well as Pearson's product correlation.

RESULTS

Of 146 patients with a mean follow-up of 13.6 months, 80.8% achieved remission of hyperthyroidism. This was highest in toxic nodules (90.1%), compared with Graves' disease (73.8%) and toxic MNG (75.5%). In patients with Graves' disease, higher administered activity was associated with remission (p = .035). There was a weak inverse correlation between the Tc-99m pertechnetate uptake vs prescribed activity in Graves' disease (r = -0.33; p = .009). Only one patient (0.7%) had an I-131 induced flare of thyrotoxicosis.

CONCLUSION

Traditional empiric I-131 prescription is a safe and effective treatment of hyperthyroidism and suitable for most patients. However, there may be a role for personalized I-131 prescription by theranostic guidance in selected patients with high thyroid hyperactivity.

The prevalence and significance of nonuniform thyroid radio-isotope uptake in patients with Graves' disease

OBJECTIVE

To evaluate the prevalence and clinical significance of nonuniform technetium (^99m Tc) uptake among patients with Graves' disease (GD).

DESIGN, PATIENTS AND MEASUREMENTS

Patients with GD, referred between July 2005 and March 2018, had Tc⁹⁹ - uptake scans and TSH-receptor antibody (TRAb) measured before antithyroid drug (ATD) therapy. Risk of relapse after ATD cessation was monitored until June 2021 and compared between GD patients based on uptake patterns.

RESULTS

Of the 276 GD patients (mean age, 49.8 years; 84% female), 25 (9.0%) had nonuniform Tc⁹⁹ uptake. At diagnosis, individuals with nonuniform uptake were older (mean age of 61.8 vs. 48.5 years, p < .001), had lower mean thyroid hormone levels (free thyroxine: 36.3 vs. 45.4  pmol/L, p = .04 and free triiodothyronine: 10.0 vs. 17.8 pmol/L, p < .001) and median TRAb levels (4.2 vs. 6.6 U/L, p = .04) compared with those with a uniform uptake. Older age was a significant predictor for the presence of nonuniform uptake in GD patients; odds ratio (95% confidence intervals) of 1.07 (1.03 - 1.10). The risk of relapse was similar in both groups after a median (IQR) follow-up of 41 (13-74) months after ATD cessation (56.0% vs. 46.3%, respectively); hazard ratio (95% confidence intervals) of 1.74 (0.96-3.15).

CONCLUSIONS

Nonuniform radio-isotope uptake is seen in 1 in 11 patients with GD which could be misdiagnosed as toxic multinodular goitre if TRAb levels are not measured. Treatment of GD patients with nonuniform radio-isotope uptake with ATD therapy as first-line appears to be equally effective as compared with those with uniform uptake. TRAb testing should be the main diagnostic test for patients with suspected GD with radio-labelled uptake scans being reserved for those who are TRAb negative.

Differential Diagnosis of Thyrotoxicosis by Machine Learning Models with Laboratory Findings

Differential diagnosis of thyrotoxicosis is essential because therapeutic approaches differ based on disease etiology. We aimed to perform differential diagnosis of thyrotoxicosis using machine learning algorithms with initial laboratory findings. This is a retrospective study through medical records. Patients who visited a single hospital for thyrotoxicosis from June 2016 to December 2021 were enrolled. In total, 230 subjects were analyzed: 124 (52.6%) patients had Graves’ disease, 65 (28.3%) suffered from painless thyroiditis, and 41 (17.8%) were diagnosed with subacute thyroiditis. In consideration that results for the thyroid autoantibody test cannot be immediately confirmed, two different models were devised: Model 1 included triiodothyronine (T3), free thyroxine (FT4), T3 to FT4 ratio, erythrocyte sediment rate, and C-reactive protein (CRP); and Model 2 included all Model 1 variables as well as thyroid autoantibody test results, including thyrotropin binding inhibitory immunoglobulin (TBII), thyroid-stimulating immunoglobulin, anti-thyroid peroxidase antibody, and anti-thyroglobulin antibody (TgAb). Differential diagnosis accuracy was calculated using seven machine learning algorithms. In the initial blood test, Graves’ disease was characterized by increased thyroid hormone levels and subacute thyroiditis showing elevated inflammatory markers. The diagnostic accuracy of Model 1 was 65–70%, and Model 2 accuracy was 78–90%. The random forest model had the highest classification accuracy. The significant variables were CRP and T3 in Model 1 and TBII, CRP, and TgAb in Model 2. We suggest monitoring the initial T3 and CRP levels with subsequent confirmation of TBII and TgAb in the differential diagnosis of thyrotoxicosis.

