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Azizi F, Amouzegar A, Khalili D, Abdi H, Tohidi M, Hedayati M, Cheraghi L, Mehrabi Y, Takyar M. Risk of recurrence at the time of withdrawal of short- or long-term methimazole therapy in patients with Graves' hyperthyroidism: a randomized trial and a risk-scoring model. Endocrine 2024; 84:577-588. [PMID: 38165576 DOI: 10.1007/s12020-023-03656-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/23/2023] [Accepted: 12/10/2023] [Indexed: 01/04/2024]
Abstract
PURPOSE In Graves' disease, administration of low-dose methimazole for more than 60 months induces higher remission rates compared with the conventional duration of 12-18 months. However, the risk of recurrence and its predictors beyond 48 months of drug withdrawal are not known. The aims of this study were to determine the risk of recurrence during 84 months after withdrawal of short- or long-term methimazole therapy and a risk stratification for recurrence of hyperthyroidism. METHODS A total of 258 patients were treated with methimazole for a median of 18 months and randomized to discontinuation of the drug(conventional short-term group; n = 128) or continuation of the treatment up to 60-120 months(long-term group; n = 130). Patients were followed for 84 months after methimazole withdrawal. Cox proportional hazards modeling was performed to identify factors associated with relapse and develop a risk-scoring model at the time of discontinuing the treatment. RESULTS Hyperthyroidism recurred in 67 of 120(56%) of conventionally-treated patients versus 20 of 118(17%) of those who received long-term methimazole treatment, p < 0.001. Age, sex, goiter grade, triiodothyronine, thyrotropin, and thyrotropin receptor antibodies were significant predictors of recurrence in both "conventional" and "long-term" groups but free thyroxine just in the "long-term" group. The risk-scoring model had a good discrimination power (optimism corrected c-index = 0.78,95%CI = 0.73-0.82) with a range of 0-14 and sensitivity of 86% and specificity of 62% at the risk-score of eight. CONCLUSION A relapse-free state was achieved in 83% of patients with Graves' hyperthyroidism 84 months after cessation of long-term methimazole treatment which could be predicted by some significant predictors in a simple risk-scoring system.
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Affiliation(s)
- Fereidoun Azizi
- Endocrine Research Center, Research Institute for Endocrine Sciences, Shahid Beheshti University of Medical Sciences, Tehran, Iran.
| | - Atieh Amouzegar
- Endocrine Research Center, Research Institute for Endocrine Sciences, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Davood Khalili
- Prevention of Metabolic Disorders Research Center, Research Institute for Endocrine Sciences, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Hengameh Abdi
- Endocrine Research Center, Research Institute for Endocrine Sciences, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Maryam Tohidi
- Prevention of Metabolic Disorders Research Center, Research Institute for Endocrine Sciences, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Mehdi Hedayati
- Cellular and Molecular Endocrine Research Center, Research Institute for Endocrine Sciences, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Leila Cheraghi
- Department of Epidemiology and Biostatistics, Research Institute for Endocrine Sciences, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Yadollah Mehrabi
- Department of Epidemiology and Biostatistics, School of Public Health and Safety, Shahid Beheshti University of Medical Science, Tehran, Iran
| | - Miralireza Takyar
- Endocrine Research Center, Research Institute for Endocrine Sciences, Shahid Beheshti University of Medical Sciences, Tehran, Iran
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Calissendorff J, Cramon PK, Hallengren B, Khamisi S, Lantz M, Planck T, Sjölin G, Wallin G, Holmberg M. Long-Term Outcome of Graves' Disease: A Gender Perspective. WOMEN'S HEALTH REPORTS (NEW ROCHELLE, N.Y.) 2023; 4:487-496. [PMID: 37818181 PMCID: PMC10561747 DOI: 10.1089/whr.2023.0073] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Accepted: 08/22/2023] [Indexed: 10/12/2023]
Abstract
Introduction In gender-skewed conditions such as Graves' disease (GD), the outcome naturally becomes dominated by the majority. This may lead to gender-biased misunderstandings regarding treatment outcomes. This especially holds true when complications, such as depression, are unevenly distributed. We have, therefore, studied the long-term outcome of GD from a gender perspective. Materials and Methods A cohort of 1186 patients with GD was included in a follow-up 6-10 years after inclusion. Choice of treatment, the feeling of recovery, long-term treatment, comorbidity, and quality of life were investigated with questionnaires. All results were studied sex-divided. Results We included 973 women and 213 men. There was no difference between men and women in the choice of treatment. At follow-up, women scored significantly worse in the general questionnaire 36-item Short-Form Health Status (SF-36) domain bodily pain and in the thyroid-specific Thyroid-Related Patient-Reported Outcome (ThyPRO) domains depression, impaired sex life, and cosmetic complaints, all p < 0.05. Women were twice as likely (29.5%) to be treated with levothyroxine after successful treatment with antithyroid drugs (ATD) compared with men (14.9%, p < 0.05). Conclusion After treatment for GD, women were more affected by depression, impaired sex life, cosmetic issues, and bodily pain despite successful cure of hyperthyroidism. The prevalence of hypothyroidism was also doubled in women. Whether these observed gender differences reflect a worse outcome of GD in women or a natural consequence of a higher prevalence of these symptoms and autoimmunity in the female population is difficult to disentangle. Nevertheless, several years after GD, women reveal more persistent symptoms.
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Affiliation(s)
- Jan Calissendorff
- Department of Molecular Medicine and Surgery, Karolinska Institutet, Stockholm, Sweden
- Department of Endocrinology, Metabolism and Diabetes, Karolinska University Hospital, Stockholm, Sweden
| | - Per Karkov Cramon
- Department of Clinical Physiology and Nuclear Medicine, Copenhagen University Hospital—Rigshospitalet, Copenhagen, Denmark
| | - Bengt Hallengren
- Department of Endocrinology, Skåne University Hospital, Malmö, Sweden
- Department of Clinical Sciences, Lund University, Lund, Sweden
| | - Selwan Khamisi
- Department of Endocrinology, Uppsala University Hospital, Uppsala, Sweden
- Department of Medical Sciences, Uppsala University, Uppsala, Sweden
| | - Mikael Lantz
- Department of Endocrinology, Skåne University Hospital, Malmö, Sweden
- Department of Clinical Sciences, Lund University, Lund, Sweden
| | - Tereza Planck
- Department of Endocrinology, Skåne University Hospital, Malmö, Sweden
- Department of Clinical Sciences, Lund University, Lund, Sweden
| | - Gabriel Sjölin
- Faculty of Medicine and Health, Örebro University Hospital, Örebro, Sweden
| | - Göran Wallin
- Department of Molecular Medicine and Surgery, Karolinska Institutet, Stockholm, Sweden
- Faculty of Medicine and Health, Örebro University Hospital, Örebro, Sweden
| | - Mats Holmberg
- ANOVA, Karolinska University Hospital, Stockholm, Sweden
- Department of Medicine, Huddinge, Karolinska Institutet, Stockholm, Sweden
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Suonsyrjä N, Laihia I, Huhtala H, Jaatinen P, Metso S. Thyroid function test variability and cardiovascular morbidity in hyperthyroidism. Clin Endocrinol (Oxf) 2023; 99:428-436. [PMID: 37497807 DOI: 10.1111/cen.14948] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/25/2022] [Revised: 05/26/2023] [Accepted: 06/28/2023] [Indexed: 07/28/2023]
Abstract
OBJECTIVE The variability of thyroid function tests (TFTs) during antithyroid drug (ATD) therapy and its association with adverse health outcomes have not been previously studied. The aim of this study was to evaluate the association of TFT variability and cardiovascular morbidity during ATD therapy. DESIGN Retrospective cohort study. PATIENTS AND MEASUREMENTS Hyperthyroid patients (n = 394) treated with ATD therapy at Tampere University Hospital between March 2016 and December 2018 were followed up for a median time of 1.5 years (interquartile range 0.8-2.0). The coefficients of variation (CVs) of the follow-up thyroid-stimulating hormone (TSH), free thyroxine (fT4) and free triiodothyronine (fT3) measurements were determined. The associations of TFT variability and baseline clinical factors with cardiovascular disease (CVD) -associated hospital visits were assessed with logistic regression analyses. RESULTS In the multivariable analyses, age (odds ratio [OR]: 1.06, 95% confidence interval [CI]: 1.03-1.09), male gender (OR: 2.33, 95% CI: 1.03-5.28) and fT4-CV (OR: 1.02, 95% CI: 1.01-1.04) were independent risk factors for cardiovascular morbidity, whereas baseline positive thyrotropin receptor antibodies (TRAbs) were associated with lower cardiovascular morbidity (OR: 0.29, 95% CI: 0.14-0.61). When the patients with baseline TRAb positivity were studied separately, fT4-CV was associated with cardiovascular morbidity (OR: 1.03, 95% CI: 1.00-1.05). CONCLUSIONS During ATD therapy, fT4 variability is associated with an increased cardiovascular morbidity. Although positive TRAbs are associated with a lower cardiovascular morbidity compared with hyperthyroidism with negative autoantibodies, the variability of fT4 is associated with cardiovascular morbidity also in patients with positive TRAbs.