Antithyroid drug therapy in pregnancy and risk of congenital anomalies: Systematic review and meta-analysis

OBJECTIVES

The risk of congenital anomalies following in utero exposure to thionamide antithyroid drugs (ATDs) is unresolved. Observational studies are contradictory and existing meta-analyses predate and preclude more recent studies. We undertook an updated meta-analysis of congenital anomaly risk in women exposed to carbimazole or methimazole (CMZ/MMI), propylthiouracil (PTU), or untreated hyperthyroidism in pregnancy.

METHODS

We searched Medline, Embase, and the Cochrane database for articles published up till August 2021. We pooled separate crude and adjusted risk estimates using random effects models and subgroup analyses to address heterogeneity.

RESULTS

We identified 16 cohort studies comprising 5957, 15,785, and 15,666 exposures to CMZ/MMI, PTU, and untreated hyperthyroidism, respectively. Compared to nondisease controls, adjusted risk ratio (RR) and 95% confidence intervals (95% CIs) for congenital anomalies was increased for CMZ/MMI (RR, 1.28; 95% CI, 1.06-1.54) and PTU (RR, 1.16; 95% CI, 1.08-1.25). Crude risk for CMZ/MMI was increased relative to PTU (RR, 1.20; 95% CI, 1.01-1.43). Increased risk was also seen with exposure to both CMZ/MMI and PTU, that is, women who switched ATDs in pregnancy (RR, 1.51; 95% CI, 1.14-1.99). However, the timing of ATD switch was highly variable and included prepregnancy switches in some studies. The excess number of anomalies per 1000 live births was 17.2 for patients exposed to CMZ/MMI, 9.8, for PTU exposure, and 31.4 for exposure to both CMZ/MMI and PTU. Risk in the untreated group did not differ from control or ATD groups. The untreated group was however highly heterogeneous in terms of thyroid status. Subgroup analysis showed more positive associations in studies with >500 exposures and up to 1-year follow-up.

CONCLUSIONS

ATD therapy carries a small risk of congenital anomalies which is higher for CMZ/MMI than for PTU and does not appear to be reduced by switching ATDs in pregnancy. Due to key limitations in the available data, further studies will be required to clarify the risks associated with untreated hyperthyroidism and with switching ATDs in pregnancy.

The bidirectional relationship of thyroid disease and atrial fibrillation: Established knowledge and future considerations

Atrial fibrillation (AF) tends to occur frequently in patients with thyroid disease, primarily hyperthyroidism. In hyperthyroidism, increased levels of thyroid hormones, via intra- and extranuclear mechanisms, have profound effects on cardiac electrophysiology. Hypothyroidism carries a lower risk for AF and is mainly associated with the overtreatment of hypothyroid patients. New-onset AF is frequently the only manifestation of thyroid disease, which renders screening for thyroid dysfunction in that scenario clinically useful. Managing thyroid disease and comorbid AF is essential. This includes thyroid hormones control along with conventional AF therapy. However, there are several open issues with this comorbid duo. The optimal management of thyroid disease and its impact on AF burden remains obscure. There is scanty information on clear-cut benefits for therapy of subclinical thyroid disease and screening of asymptomatic patients. Furthermore, the immunogenetic overlap between the autoantibodies in Graves' disease and AF genesis may lead to novel therapeutic implications. The objective of this review is to summarize the up-to-date epidemiology, pathogenesis, pathophysiology and management of interacting thyroid disease and AF.