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Affiliation(s)
- Nelli Suonsyrjä
- Department of Internal Medicine, Faculty of Medicine and Health Technology, Tampere University, Tampere, Finland
| | - Iina Laihia
- Department of Internal Medicine, Faculty of Medicine and Health Technology, Tampere University, Tampere, Finland
| | - Heini Huhtala
- Department of Internal Medicine, Faculty of Social Sciences, Tampere University, Tampere, Finland
| | - Pia Jaatinen
- Department of Internal Medicine, Faculty of Medicine and Health Technology, Tampere University, Tampere, Finland
- Department of Internal Medicine, Tampere University Hospital, Tampere, Finland
- Division of Internal Medicine, Seinäjoki Central Hospital, Seinäjoki, Finland
| | - Saara Metso
- Department of Internal Medicine, Faculty of Medicine and Health Technology, Tampere University, Tampere, Finland
- Department of Internal Medicine, Tampere University Hospital, Tampere, Finland
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Purnamasari D, Wildan A, Kurniawan J, Mulansari NA, Karim B, Danil Yulian E. Therapeutic Plasma Exchange as a Bridging Therapy for the Definitive Treatment of a Patient with Graves' Disease and Methimazole-Induced Liver Injury. Int J Endocrinol Metab 2023; 21:e136608. [PMID: 38028251 PMCID: PMC10676661 DOI: 10.5812/ijem-136608] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/03/2023] [Revised: 06/20/2023] [Accepted: 06/25/2023] [Indexed: 12/01/2023] Open
Abstract
Introduction Graves' disease (GD) is an autoimmune condition affecting the thyroid gland. The aim of treating GD is to control the symptoms of hyperthyroidism and achieve long-term remission. Antithyroid drugs (ATDs) are the medications of choice among newly-diagnosed GD patients as they are easy to be delivered and cause remission in more than 50% of patients. However, ATDs increase the risk of hepatotoxicity, especially among patients with liver abnormalities. Patients who cannot tolerate ATDs should receive definitive therapy such as radioactive iodine (RAI) or surgery. In order to minimize the risk of thyroid storm during these procedures, patients should be in euthyroid condition and receive bridging therapy. Therapeutic plasma exchange (TPE), which aims to remove thyroid hormones from plasma, is one of the modalities that can be considered as a bridging therapy during the perioperative period among GD patients who cannot tolerate ATD. Case Presentation A 35-year-old man with general weakness and thyrotoxicosis symptoms was admitted to the emergency room. Lid retraction, diffuse Goiter, and tremors were evident. Laboratory findings revealed TSH = 0.005 µIU/mL, FT4 = 7.77 ng/dL, TRAb = 9.90 IU/L, ALT = 123 U/L, total bilirubin = 23.94 µmol/L, and direct bilirubin = 10.26 µmol/L. Ultrasonographic examination showed the enlargement of the thyroid gland, and abdomen ultrasonographic evaluation showed mild hepatomegaly with mild fatty infiltration. The patient was diagnosed with GD, suspected thyroid storm, elevated liver transaminases, and fatty liver disease. The patient then received methimazole, propranolol, and glycyrrhizin. During observation, the patient developed drug-induced liver injury (DILI) evidenced by an increase in liver enzymes (ALT up to 1023 U/L) and the elevation of total bilirubin to 258.21 µmol/L, so methimazole was stopped. After discontinuing methimazole, liver injury improved. However, thyrotoxicosis symptoms returned, so the patient underwent a total thyroidectomy. In order to achieve a euthyroid status before surgery, five sessions of therapeutic plasma exchange were performed, which improved the signs and symptoms of hyperthyroidism and retained the thyroxine hormone within the normal range. Thyroidectomy was then performed successfully without serious complications (e.g., thyroid storm, etc.). Conclusions Therapeutic plasma exchange is a safe and effective bridging therapy for GD patients who require thyroidectomy but cannot tolerate ATDs.
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Affiliation(s)
- Dyah Purnamasari
- Division of Endocrinology, Metabolism, and Diabetes, Department of Internal Medicine, Faculty of Medicine Universitas Indonesia, Dr. Cipto Mangunkusumo National General Hospital, Jakarta, Indonesia
| | - Ardy Wildan
- Division of Endocrinology, Metabolism, and Diabetes, Department of Internal Medicine, Faculty of Medicine Universitas Indonesia, Dr. Cipto Mangunkusumo National General Hospital, Jakarta, Indonesia
| | - Juferdy Kurniawan
- Division of Hepatobiliary, Department of Internal Medicine, Faculty of Medicine Universitas Indonesia, Dr. Cipto Mangunkusumo National General Hospital, Jakarta, Indonesia
| | - Nadia Ayu Mulansari
- Division of Hematology Medical Oncology, Department of Internal Medicine, Faculty of Medicine Universitas Indonesia, Dr. Cipto Mangunkusumo National General Hospital, Jakarta, Indonesia
| | - Birry Karim
- Division of Cardiology, Department of Internal Medicine, Faculty of Medicine Universitas Indonesia, Dr. Cipto Mangunkusumo National General Hospital, Jakarta, Indonesia
| | - Erwin Danil Yulian
- Division of Surgical Oncology, Department of Surgery, Faculty of Medicine Universitas Indonesia, Dr. Cipto Mangunkusumo National General Hospital, Jakarta, Indonesia
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Guia Lopes ML, Tavares Bello C, Cidade JP, Limbert C, Sequeira Duarte J. Influence of Thyroid Peroxidase Antibodies Serum Levels in Graves' Disease: A Retrospective Cohort Study. Cureus 2023; 15:e40140. [PMID: 37425546 PMCID: PMC10329486 DOI: 10.7759/cureus.40140] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/08/2023] [Indexed: 07/11/2023] Open
Abstract
Purpose Graves' disease (GD) is an autoimmune disorder caused by the presence of antibodies to the thyroid stimulating hormone (TSH) receptor (TRAbs), usually presenting with clinical signs of hyperthyroidism. Previous evidence suggests that higher serum levels of thyroid peroxidase antibodies (TPOAbs) may lead to more sustained remission of hyperthyroidism after treatment with antithyroid drugs (AT). However, doubts about the influence of TPOAbs in Graves' disease outcomes still remain. Methods A retrospective, unicenter cohort study was performed. All patients with GD (TRAbs > 1.58U/L), biochemical primary hyperthyroidism (TSH < 0.4 µUI/mL), and TPOAbs measurement at diagnosis, treated with AT between January 2008 and January 2021, were included for analysis. Results One hundred and forty-two patients (113 women) with a mean age of 52 ± 15 years old were included. They were followed up for 65.4 ± 43.8 months. TPOAbs positivity was present in 71.10% (n=101) of those patients. Patients were treated with AT for a median of 18 (IQR (12; 24)) months. Remission occurred in 47.2% of patients. Patients with remission presented with lower TRAbs and free thyroxine (FT4) levels at the diagnosis. (p-value <0.001, p-value 0.003, respectively). No association was found in the median TPOAbs serum levels of patients who remitted and those who maintained biochemical hyperthyroidism after the first course of AT. Relapse of hyperthyroidism occurred in 54 patients (57.4%). No difference was found in TPOAbs serum levels regarding the patient's relapse. Moreover, a time-based analysis revealed no differences in the relapse rate after 18 months of AT therapy between patients with and without TPOAbs positivity at the diagnosis (p-value 0.176). It was found a weak positive correlation (r=0.295; p-value <0.05) between TRAbs and TPOAbs titters at the moment of Graves' diagnosis. Conclusion In this study, a correlation between TRAbs measurements and TPOAbs titter was described, although no significant association was found between the presence of TPOAbs and the outcomes of patients with GD treated with AT. These results do not support the use of TPOAbs as a useful biomarker to predict remission or relapse of hyperthyroidism in GD patients.
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Affiliation(s)
- Maria L Guia Lopes
- Department of Endocrinology, Hospital Egas Moniz, Centro Hospitalar Lisboa Ocidental, Lisbon, PRT
| | | | - José P Cidade
- Department of Internal Medicine, Hospital Egas Moniz, Centro Hospitalar Lisboa Ocidental, Lisbon, PRT
- Department of Intensive Care, Hospital de São Francisco Xavier, Centro Hospitalar Lisboa Ocidental, Lisbon, PRT
- Department of Physiology, Nova Medical School, New University of Lisbon, Lisbon, PRT
| | - Clotilde Limbert
- Department of Endocrinology, Hospital Egas Moniz, Centro Hospitalar Lisboa Ocidental, Lisbon, PRT
| | - Joao Sequeira Duarte
- Department of Endocrinology, Hospital Egas Moniz, Centro Hospitalar Lisboa Ocidental, Lisbon, PRT
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Alhubaish ES, Alibrahim NT, Mansour AA. The Clinical Implications of Anti-thyroid Peroxidase Antibodies in Graves’ Disease in Basrah. Cureus 2023; 15:e36778. [PMID: 37123800 PMCID: PMC10133893 DOI: 10.7759/cureus.36778] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/27/2023] [Indexed: 03/30/2023] Open
Abstract
Background Graves' disease (GD) is an autoimmune disease, with thyrotropin receptor antibodies (TRAbs) being the most important cause in the pathogenesis. The aim of this study is to assess the clinical significance of anti-TPO Abs in GD. Methods A retrospective study was conducted at the Faiha specialized Diabetes, Endocrine, and Metabolism Center (FDEMC) in Basrah during the period between December 2021 and December 2022. A total of 141 patients with GD were involved in this study, and of them, 97 (68.8%) were women. They were divided into two groups: patients with positive and negative anti-TPO Abs groups. Results Positive anti-TPO Abs were seen in 83 patients (58.9%) with GD. Pretreatment-free thyroxine level (ng/dL) was higher in the anti-TPO Abs positive GD patients than in those with negative antibodies (3.7±0.2 versus 3.0±0.2 with a p=0.021). Similarly, higher TRAb titers (IU/ml) at baseline were also seen in patients with positive anti-TPO Abs (9.8±0.7 versus 6.8±0.8) with a p=0.008. Giraffe appearance on thyroid ultrasound was more common in the group with positive anti-TPO Abs as compared to patients with negative anti-TPO Abs: 20 (87.0%) versus 3 (13.0%) with a p=0.005. A higher anti-TPO Abs titer (IU/mL) was associated with a baseline TRAb level of more than 6.4 IU/mL, and giraffe appearance on thyroid ultrasound (206.5±20.0 p-value<0.0001 and 228.0±35.3 p value=0.007, respectively). Conclusion A positive anti-TPO Abs in GD is associated with a high TRAb titer and free T4 level at baseline, as well as a giraffe appearance on thyroid ultrasound.
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Katahira M, Tsunekawa T, Mizoguchi A, Yamaguchi M, Tsuru K, Takashima H, Terada R. Clinical significance of thyroglobulin antibodies and thyroid peroxidase antibodies in Graves' disease: a cross-sectional study. Hormones (Athens) 2023; 22:253-261. [PMID: 36811756 DOI: 10.1007/s42000-023-00437-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/08/2022] [Accepted: 02/07/2023] [Indexed: 02/24/2023]
Abstract
PURPOSE The significance of thyroglobulin antibodies (TgAbs) and thyroid peroxidase antibodies (TPOAbs) in Graves' disease (GD) remains unclear. Therefore, this study aimed to clarify the clinical significance of TgAbs and TPOAbs in GD. METHODS A total of 442 patients with GD were recruited and divided into four groups based on TgAb and TPOAb positivity. Their clinical parameters and the characteristics of the groups were compared. Cox proportional hazard regression analysis was performed to assess risk factors for GD remission. RESULTS The free triiodothyronine (FT3) level was significantly higher in groups positive for TgAbs and TPOAbs than in the other groups. The FT3 to free thyroxine (FT4) (FT3/FT4) ratio was significantly higher and thyrotropin-stimulating hormone (TSH) receptor antibodies (TRAbs) were significantly lower in the TgAb+/TPOAb- group. Time to FT4 recovery was significantly shorter for groups negative for TPOAbs, whereas time to TSH recovery was significantly longer for groups positive for TPOAbs. Cox proportional hazard regression analysis revealed that TgAb positivity, prolonged treatment duration with antithyroid drugs, and Graves' ophthalmopathy treated with methylprednisolone were significantly associated with GD remission and that a smoking history, elevated FT3/FT4 ratio, and treatment with propylthiouracil hindered GD remission. CONCLUSION The contributions of TgAbs and TPOAbs to GD pathogenesis differ. Patients positive for TgAbs develop GD with lower TRAb titers and undergo earlier remission than those negative for TgAbs. Patients positive for TPOAbs develop GD with high TRAb titers and need a long time to achieve remission.
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Affiliation(s)
- Masahito Katahira
- Aichi Prefectural University School of Nursing and Health, Togoku, Kamishidami, Moriyama-ku, Nagoya, 463-8502, Japan.
- Department of Endocrinology and Diabetes, Ichinomiya Municipal Hospital, 2-2-22 Bunkyo, Ichinomiya, 491-8558, Japan.