Revisiting the role of surgery in the treatment of Graves' disease

Graves' disease (GD) can be managed by antithyroid drugs (ATD), radioactive iodine (RAI) and surgery. Thyroidectomy offers the highest success rates for both primary and persistent disease, yet it is the least recommended or utilized option reaching <1% for primary disease and <25% for persistent disease. Several surveys have found surgery to be the least recommended by endocrinologists worldwide. With the development of remote access thyroidectomies and intraoperative nerve monitoring of the recurrent laryngeal nerve, combined with current knowledge of possible risks associated with RAI or failure of ATDs, revaluation of the benefit to harm ratio of surgery in the treatment of GD is warranted. The aim of this review is to discuss possible reasons for the low proportion of surgery in the treatment of GD, emphasizing an evidence-based approach to the clinicians' preferences for surgical referrals, surgical indications and confronting traditional reasons and concerns relating to the low referral rate with up-to-date data.

Appropriate duration of antithyroid drug treatment as a predictor for relapse of Graves' disease: a systematic scoping review

BACKGROUND

Following the conventional 12-18 month antithyroid drug (ATD) treatment in Graves' disease (GD), 50% of patients experience relapse of hyperthyroidism.

OBJECTIVE

The aim of this systematic scoping review was critical appraisal of duration of ATD therapy in the last 80 years.

METHODS

Articles were identified through the search of PubMed from January 1, 1941 to April 30, 2021. All study types were included. Articles were eligible if they reported data on the length of ATD treatment, particularly thyroid hormones and TSH receptor antibodies (TRAb) concentrations and specifically those with data on the remission and/or relapse rates.

RESULTS

We described major progress regarding the duration of ATD therapy and related outcomes at every 20 years. Articles of 1941-1960 were mainly concerned with determination of favorable treatment, minimal effective dose, side effects and rate of remission after < 12-month ATD therapy. Studies with larger number of patients and longer follow-ups appeared in 1961-1980; higher remission rate after 18-24 months versus 6 months of ATD therapy was reported. Articles of 1981-2000 focused on identification of factors associated with high relapse rates after discontinuation of ATD. In 2001-2021, ATD became the first choice of treatment in many countries. However, 12-18 months of ATD therapy was arbitrarily chosen as the appropriate option. According to recent studies, persistent normalization of TRAb occurs after 5 years of methimazole therapy and ATD treatment of > 60 months could offer a 4-year remission rate of 85%.

CONCLUSION

Long-term ATD treatment for more than 60 months is safe and effective, has the highest remission rate and cures most patients with GD; hence, it should be considered as the most appropriate duration for ATD therapy in these patients.

Accuracy of 123I Na Thyroid Imaging in calculating thyroid volume

Introduction: Hyperthyroidism is often managed with radioactive iodine therapy. The dose of 131Iadministered to the patient is determined based on the calculated size of the thyroid gland in gram and 24 hour iodine uptake. Ultrasonography is a validated modality for determination of thyroid volume. Though necessary for assessing degree of 123I uptake, nuclear scintigraphy also allows for the capability of estimating thyroid volume. Here we compare volume measurements calculated based on ultrasonography and nuclear scintigraphy in a cohort of hyperthyroid patients. Methods: This prospective study designed to evaluate 110 consecutive hyperthyroidism patients who were undergoing thyroid ultrasound and 123I scintigraphy. Scintigraphy was performed after oral administration of approximately 11 MBq 123Isodium, and uptakes at 2 and 24 hours were measured. At 24 hours, the patients underwent thyroid scan with a nuclear medicine camera with LEHR (low energy high resolution) collimator next to the patient's chin. Thyroid measurements were calculated via the formula for determining a prolate ellipsoid. The formula was modified for RAIU as it is a planar image. Volumes calculated with these two modalities were subsequently analyzed and compared by linear regression. All patients had undergone ultrasonography with an average three months from nuclear scan. All of our patient 131I dosages were based on the thyroid measurements obtained by thyroid scintigraphy. Results: We included 110 patients (95 females, 15 males) with age range 20-95 years and average age 56 +/- 17.4 years old. Diagnoses included 66 patients with nodular goiter, and 44 patients with Graves' Disease. There was a linear relationship between measurement of thyroid gland weight by two modalities which can be explained in the following formula: log US(g) = 0.841 + 0.649*log NM(g). Conclusion: We have validated that this method has helped obtain more accurate measurements of the thyroid gland by thyroid scintigraphy. Additionally, we have derived conversion factors that convert the estimated thyroid volume calculated from thyroid scintigraphy to the expected ultrasound value.

Long-term methimazole therapy in Graves' hyperthyroidism and adverse reactions: a Danish multicenter study

Purpose

In this prospective multicenter study with patients newly diagnosed with Graves' hyperthyroidism (GH), we studied the timing and characteristics of adverse drug reactions in patients treated with anti-thyroid drugs (ATD) for up to 48 months.

Methods

Patients with GH were treated with ATD until remission and hereafter with a low-dose regime to keep the patients in remission. The patients were followed with blood samples and recording of adverse events approximately every second month for the first 2 years and every third month for the following 2 years.

Results

We included 208 patients and the patients were treated for a median of 22 (range: 0.5-49) months. Ten percent of the patients experienced adverse drug reactions and 75% of the cases occurred during the first 6 months. After 24 months, the methimazole dose was lowered to 5 mg/day, and after this time point, no further adverse drug reactions were recorded. Skin reactions were the most prominent reaction, comprising 68% of the registered reactions, and no hepatic and bonemarrow affection was recorded.

Conclusion

With this study, we report the frequency, timing of occurrence, and characteristics of adverse drug reactions when treating GH with the ATD drug methimazole for up to 48 months. Long-term low-dose methimazole treatment can be a cost-effective and straightforward treatment option if adverse drug reactions such as severe hepatic and bone marrow affection are kept in mind.

Efficacy of Radioiodine Therapy in Patients With Primary Hyperthyroidism: An Institutional Review From Pakistan

Background

Radioactive iodine (RAI) is the treatment of choice for most patients with primary hyperthyroidism. The most common etiologies of hyperthyroidism are Graves' disease (GD), toxic adenoma (TA), and toxic multinodular goiter (TMNG). A single dose of RAI is usually sufficient to cure hyperthyroidism. The aim of this study was to assess the effectiveness of RAI therapy for patients diagnosed with primary hyperthyroidism.

Methods and materials

Patients diagnosed with hyperthyroidism who received RAI therapy between 2008 and 2018 were included in the study. The data was acquired from the hospital's electronic medical record system. Following the RAI treatment, a cure was defined as the development of euthyroidism or hypothyroidism after a single fixed-dose without antithyroid medication within one year of RAI therapy. In addition, a simple logistics regression model was used to identify the prognostic factors that may lead to better outcomes.

Results

A total of 112 patients diagnosed with hyperthyroidism with a mean age of 47 ± 14 were included in this study. The majority of the patients were female, 79 (70.5%). Within one year of RAI therapy, 84 (75%) patients achieved a cure that is either hypothyroid or euthyroid status. RAI dose was higher in responsive patients (18.50 ± 4.10 millicurie [mCi] versus 16.50 ± 4.10 mCi) than in non-responsive patients. The mean RAI doses were 16.05 ± 2.99 mCi in GD, 19.81 ± 4.40 mCi in TMNG, and 20.50 ± 3.30 mCi in TA, with a statistically significant p-value of 0.001. In the univariable logistic regression model, RAI dose was a significant prognostic factor of the responsive group (OR: 1.15, CI [1.01-1.31], p-value 0.03).

Conclusion

Our data presented that RAI therapy is effective for primary hyperthyroidism. We achieved remission with a single fixed-dose in the majority of patients. Most of our patients were cured within three months of RAI therapy. In addition, the RAI dose was higher in the responsive group as compared to the non-responsive group.

Thyrotoxicosis occurrence in SARS-CoV-2 infection: A case report

Introduction

Coronavirus Disease 2019 (COVID-19) is predominantly manifested as respiratory distress. There are growing reports of extrapulmonary clinical manifestations of COVID-19 in addition to the respiratory symptoms. COVID-19 has been associated with the thyroid function through Angiotensin-converting enzyme 2 (ACE2), the central mechanism through Thyroid Stimulating Hormone (TSH), and direct replication of the virus.