| | - Taku Tsunekawa
- Department of Endocrinology and Diabetes, Ichinomiya Municipal Hospital, 2-2-22 Bunkyo, Ichinomiya, 491-8558, Japan
| | - Akira Mizoguchi
- Department of Endocrinology and Diabetes, Ichinomiya Municipal Hospital, 2-2-22 Bunkyo, Ichinomiya, 491-8558, Japan
| | - Mariko Yamaguchi
- Department of Endocrinology and Diabetes, Ichinomiya Municipal Hospital, 2-2-22 Bunkyo, Ichinomiya, 491-8558, Japan
| | - Kahori Tsuru
- Department of Endocrinology and Diabetes, Ichinomiya Municipal Hospital, 2-2-22 Bunkyo, Ichinomiya, 491-8558, Japan
| | - Hiromi Takashima
- Department of Endocrinology and Diabetes, Ichinomiya Municipal Hospital, 2-2-22 Bunkyo, Ichinomiya, 491-8558, Japan
| | - Ryoma Terada
- Department of Endocrinology and Diabetes, Ichinomiya Municipal Hospital, 2-2-22 Bunkyo, Ichinomiya, 491-8558, Japan
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Praw SS, Brent GA. Approach to the Patient With a Suppressed TSH. J Clin Endocrinol Metab 2023; 108:472-482. [PMID: 36329632 DOI: 10.1210/clinem/dgac635] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/24/2022] [Revised: 10/03/2022] [Indexed: 11/06/2022]
Abstract
Subclinical hyperthyroidism (SCH) is a laboratory diagnosis defined by a serum thyrotropin (TSH) concentration below the reference range (< 0.4 mU/L in most assays), and a free thyroxine (FT4) and 3,5,3'-triiodothyronine levels (FT3) in the reference range. Many patients diagnosed with SCH will be clinically euthyroid while others may present with manifestations characteristic of thyroid hormone excess, such as tachycardia, tremor, intolerance to heat, bone density loss, or weight loss. In addition to the laboratory abnormalities, patient factors such as age, symptoms, and underlying heart and bone disease are used to stratify patients for the risk of adverse outcomes and determine the appropriate treatment. Evaluation should include repeat thyroid function tests to document persistent TSH suppression, investigation of the underlying cause, as well as evaluation of the patient's risk of adverse outcomes in the setting of a subnormal TSH. Persistent SCH has been associated with an increased risk of a range of adverse events, including cardiovascular events such as atrial fibrillation and heart failure, bone loss and fracture, and in some studies, cognitive decline. Despite the consistent association of these adverse events with SCH, prospective studies showing improved outcomes with treatment remain limited. Management options include observation without active therapy, radioactive iodine ablation of the thyroid, antithyroid medication, thyroid surgery, or radiofrequency ablation, as appropriate for the patient and clinical setting. The choice of therapy should be guided by the underlying etiology of disease, patient factors, and the risks and benefits of each treatment option.
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Affiliation(s)
- Stephanie Smooke Praw
- Division of Endocrinology, Diabetes, and Metabolism, Department of Medicine, David Geffen School of Medicine at UCLA, Los Angeles, California 90095, USA
| | - Gregory A Brent
- Division of Endocrinology, Diabetes, and Metabolism, Department of Medicine, David Geffen School of Medicine at UCLA, Los Angeles, California 90095, USA
- Department of Medicine, VA Greater Los Angeles Healthcare System, Los Angeles, California 90073, USA
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Yoshizawa K, Aso K, Satoh M. Predictive effect of antithyroid antibody for relapse of Graves' disease. Pediatr Int 2022; 64:e14749. [PMID: 33884704 DOI: 10.1111/ped.14749] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/12/2021] [Revised: 03/22/2021] [Accepted: 04/16/2021] [Indexed: 11/26/2022]
Abstract
BACKGROUND The remission rate in children with Graves' disease (GD) after 2-6 years of antithyroid drug (ATD) treatment is 40-50%. It has been reported that it is difficult to predict the GD prognosis based on the thryroid stimulating hormone (TSH) receptor antibody (TRAb) level at the cessation of ATD treatment. We studied whether the persistence of negative TRAb at ATD treatment cessation increased the remission rate in pediatric patients with GD. METHODS We included 22 patients diagnosed with GD who discontinued ATD treatment after confirmation of negative TRAb on two or more consecutive tests. Remission was defined as the maintenance of normal thyroid function, including serum TSH level, with negative TRAb more than 2 years after ATD discontinuation. RESULTS Of the 22 patients, 12 achieved remission (remission rate 54.5%), with no significant between-group difference in the median duration of ATD treatment in the remission and relapse groups (4.4 vs 3.9 years). Of the 10 patients who relapsed, four (40.0%) relapsed within 2 years after ATD discontinuation, and 4 (40.0%) relapsed more than 5 years after ATD discontinuation. CONCLUSIONS The persistence of negative TRAb at ATD treatment cessation might indicate prolonged duration of remission but does not increase the final remission rate in patients with childhood-onset GD.
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Affiliation(s)
- Kazuko Yoshizawa
- Department of Pediatrics, Toho University Omori Medical Center, Tokyo, Japan
| | - Keiko Aso
- Department of Pediatrics, Toho University Omori Medical Center, Tokyo, Japan
| | - Mari Satoh
- Department of Pediatrics, Toho University Omori Medical Center, Tokyo, Japan
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Park SY, Kim BH, Kim M, Hong AR, Park J, Park H, Choi MS, Kim TH, Kim SW, Kang HC, Chung JH. The longer the antithyroid drug is used, the lower the relapse rate in Graves' disease: a retrospective multicenter cohort study in Korea. Endocrine 2021; 74:120-127. [PMID: 33860431 DOI: 10.1007/s12020-021-02725-x] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/30/2020] [Accepted: 04/03/2021] [Indexed: 01/01/2023]
Abstract
PURPOSE Current literature suggests 12-18 months of antithyroid drug (ATD) treatment for patients with Graves' disease, but the risk of relapse is high. Although some studies reported better outcomes of long-term ATD treatment, recent data that suggest the optimal treatment duration are limited. METHODS We performed a multicenter retrospective cohort study of 908 patients newly diagnosed with Graves' disease between 2006 and 2013. The relapse rate according to ATD treatment duration was analyzed. RESULTS After initial ATD treatment, 338 patients (37.2%) had relapsed. The relapse rate according to ATD treatment duration was 42.4% at 1 year, 38.5% at 2 years, 33.8% at 3 years, 31.7% at 4 years, 30.2% at 5 years, 27.8% at 6 years, and 19.1% at more than 6 years, respectively, demonstrating a significant decreasing trend (p = 0.003). In a multivariable Cox regression analysis, ATD treatment duration was an independent risk factor for relapse (p = 0.043). CONCLUSIONS The longer that ATD therapy is used, the lower the relapse rate is in patients with Graves' disease. Long-term ATD treatment may be considered in Graves' patients who do not show complications or an economic burden from hyperthyroidism.
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Affiliation(s)
- So Young Park
- Division of Endocrinology and Metabolism, Department of Medicine, Thyroid Center, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
- Division of Endocrinology, Department of Medicine, Korea University Ansan Hospital, Ansan, Korea
| | - Bo Hyun Kim
- Division of Endocrinology and Metabolism, Department of Internal Medicine, Biomedical Research Institute, Pusan National University Hospital, Busan, Korea
| | - Mijin Kim
- Division of Endocrinology and Metabolism, Department of Internal Medicine, Biomedical Research Institute, Pusan National University Hospital, Busan, Korea
| | - A Ram Hong
- Department of Internal Medicine, Chonnam National University Medical School, Gwangju, Korea
| | - Jun Park
- Division of Endocrinology and Metabolism, Department of Medicine, Thyroid Center, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Hyunju Park
- Division of Endocrinology and Metabolism, Department of Medicine, Thyroid Center, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Min Sun Choi
- Division of Endocrinology and Metabolism, Department of Medicine, Thyroid Center, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Tae Hyuk Kim
- Division of Endocrinology and Metabolism, Department of Medicine, Thyroid Center, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Sun Wook Kim
- Division of Endocrinology and Metabolism, Department of Medicine, Thyroid Center, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Ho-Cheol Kang
- Department of Internal Medicine, Chonnam National University Medical School, Gwangju, Korea.
| | - Jae Hoon Chung
- Division of Endocrinology and Metabolism, Department of Medicine, Thyroid Center, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea.
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Abstract
PURPOSE OF REVIEW Over the last 1-2 decades, patients and physicians have preferred antithyroid drug therapy as the initial treatment of Graves' disease, rather than radioactive iodine or surgery. More recently, the concept of long-term antithyroid drug therapy (LTADT; >24 months of treatment) has also become increasingly popular. RECENT FINDINGS Data from cohort studies and a prospective randomized trial suggest that LTATD therapy is safe and is associated with a higher chance of remission from Graves' disease than is shorter-term therapy. Also, LTADT may be associated with better quality of life and other clinical outcomes compared to radioiodine and surgery. SUMMARY Long-term antithyroid drug therapy is appropriate for children and young adults. This approach is a reasonable option in those who are doing well on a stable low dose of antithyroid drug therapy, and especially those who wish to avoid definitive treatment with radioactive iodine or surgery, given their inherent risks and need for lifelong hormonal replacement therapy.