Case presentation

A 26-year-old woman presented with complaints of palpitation and abdominal pain for three days. Because the symptoms were worsening, she was brought to the emergency room. Her temperature was 37.9 °C without any symptoms of cough, coryza, sneezing, nor headache. Physical examination revealed tremor, tachycardia with 162 beats per minute (bpm), excessive sweating, hyperreflexia of patellar reflex, and no prominent lump in the neck. Electrocardiography (ECG) showed supraventricular tachycardic rhythm (SVT) and 150 J cardioversions were performed. The ECG converted to sinus rhythm, regular, with 120 bpm. Thyroid function tests showed an elevated fT4 level (>7.77 ng/dL) and low TSH level (<0.005 μIU/mL). Chest X-ray showed slight cardiomegaly without prominent abnormality in the lungs that was confirmed with thoracic computerized tomography. The result of the rapid antigen test for COVID-19 was positive and confirmed with polymerase chain reaction testing. She was then treated in the intensive isolation room with remdesivir, anti-hyperthyroid, and supportive therapy. As her condition improved, she was shifted to a non-intensive isolation room and was discharged from the hospital at day 7.

Discussion

COVID-19 could present as a thyroid crisis as the initial clinical manifestation. Clinicians should be aware that presentation of thyroid dysfunction in a patient without previous endocrine disease could be due to COVID-19 infection. Early recognition, anti-hyperthyroid therapy, and following isolation procedures for COVID-19 are required in the emergency condition.

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Thyroid crisis could be associated with COVID-19 infection.

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Extra-respiratory manifestations of COVID-19 infection vary among patients.

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Clinicians should be aware of thyroid crisis as a COVID-19 infection manifestation.

New Therapeutic Horizon of Graves' Hyperthyroidism: Treatment Regimens Based on Immunology and Ingredients From Traditional Chinese Medicine

Graves’ disease is an autoimmune disease characterized by goiter and hyperthyroidism, and 25% patients develop GO. Traditional treatment options, such as antithyroid drugs, radioiodine or thyroidectomy, have remained largely unchanged over the past 70 years. For many patients, there is a high rate of recurrence after antithyroid drugs and lifelong hypothyroidism after ablation and thyroidectomy. The symptoms and quality of life of some patients have not been effectively improved. The clinical demand for new therapeutic regimens, coupled with a deeper understanding of the pathophysiology and immunobiology of Graves’ disease, has led to the emergence of several new therapeutic ideas, including biologics, small molecule peptides, immunomodulators and teprotumumab, a specific antibody targeting IGF-1R. Besides, the elements of TCM have attracted more and more interests in modern medicine, because some effective components have been successfully used in the treatment of autoimmune diseases. Based on the pathophysiology and efficacy of clinical management and treatment in Graves’ hyperthyroidism, here we review the new strategies under investigation and summarize the effective components of traditional Chinese medicine used for Graves’ hyperthyroidism, and explore their mechanisms. These therapies have opened a new window for the treatment of Graves’ disease, but the exact mechanism and the research direction still need to be further explored.

Drug safety in thyroid eye disease - a systematic review

INTRODUCTION

The autoimmune-induced thyroid eye disease (TED) is a frequent extrathyroidal manifestation of Graves' disease and less frequently of Hashimoto's thyroiditis. Pathognomonic clinical signs, i.e. exophthalmos, double vision, and inflammation of the orbital tissue cause physical, ophthalmic, and socio-psychological limitations.

AREAS COVERED

PubMed and MeSH database were searched for specific guidelines, randomized controlled trials, prospective clinical studies, systematic reviews and meta-analyses pertaining to the safety profile of currently administered immunosuppressive agents for the treatment of TED. Occurred adverse events (AE), severe AE (SAE), side effects (SE), and severe SE (SSE) were classified according to the standardized medical dictionary for regulatory activities (MedDRA).

EXPERT OPINION

This novel systematic analysis offers an overview of potential AE, SAE and SE for currently recommended immunosuppressive drugs for the treatment of TED. Non-specific, anti-inflammatory drugs and more specific, targeted biologicals are treatment options for active and severe TED. Critical evaluation of the pertinent literature confirms an evidence-based, beneficial efficacy/risk ratio of the current first-line and second-line treatment recommendations endorsed by the European Society of Endocrinology. However, further large, well-conceived trials are mandatory to enhance our knowledge and experience with novel specific small molecules and/or monoclonal antibodies targeting the key autoantigens in TED.

Genetics of Thyroid Disorders

Thyroid diseases in children and adolescents include acquired or congenital conditions, including genetic disorders either isolated or part of a syndrome. Briefly, we will review the physiology and pathophysiology of the thyroid gland and its disorders. The aim of this chapter is to describe genetic abnormalities of the thyroid gland.

Effects of calorie intake and sampling time on thyroid stimulating hormone concentration

BACKGROUND

This study aimed to investigate the effects of blood sampling after calorie intake on thyroid stimulating hormone (TSH) level, compared with blood sampling in fasting state.

METHODS

This was a prospective, randomized, controlled study. Subjects from the outpatients in the department of endocrinology without evidence of thyroid diseases were included and then randomized into the fasting group, diet intake group, and glucose intake group, respectively. Fasting blood was collected from all subjects at 7:00 am for the measurement of TSH and free thyroxine (FT₄) concentrations. Afterwards, the subjects were maintained at fasting state (fasting group), had an intake of the mixed diet with 400 kcal calories (diet intake group), and had an intake of 75 g glucose (glucose intake group), respectively, and blood was collected again 2 h later (9:00 am on the same day) for TSH and FT₄ level measurement and comparison.

RESULTS

A total of 150 subjects were enrolled, of whom 146 met the inclusion criteria, with 48, 48, and 50 in the diet intake group, glucose intake group, and fasting group, respectively. The TSH in the diet intake group was significantly lower at 9:00 am (TSH_9am) than the level at 7:00 am (TSH_7am) (P < 0.001), with a median variation of -0.71 mU/L, and a median variation rate of -32.4%. In the glucose intake group, TSH_9am was also significantly lower than TSH_7am (P < 0.001), with a median variation of -0.73 mU/L, and a median variation rate of -31.5%. For the fasting group, TSH_9am decreased slightly but was significantly lower than TSH_7am (P < 0.001), with a median variation of -0.1 mU/L, and a median variation rate of -5.2%. According to TSH_7am measurements, 9 subjects (3 subjects in each group) met the diagnostic criteria of subclinical hypothyroidism. However, according toTSH_9am measurements, only 2 patients in the fasting group met the diagnostic criteria of subclinical hypothyroidism.

CONCLUSION

Compared with the fasting state, the TSH level at 2 h after the calorie intake was decreased by about 30%, which might influence the diagnosis of subclinical hypothyroidism.

TRIAL REGISTRATION

ChiCTR2100047454 (18/06/2021).

Efficacy of preoperative therapeutic plasma exchange in patients with hyperthyroidism and factors affecting the number of sessions

PURPOSE

Achieving preoperative euthyroidism in patients with hyperthyroidism for whom antithyroid drugs (ATDs) cannot be used for treatment is a serious clinical problem. We aimed to evaluate the effectiveness of therapeutic plasma exchange (TPE) in hyperthyroid patients scheduled for surgery and predictive factors for a high number of TPE sessions.

METHODS

We retrospectively analyzed the data of 21 patients with hyperthyroidism who were treated with TPE for preoperative euthyroidism in our institution. Pre- and post-TPE thyroid function tests were compared to assess efficacy. Binary logistic regression analysis was applied to determine predictors of patients requiring a high number of TPE sessions.

RESULTS

All patients (20 patients with Graves' disease and 1 patient with toxic multinodular goiter; 12 women and 9 men; mean age 35.71 ± 12.38 years) had severe hyperthyroidism before TPE. The changes before and after TPE in fT3, fT4, and TSH levels were statistically significant (p < 0.001, p < 0.001, p = 0.002, respectively). The median number of TPE sessions was 8 (range: 1-24). Levels of fT3 before TPE were significantly higher in patients for whom higher numbers of TPE sessions were required (≥8) (OR: 1.427, 95% CI: 1.038-1.961, p = 0.028). Receiver operating characteristic curve analysis revealed an optimum cut-off value of 12.8 pg/ml for fT3 before TPE (91% sensitivity, 80% specificity, area under the curve: 0.927).