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Affiliation(s)
- David S Cooper
- Division of Endocrinology, Diabetes, and Metabolism, The Johns Hopkins University School of Medicine, 1830 East Monument Street, Suite 333, Baltimore, Maryland, USA
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12
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Sitohang IBS, Nelson B, Marissa M, Indriatmi W, Wisnu W. Evaluation of Modified Melasma Area and Severity Index in Hyperthyroid Patients Receiving Anti-thyroid Drugs. Open Access Maced J Med Sci 2021. [DOI: 10.3889/oamjms.2021.6082] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022] Open
Abstract
BACKGROUND: Melasma is a common hyperpigmentation disorder, which causes brownish discoloration of the face. Despite unclear mechanisms, thyroid hormones were thought to play a role in melasma.
AIM: This study aims to determine and compare the clinical improvement of melasma in hyperthyroid patients receiving anti-thyroid drugs.
METHODS: An interventional study with a quasi-experimental design (pre-post-intervention study) was conducted at the Internal Medicine Outpatient Clinic and Dermatology and Venereology Outpatient Clinic, Cipto Mangunkusumo Hospital, Jakarta, Indonesia, from July 2019 to March 2020. A comparative analysis was done to compare the modified melasma area and severity index (mMASI) in hyperthyroid patients before and after 12 weeks of anti-thyroid drugs. All subjects did not receive any additional topical therapies for their melasma. The clinical features were evaluated objectively at baseline and 12th-week visit, by mMASI score on different areas of the face (forehead, left-right malar, and chin) and Wood’s lamp examination.
RESULTS: All areas showed a decline in mMASI score components (e.g., involvement areas and darkness degree) after 12 weeks of treatment. However, only the malar area showed a significant decline (p < 0.05). Wood’s lamp examination at baseline revealed dermal type melasma on 17 subjects, mixed type on six subjects, and epidermal type on one subject. All types remained unchanged after 12 weeks of treatment.
CONCLUSIONS: Our study demonstrated that mMASI score in malar area improved significantly, this might be because malar area included this study were comprised of epidermal, dermal, and mixed type. On the other hand, based on Wood’s lamp examination, all types of melasma remained unchanged after 12 weeks of treatment.
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13
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Nelson B, Sitohang IBS, Marissa M, Indriatmi W, Wisnu W. A comparative study of melasma severity after hyperthyroid therapy in hyperthyroid subjects with melasma. ACTA DERMATOVENEROLOGICA ALPINA PANNONICA ET ADRIATICA 2021. [DOI: 10.15570/actaapa.2021.7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
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14
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Zhou Y, Zhou M, Qi Y, Wang W, Chen X, Wang S. The prognostic value of thyroid-stimulating immunoglobulin in the management of Graves' disease. Ther Adv Endocrinol Metab 2021; 12:20420188211044943. [PMID: 34603682 PMCID: PMC8481717 DOI: 10.1177/20420188211044943] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/11/2021] [Accepted: 08/06/2021] [Indexed: 12/04/2022] Open
Abstract
BACKGROUND The bioassay of thyroid-stimulating immunoglobulin was reported to have a similar performance to the commonly used thyroid-stimulating hormone binding inhibition assay, also known as thyroid receptor antibody assay. The normal reference range of thyroid receptor antibody levels indicates the withdrawal of anti-thyroid drugs in the recent clinical guidelines. METHODS A prospective, longitudinal observational study was conducted to evaluate the prognostic value of thyroid-stimulating immunoglobulin in patients with Graves' disease. RESULTS A total of 77 patients with Graves' disease treated with anti-thyroid drugs were in a continuous follow-up until 1 year after anti-thyroid drugs discontinuation. Commercial kits of thyroid-stimulating immunoglobulin and M22-thyroid-stimulating hormone binding inhibition assay were used and compared. Thyroid-stimulating immunoglobulin was all negative in healthy controls, Hashimoto thyroiditis, and subacute thyroiditis. Thyroid-stimulating immunoglobulin value was highest in untreated patients with Graves' disease (p < 0.001). Under anti-thyroid drugs treatment, thyroid-stimulating immunoglobulin value decreased gradually. A total of 21 patients had positive thyroid-stimulating immunoglobulin at the end of treatment. According to clinical fate of patients with Graves' disease after withdrawal of anti-thyroid drugs, thyroid-stimulating immunoglobulin value and positivity in patients with relapse were significantly higher than that reported in patients with remission (p = 0.001, p < 0.001). After adjustment for age, gender, initial thyroid receptor antibody, initial thyroid-stimulating immunoglobulin, and thyroid receptor antibody at the end of treatment, the odds ratio of positive thyroid-stimulating immunoglobulin for the risk of relapse was 33.271 (95% confidence interval: 4.741-233.458, p < 0.001) and odds ratio of quantitative thyroid-stimulating immunoglobulin was 1.009 (95% confidence interval: 1.002-1.015, p < 0.001). CONCLUSION Thyroid-stimulating immunoglobulin is a good predictor of relapse in patients with Graves' disease treated with anti-thyroid drugs. It might be safer to discontinue anti-thyroid drugs when thyroid-stimulating immunoglobulin and thyroid receptor antibody were both negative.
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Affiliation(s)
- Yulin Zhou
- Shanghai Clinical Center for Endocrine and Metabolic Diseases, Department of Endocrinology, Shanghai Institute of Endocrine and Metabolic Diseases, Ruijin Hospital, Shanghai Jiao Tong University School Medical School, Shanghai, P.R. China
| | - Mengxi Zhou
- Shanghai Clinical Center for Endocrine and Metabolic Diseases, Department of Endocrinology, Shanghai Institute of Endocrine and Metabolic Diseases, Ruijin Hospital, Shanghai Jiao Tong University School Medical School, Shanghai, P.R. China
| | - Yicheng Qi
- Shanghai Clinical Center for Endocrine and Metabolic Diseases, Department of Endocrinology, Shanghai Institute of Endocrine and Metabolic Diseases, Ruijin Hospital, Shanghai Jiao Tong University School Medical School, Shanghai, P.R. China
| | | | | | - Shu Wang
- Shanghai Clinical Center for Endocrine and Metabolic Diseases, Department of Endocrinology, Shanghai Institute of Endocrine and Metabolic Diseases, Ruijin Hospital, Shanghai Jiao Tong University School Medical School, 197 Ruijin 2nd Road, Shanghai 200025, P.R. China
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15
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Kim M, Kim BH, Jang MH, Kim JM, Kim EH, Jeon YK, Kim SS, Kim IJ. High neutrophil-to-lymphocyte ratio is associated with relapse in Graves' disease after antithyroid drug therapy. Endocrine 2020; 67:406-411. [PMID: 31749116 DOI: 10.1007/s12020-019-02137-y] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/25/2019] [Accepted: 11/09/2019] [Indexed: 12/13/2022]
Abstract
PURPOSE Antithyroid drugs (ATDs) are effective in controlling hyperthyroidism due to Graves' disease (GD); however, long-term remission rates are low. The neutrophil-to-lymphocyte ratio (NLR) is a useful prognostic marker in many inflammatory diseases. We aimed to evaluate whether NLR can be used as a prognostic marker for relapse in patients with GD after ATD therapy. METHODS This retrospective cohort study included 108 patients with newly diagnosed GD who achieved remission after ATD therapy and were followed-up for >12 months after ATD discontinuation. The primary outcome was relapse-free survival (RFS). RESULTS Patients were classified into two groups according to baseline NLR: low NLR group with NLR < 1.14 (n = 59; 55%) and high NLR group with NLR ≥ 1.14 (n = 49; 45%). During the median follow-up of 6.5 years, disease relapse after a year of ATD withdrawal occurred in 23 (21%) patients. The patients with high NLR had poorer RFS than those with low NLR, and RFS curves were significantly different between the two groups (p = 0.002). In multivariate analysis, a high NLR (OR = 4.22, p = 0.016) was an independent prognostic factor for relapse in patients with GD after adjusting for age, sex, goiter, orbitopathy, thyroid hormone levels, thyrotropin binding inhibiting immunoglobulin titer, and the duration of ATD therapy. CONCLUSIONS This study showed that NLR can be an early and cost-effective prognostic biomarker for relapse in patients with GD after ATD therapy. Further studies are needed to validate the prognostic role of NLR in GD.