CONCLUSION

TPE should be considered as an effective alternative treatment option that can be used to rapidly achieve euthyroidism before surgery when ATDs cannot be used. Pre-TPE fT3 levels of >12.8 pg/ml may be an independent factor predicting the need for higher numbers of TPE sessions (≥8).

CD11c+ B Cells Participate in the Pathogenesis of Graves’ Disease by Secreting Thyroid Autoantibodies and Cytokines

Graves’ disease (GD) is a common autoimmune disorder with an elevation in pathogenic autoantibodies, specifically anti-thyrotropin receptor antibodies (TRAbs), which are secreted by autoreactive B cells. To date, there has been little research on self-reactive B cells in GD. In the current study, we reported that a unique B-cell subset, CD11c+ B cells, was expanded in the peripheral blood (PB) of GD patients, as detected by flow cytometry. The frequency of CD11c+ B cells was positively correlated with serum TRAb levels. The flow cytometry data showed that CD11c expression was higher in a variety of B-cell subsets and that CD11c+ B cells presented a distinct immunophenotype compared to paired CD11c- B cells. Immunohistochemical and immunofluorescence staining indicated the presence of CD11c+CD19+ B cells in lymphocyte infiltration areas of the GD thyroid. Flow cytometric analysis of PB and fine-needle aspiration (FNA) samples showed that compared to PB CD11c+ B cells, CD11c+ B cells in the thyroid accumulated and further differentiated. We found that CD11c+ B cells from the PB of GD patients were induced to differentiate into autoreactive antibody-secreting cells (ASCs) capable of secreting TRAbs in vitro. Luminex liquid suspension chip detection data showed that CD11c+ B cells also secreted a variety of cytokines, including proinflammatory cytokines, anti-inflammatory cytokines, and chemokines, which might play roles in regulating the local inflammatory response and infiltration of lymphocytes in the thyroid. In addition, we performed a chemotaxis assay in a Transwell chamber to verify that CD11c+ B cells were recruited by thyroid follicular cells (TFCs) via the CXCR3-CXCL10 axis. In conclusion, our study determined that CD11c+ B cells were involved in the pathogenesis of GD in multiple ways and might represent a promising immunotherapeutic target in the future.

Efficacy of propylthiouracil in the treatment of pregnancy with hyperthyroidism and its effect on pregnancy outcomes: A meta-analysis

Background

Hyperthyroidism affects about 0.2%-2.7% of all pregnancies, and is generally treated with propylthiouracil (PTU). However, previous studies about the effects of propylthiouracil on maternal or foetal are contentious.

Objective

This meta-analysis was carried out to investigate the safety and efficacy of propylthiouracil during pregnancy.

Materials and methods

PubMed, EBSCO, Embase, Scopus, Web of Science, Cochrane, CNKI, Wanfang and VIP database were searched from inception until August 31, 2021 for all available randomized controlled trials (RCTs) or cohort studies that evaluated the efficacy of propylthiouracil and its effects on pregnancy outcomes. Odds ratio (OR) and 95% confidence interval (CI) were used for binary variables, weighted mean difference (WMD) and 95% confidence interval (CI) were used for continuous variables. RevMan5.4 and Stata 16.0 were used for performing the meta-analysis.

Results

The researchers examined data from 13 randomized controlled trials and cohort studies involving 18948 infants. Congenital anomalies were not significantly associated with PTU in the pooled results (OR = 1.03, 95%CI: 0.84–1.25, P = 0.80, I² = 40.3%). There were no statistically significant differences in neonatal hypothyroidism (OR = 0.55, 95%CI: 0.06–4.92, P = 0.593, I² = 57.0%) or hepatotoxicity (OR = 0.34, 95%CI: 0.08–1.48, P = 0.151, I² = 0.0%) exposed to PTU compared to the control group. The serum levels of FT3, FT4, TT3, and TT4 were significantly lower in the propylthiouracil group compared to the control group.

Conclusion

This meta-analysis confirmed the beneficial effects of propylthiouracil treatment, namely the risks of adverse pregnancy outcomes were not increased, and it also proved PTU’s efficacy in the treatment of pregnant women with hyperthyroidism. The findings supported the use of propylthiouracil during pregnancy with hyperthyroidism in order to improve clinical pregnancy outcomes in patients with thyroid dysfunction.

Thyroidectomies in Italy: A Population-Based National Analysis from 2001 to 2018

Background: The incidence of thyroid disease is generally increasing, and it is subject to major geographic variability, between and within countries. Moreover, the incidence rates and the proportion of overdiagnosis for thyroid cancer in Italy are among the highest worldwide. This study aimed to estimate population-based frequency and trends of thyroidectomies in Italy by type of surgical procedure (total/partial), indication (tumors/other conditions), sex, age, and geographical region. Materials and Methods: Age-standardized rates (ASRs) of thyroidectomies were estimated from 2001 to 2018 using the national hospital discharges database. Results: In Italy, ASRs of thyroidectomies were nearly 100 per 100,000 women in 2002-2004 and decreased to 71 per 100,000 women in 2018. No corresponding variation was shown in men (ASR 27 per 100,000 men) in the overall period. A more than twofold difference between Italian regions emerged in both sexes. The proportion of total thyroidectomies (on the sum of total and partial thyroidectomies) in the examined period increased from 78% to 86% in women and from 72% to 81% in men. Thyroidectomies for goiter and nonmalignant conditions decreased consistently throughout the period (from 81 per 100,000 women in 2002 to 49 in 2018 and from 22 to 16 per 100,000 men), while thyroidectomies for tumors increased until 2013-2014 up to 24 per 100,000 women (9 per 100,000 men) and remained essentially stable thereafter. Conclusions: The decrease in thyroidectomies for nonmalignant diseases since early 2000s in Italy may derive from the decrease of goiter prevalence, possibly as a consequence of the reduction of iodine deficiency and the adoption of conservative treatments. In a context of overdiagnosis of thyroid cancer, recent trends have suggested a decline in the diagnostic pressure with a decrease in geographic difference. Our results showed the need and also the possibility to implement more conservative surgical approaches to thyroid diseases, as recommended by international guidelines.

Management of Graves' hyperthyroidism: present and future

INTRODUCTION

Graves' disease (GD) is an autoimmune disorder due to loss of tolerance to the thyrotropin receptor (TSHR) and ultimately caused by stimulatory TSHR antibodies (TSHR-Ab). GD may be associated with extrathyroidal manifestations, mainly Graves' orbitopathy. Treatment of GD relies on antithyroid drugs (ATDs), radioactive iodine (RAI), thyroidectomy. The major ATD limitation is the high recurrence rate after treatment. The major drawback of RAI and thyroidectomy is the inevitable development of permanent hypothyroidism.

AREAS COVERED

Original articles, clinical trials, systematic reviews, meta-analyses from 1980 to 2021 were searched using the following terms: Graves' disease, management of Graves' disease, antithyroid drugs, radioactive iodine, thyroidectomy, Graves' orbitopathy, thyroid-eye disease.

EXPERT OPINION

ATDs are the first-line treatment worldwide, are overall safe and usually given for 18-24 months, long-term treatment may decrease relapses. RAI is safe, although associated with a low risk of GO progression, particularly in smokers. Thyroidectomy requires skilled and high-volume surgeons. Patients play a central role in the choice of treatment within a shared decision-making process. Results from targeted therapies acting on different steps of the autoimmune process, including iscalimab, ATX-GD-59, rituximab, blocking TSHR-Ab, small molecules acting as antagonists of the TSHR, are preliminary or preclinical, but promising in medium-to-long perspective.

Management of Psychiatric Disorders in Patients with Endocrine Disorders

The neuropsychiatric symptoms and disorders among endocrine disorders are discussed in the context of current global and local epidemiological data. Neuropsychiatric symptoms, clinical differentials in hypothyroidism, hyperthyroidism, and parathyroid disorders, and relevant management protocols are described. HPT axis and its interaction with psychotropic usage are mentioned. Stress diathesis, depression, anxiety disorders, and severe mental illnesses and their respective association with diabetes, the relevant mechanisms, and management protocols are stated. The metabolic syndrome, its definition, and its relationship to psychotropic usage are laid out. Moreso, best clinical practices for scenarios such as hyperprolactinemia and psychiatric illnesses, and steroid-induced psychosis are mentioned.