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Affiliation(s)
- Mijin Kim
- Department of Internal Medicine, Biomedical Research Institute, Pusan National University Hospital, Busan, Korea
| | - Bo Hyun Kim
- Department of Internal Medicine, Biomedical Research Institute, Pusan National University Hospital, Busan, Korea.
| | - Min Hee Jang
- Department of Internal Medicine, Biomedical Research Institute, Pusan National University Hospital, Busan, Korea
| | - Jeong Mi Kim
- Department of Internal Medicine, Biomedical Research Institute, Pusan National University Hospital, Busan, Korea
| | - Eun Heui Kim
- Department of Internal Medicine, Biomedical Research Institute, Pusan National University Hospital, Busan, Korea
| | - Yun Kyung Jeon
- Department of Internal Medicine, Biomedical Research Institute, Pusan National University Hospital, Busan, Korea
| | - Sang Soo Kim
- Department of Internal Medicine, Biomedical Research Institute, Pusan National University Hospital, Busan, Korea
| | - In Joo Kim
- Department of Internal Medicine, Biomedical Research Institute, Pusan National University Hospital, Busan, Korea
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16
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Mettler J, Armefti S, Schmidt M, Faust M, Engels M, Chiapponi C. Benign Thyroid Diseases: Are There Gender-Specific Differences for Diagnosis and Treatment of Nontoxic Thyroid Nodules? Results from a 4-Year Retrospective Analysis of an Endocrine Tumor Board. Visc Med 2020; 36:28-33. [PMID: 32110654 DOI: 10.1159/000505499] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/27/2019] [Accepted: 12/17/2019] [Indexed: 11/19/2022] Open
Abstract
Introduction Benign nodular goiters are endemic in Germany and diagnostic thyroidectomy is one of the most frequent surgical procedures. Less than 10% result in a malignant finding which is a poor ratio in comparison to other European countries. There is a female preponderance in almost all thyroid pathologies according to the current literature but not much is known concerning gender-specific differences in thyroid nodules. Objective We aimed at finding gender-specific differences in diagnosis and treatment of nontoxic thyroid nodules and focused on preoperative workup as well as cytological and histological findings of patients with solitary and multinodular nontoxic goiters. Methods We retrospectively analyzed 392 cases out of 693 thyroid cases managed interdisciplinarily by the endocrine board of a university center between January 2015 and December 2018 (4 years). Results The combination of fine needle biopsy and interdisciplinary case discussion resulted in a rate of malignancy of 28.9% in patients undergoing surgery for solitary and multinodular nontoxic goiter. Although there was no significant gender-specific difference in the distributions and malignancy rates of Bethesda categories, male patients had a significantly higher malignancy rate of 40% in our collective (p = 0.04). Conclusions Surgical treatment for male patients with suspicious hypofunctioning thyroid nodules should be favored. However, well-designed prospective studies are required to investigate gender-specific recommendations for the treatment of benign thyroid diseases in the future.
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Affiliation(s)
- Jasmin Mettler
- Department of Nuclear Medicine, Faculty of Medicine, University of Cologne and University Hospital Cologne, Cologne, Germany
| | - Stella Armefti
- Department of General, Visceral, Cancer and Transplantation Surgery, University of Cologne, Cologne, Germany
| | - Matthias Schmidt
- Department of Nuclear Medicine, Faculty of Medicine, University of Cologne and University Hospital Cologne, Cologne, Germany
| | - Michael Faust
- Department of Endocrinology, Diabetes and Preventive Medicine, University of Cologne, Cologne, Germany
| | - Marianne Engels
- Department of Pathology, University of Cologne, Cologne, Germany
| | - Costanza Chiapponi
- Department of General, Visceral, Cancer and Transplantation Surgery, University of Cologne, Cologne, Germany
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Abbara A, Clarke SA, Brewster R, Simonnard A, Eng PC, Phylactou M, Papadopoulou D, Izzi-Engbeaya C, Sam AH, Wernig F, Jonauskyte E, Comninos AN, Meeran K, Kelsey TW, Dhillo WS. Pharmacodynamic Response to Anti-thyroid Drugs in Graves' Hyperthyroidism. Front Endocrinol (Lausanne) 2020; 11:286. [PMID: 32477269 PMCID: PMC7236601 DOI: 10.3389/fendo.2020.00286] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/15/2020] [Accepted: 04/16/2020] [Indexed: 12/31/2022] Open
Abstract
Objective: Graves' disease is the commonest cause of hyperthyroidism in populations with sufficient dietary iodine intake. Anti-thyroid drugs (ATD) are often used as the initial treatment for Graves' hyperthyroidism, however there is a paucity of data relating the dose of ATD therapy to the effect on thyroid hormone levels, increasing the risk of both over- and under-treatment. We aimed to determine the pharmacodynamic response to the ATD carbimazole. Design: Retrospective cohort study. Methods: Participants were patients (n = 441) diagnosed with Graves' disease at Imperial College Healthcare NHS Trust between 2009 and 2018. The main outcome measure was change in thyroid hormone levels in response to ATD. Results: Baseline thyroid hormone levels were positively associated with TSH receptor antibody titres (P < 0.0001). Baseline free triiodothyronine (fT3) were linearly related to free thyroxine (fT4) levels in the hyperthyroid state (fT3 = fT4*0.97-11), and fell proportionately with carbimazole. The percentage falls in fT4 and fT3 per day were associated with carbimazole dose (P < 0.0001). The magnitude of fall in thyroid hormones after the same dose of carbimazole was lower during follow up than at the initiation visit. The fall in thyroid hormone levels approximated to a linear response if assessed at least 3 weeks after commencement of carbimazole. Following withdrawal of antithyroid drug treatment, the risk of relapse was greater in patients with higher initial fT4, initial TSH receptor antibody titre, males, smokers, and British Caucasian ethnicity. Conclusion: We identify a dose-response relationship for fall in thyroid hormones in response to carbimazole to aid in the selection of dose for Graves' hyperthyroidism.
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Affiliation(s)
- Ali Abbara
- Section of Endocrinology and Investigative Medicine, Division of Diabetes, Endocrinology and Metabolism, Hammersmith Hospital, Imperial College London, London, United Kingdom
- Department of Endocrinology, Imperial College Healthcare NHS Trust, London, United Kingdom
| | - Sophie A. Clarke
- Section of Endocrinology and Investigative Medicine, Division of Diabetes, Endocrinology and Metabolism, Hammersmith Hospital, Imperial College London, London, United Kingdom
- Department of Endocrinology, Imperial College Healthcare NHS Trust, London, United Kingdom
| | - Rosalind Brewster
- Section of Endocrinology and Investigative Medicine, Division of Diabetes, Endocrinology and Metabolism, Hammersmith Hospital, Imperial College London, London, United Kingdom
| | - Alexia Simonnard
- Section of Endocrinology and Investigative Medicine, Division of Diabetes, Endocrinology and Metabolism, Hammersmith Hospital, Imperial College London, London, United Kingdom
| | - Pei Chia Eng
- Section of Endocrinology and Investigative Medicine, Division of Diabetes, Endocrinology and Metabolism, Hammersmith Hospital, Imperial College London, London, United Kingdom
| | - Maria Phylactou
- Section of Endocrinology and Investigative Medicine, Division of Diabetes, Endocrinology and Metabolism, Hammersmith Hospital, Imperial College London, London, United Kingdom
| | - Deborah Papadopoulou
- Section of Endocrinology and Investigative Medicine, Division of Diabetes, Endocrinology and Metabolism, Hammersmith Hospital, Imperial College London, London, United Kingdom
- Department of Endocrinology, Imperial College Healthcare NHS Trust, London, United Kingdom
| | - Chioma Izzi-Engbeaya
- Section of Endocrinology and Investigative Medicine, Division of Diabetes, Endocrinology and Metabolism, Hammersmith Hospital, Imperial College London, London, United Kingdom
- Department of Endocrinology, Imperial College Healthcare NHS Trust, London, United Kingdom
| | - Amir H. Sam
- Section of Endocrinology and Investigative Medicine, Division of Diabetes, Endocrinology and Metabolism, Hammersmith Hospital, Imperial College London, London, United Kingdom
- Department of Endocrinology, Imperial College Healthcare NHS Trust, London, United Kingdom
| | - Florian Wernig
- Department of Endocrinology, Imperial College Healthcare NHS Trust, London, United Kingdom
| | - Eliza Jonauskyte
- School of Computer Science, University of St Andrews, St Andrews, United Kingdom
| | - Alexander N. Comninos
- Section of Endocrinology and Investigative Medicine, Division of Diabetes, Endocrinology and Metabolism, Hammersmith Hospital, Imperial College London, London, United Kingdom
- Department of Endocrinology, Imperial College Healthcare NHS Trust, London, United Kingdom
| | - Karim Meeran
- Section of Endocrinology and Investigative Medicine, Division of Diabetes, Endocrinology and Metabolism, Hammersmith Hospital, Imperial College London, London, United Kingdom
- Department of Endocrinology, Imperial College Healthcare NHS Trust, London, United Kingdom
| | - Tom W. Kelsey
- School of Computer Science, University of St Andrews, St Andrews, United Kingdom
| | - Waljit S. Dhillo
- Section of Endocrinology and Investigative Medicine, Division of Diabetes, Endocrinology and Metabolism, Hammersmith Hospital, Imperial College London, London, United Kingdom
- Department of Endocrinology, Imperial College Healthcare NHS Trust, London, United Kingdom
- *Correspondence: Waljit S. Dhillo
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Azizi F, Malboosbaf R. Safety of long-term antithyroid drug treatment? A systematic review. J Endocrinol Invest 2019; 42:1273-1283. [PMID: 31134536 DOI: 10.1007/s40618-019-01054-1] [Citation(s) in RCA: 36] [Impact Index Per Article: 7.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/30/2019] [Accepted: 04/30/2019] [Indexed: 01/22/2023]
Abstract
Continued low-dose MMI treatment for longer than 12-18 months may be considered in patients not in remission. However, ATDs are not free from adverse effects. We undertook a systematic review to clarify safety of long-term ATD treatment. Medline and the Cochrane Library for trials published between 1950 and Nov 2018 were systematically searched. We included original studies containing data for long-term (> 18 months) ATD treatment. Two reviewers independently extracted data from included trials and any disagreement was adjudicated by consensus. Of 615 related articles found, 12 fulfilled the criteria. Six articles had data for adults, five for non-adults and one article had data for both groups. The sample sizes ranged between 20 and 249 individuals, and the mean duration of ATD treatment ranged between 2.1 and 14.2 years. Considering all data from 1660 patients treated with ATD for a mean duration of 5.8 years (around 10,000 patient-years), major complications occurred only in 14 patients: 7 severe agranulocytosis, 5 severe liver damage, one ANCA-associated glomerulonephritis and one vasculitis with small cutaneous ulcerations. Minor complications rates were between 2 and 36%, while more complications were in higher doses and in the children. The most reported AE was cutaneous reaction; the other adverse events were elevated liver enzymes, leukocytopenia, arthritis, arthralgia, myalgia, thrombocytopenia, fever, nausea and oral aphthous. Long-term ATD treatment is safe, especially in low dose and in adults, indicating that it should be considered as an earnest alternative treatment for GD.
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Affiliation(s)
- F Azizi
- Internal Medicine and Endocrinology, Endocrine Research Center of Research Institute for Endocrine Sciences, Shahid Beheshti University of Medical Sciences, P.O. Box: 19395-4763, Tehran, Islamic Republic of Iran.
| | - R Malboosbaf
- Internal Medicine and Endocrinology, Endocrine Research Center, Institute of Endocrinology and Metabolism, Iran University of Medical Sciences, Tehran, Islamic Republic of Iran
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Veneti S, Anagnostis P, Adamidou F, Artzouchaltzi AM, Boboridis K, Kita M. Association between vitamin D receptor gene polymorphisms and Graves' disease: a systematic review and meta-analysis. Endocrine 2019; 65:244-251. [PMID: 30924084 DOI: 10.1007/s12020-019-01902-3] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/21/2019] [Accepted: 03/12/2019] [Indexed: 02/07/2023]
Abstract
PURPOSE The pathogenesis of Graves' disease (GD) and orbitopathy (GO) is not completely elucidated. On the other hand, vitamin D receptor (VDR) gene polymorphisms have been associated with vulnerability to a plethora of chronic autoimmune diseases. The primary aim of this study was to synthesize evidence on the association between VDR gene polymorphisms and GD. Secondary aim was to investigate their association with GO. METHODS A comprehensive search was conducted in PubMed, CENTRAL and Scopus, up to December 8, 2018. Data were expressed as odds ratio (OR) with 95% confidence intervals (CI). Heterogeneity was quantified with I2 index. RESULTS Ten studies were included in the qualitative and quantitative analysis. TT subtype of TaqI polymorphism was associated with an increased risk of GD compared with Tt and tt polymorphisms (OR: 1.42; 95% CI, 1.05-1.94, p = 0.025), whereas tt was associated with a lower risk of GD, compared with TT and Tt polymorphisms (OR: 0.79; 95% CI, 0.62-0.99, p = 0.043). No association was found for ApaI, BsmI, and FokI polymorphisms. The bb subtype of BsmI polymorphism was associated with a lower risk in Asian, but with a higher GD risk in Caucasian populations, compared with BB/Bb subtypes. No eligible study was found regarding the association between VDR gene polymorphisms and the risk of GO. CONCLUSIONS The TT subtype of the TaqI polymorphism was associated with a higher susceptibility for GD compared with Tt and tt. Regarding BsmI, the bb subtype was associated with increased GD risk in Caucasians, whereas it is protective in Asians.
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Affiliation(s)
- Stavroula Veneti
- Department of Endocrinology and Diabetes, Hippokration General Hospital of Thessaloniki, Thessaloniki, Greece
| | - Panagiotis Anagnostis
- Department of Endocrinology and Diabetes, Hippokration General Hospital of Thessaloniki, Thessaloniki, Greece.
| | - Fotini Adamidou
- Department of Endocrinology and Diabetes, Hippokration General Hospital of Thessaloniki, Thessaloniki, Greece
| | | | - Kostas Boboridis
- 1st University Department of Ophthalmology, Aristotle University of Thessaloniki, Thessaloniki, Greece
| | - Marina Kita
- Department of Endocrinology and Diabetes, Hippokration General Hospital of Thessaloniki, Thessaloniki, Greece
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20
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Diker-Cohen T, Duskin-Bitan H, Shimon I, Hirsch D, Akirov A, Tsvetov G, Robenshtok E. DISEASE PRESENTATION AND REMISSION RATE IN GRAVES DISEASE TREATED WITH ANTITHYROID DRUGS: IS GENDER REALLY A FACTOR? Endocr Pract 2018; 25:43-50. [PMID: 30383487 DOI: 10.4158/ep-2018-0365] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
OBJECTIVE Male gender is considered an adverse prognostic factor for remission of Graves disease treatment with antithyroid drugs (ATDs), although published data are conflicting. This often results in early consideration of radioiodine treatment and surgery for men. Our objective was to compare disease presentation and outcome in men versus women treated with ATDs. METHODS Retrospective study of 235 patients (64 men, 171 women) with Graves disease who were evaluated for features at presentation and outcome at the end of follow-up between 2010 and 2015. RESULTS Disease presentation was similar in men and women for age at diagnosis (41.4 ± 14 years vs. 40 ± 15 years), duration of follow-up (6.6 ± 7 years vs. 7.7 ± 6 years), rates of comorbid autoimmune diseases, and rate of Graves ophthalmopathy. Smoking was more prevalent in males (31% vs. 15%; P = .009). Free thyroxine and triiodothyronine levels were comparable. ATDs were first-line treatment in all males and in 168 of 171 females, for a median duration of 24 and 20 months, respectively ( P = .55). Remission rates were 47% in men and 58% in women ( P = .14). Males had fewer adverse events (9% vs. 18%) and treatment discontinuation (5% vs. 16%). Disease recurrence was comparable (14% vs. 20%; P = .32), as was requirement for second-line treatment, either radioiodine therapy or thyroidectomy. CONCLUSION Graves disease presentation is similar in men and women. Men treated with ATDs have high remission rates and similar recurrence rates compared to women, with fewer adverse events and less discontinuation of treatment. ATDs are an attractive first-line treatment for both genders. ABBREVIATIONS ATA = American Thyroid Association; ATD = antithyroid drug; GO = Graves ophthalmopathy; T3 = triiodothyronine; T4 = thyroxine; TSH = thyroid-stimulating hormone.
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Sarfo-Kantanka O, Sarfo FS, Ansah EO, Kyei I. Graves Disease in Central Ghana: Clinical Characteristics and Associated Factors. CLINICAL MEDICINE INSIGHTS-ENDOCRINOLOGY AND DIABETES 2018; 11:1179551418759076. [PMID: 29593440 PMCID: PMC5865516 DOI: 10.1177/1179551418759076] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 09/02/2017] [Accepted: 01/10/2018] [Indexed: 01/06/2023]
Abstract
Background Graves disease (GD) has increased in prevalence over the past decade in Africa. Despite this, the condition is not well described, especially in sub-Saharan Africa. Objective We have described the clinical characteristics and associated factors of GD in a cohort of patients attending a resource-limited setting tertiary hospital. Methods Patients were examined thoroughly and systematically tested for the degree of clinical and biochemical thyroid status. Thyroid volume, characteristics, and blood flow were assessed at presentation using ultrasonography. Factors associated with an inability to achieve clinical and biochemical thyroid remission were evaluated using multiple logistic regression analysis. Results Overall, 182 patients were studied, 152 (83.5%) were women with a female:male ratio of 5.1:1.0. The mean age at presentation was 39.9 ± 14.7 years with women significantly older than men. Thyroid-associated orbitopathy (TAO) was observed in 56% of the participants and pretibial myxoedema in 6%. About 84% of the participants were hyperthyroid at presentation, 9% were euthyroid, 4% were hypothyroid, and 3% had subclinical hyperthyroidism. Inability to achieve biochemical and clinical remission at 24 months was associated with increased thyroid volume (odds ratio [OR]: 2.35, 95% confidence interval [CI]: 1.85-2.52, P < .001), presence of TAO (OR: 2.15, 95% CI: 2.12-2.33, P < .001), increased FT3/FT4 ratio (OR: 1.33, 95% CI: 1.24-2.56, P = .004), and missed clinic appointment (OR: 5.2, 95% CI: 4.55-7.89, P < .001). Conclusions Graves disease among Ghanaians is associated with significant signs at presentation. Inability to achieve remission within the first 24 months is associated with increased thyroid volume, TAO, an increased FT3/FT4 ratio, as well as missed clinic appointment.
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Affiliation(s)
| | - Fred Stephen Sarfo
- Komfo Anokye Teaching Hospital, Kumasi, Ghana.,Kwame Nkrumah University of Science and Technology, Kumasi, Ghana
| | | | - Ishmael Kyei
- Department of Surgery, Komfo Anokye Teaching Hospital, Kumasi, Ghana
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22
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Anagnostis P, Artzouchaltzi A, Grekou A, Paschou SA, Gerou S, Tzalokostas V. Pretibial myxedema in a euthyroid patient. Hormones (Athens) 2018; 17:133-135. [PMID: 29858862 DOI: 10.1007/s42000-018-0008-6] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/19/2018] [Accepted: 02/13/2018] [Indexed: 11/30/2022]
Abstract
Pretibial myxedema (PM) is a rare extrathyroidal manifestation of Graves' disease (GD), usually during the hyperthyroid state, coexisting with orbitopathy. We describe a rare case of a biopsy-proven PM in a euthyroid patient, without history of GD or Hashimoto's thyroiditis. Assessment of commonly reported thyroid autoantibodies, such as thyroid peroxidase and thyroglobulin autoantibodies, thyroid stimulating immunoglobulins and thyroid binding inhibitory immunoglobulins, was negative. Resolution of skin pathology was achieved after topical application of corticosteroids and was sustained 1 year later.
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Affiliation(s)
- Panagiotis Anagnostis
- Division of Endocrinology, Police Medical Center of Thessaloniki, Monastiriou 326, 54121, Thessaloniki, Greece.
| | - Aikaterini Artzouchaltzi
- Division of Endocrinology, Police Medical Center of Thessaloniki, Monastiriou 326, 54121, Thessaloniki, Greece
| | - Alexandra Grekou
- Laboratory of Histopathology "Histodiagnostiki", Thessaloniki, Greece
| | - Stavroula A Paschou
- Division of Endocrinology and Diabetes, "Aghia Sophia" Hospital, Medical School, National and Kapodistrian University of Athens, Athens, Greece
| | | | - Vasilios Tzalokostas
- Division of Endocrinology, Police Medical Center of Thessaloniki, Monastiriou 326, 54121, Thessaloniki, Greece
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Hashimoto K, Nishihara E, Matsumoto M, Matsumoto S, Nakajima Y, Tsujimoto K, Yamakage H, Satoh-Asahara N, Noh JY, Ito K, Miyauchi A, Mori M, Yamada M, Ogawa Y. Sialic Acid-Binding Immunoglobulin-Like Lectin1 as a Novel Predictive Biomarker for Relapse in Graves' Disease: A Multicenter Study. Thyroid 2018; 28:50-59. [PMID: 29037117 DOI: 10.1089/thy.2017.0244] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
BACKGROUND There are currently no reliable biomarkers to predict relapse in Graves' disease (GD). In the present study, we investigated novel diagnostic biomarkers to predict the long-term remission of or relapse in GD. METHODS A DNA microarray analysis was performed to examine gene expression in the peripheral leukocytes of a frequently relapsing patient with GD and a patient in long-term remission after the discontinuation of antithyroid drugs (ATDs). Based on the DNA microarray analysis, we focused on Sialic acid-binding immunoglobulin-like lectin1 (SIGLEC1) as a candidate novel biomarker to predict GD relapse. Three hundred and fifty-eight patients with GD in the thyroid clinics of four different hospitals in Japan were included in a cross-sectional study to establish whether SIGLEC1 mRNA levels distinguish GD relapse experience from long-term remission. An additional 55 patients with GD were enrolled in a prospective study to clarify whether SIGLEC1 mRNA levels at ATD discontinuation predict GD relapse. RESULTS SIGLEC1 mRNA levels were significantly higher in patients with GD relapse experience than in those in long-term remission. Based on the receiver operating characteristic analysis, we found that high SIGLEC1 mRNA levels (≥258.9 copies) significantly distinguished GD relapse experience from long-term remission (p < 0.0001; sensitivity 66.7%, specificity 70.1%). In the prospective study, when the optimal cutoff value from the receiver operating characteristic curve analysis was applied to SIGLEC1 mRNA positivity at ATD discontinuation, SIGLEC1-positive patients (≥258.9 copies) showed a significantly higher cumulative risk of relapse than SIGLEC1-negative patients (<258.9 copies) (p = 0.022, the log-rank test). CONCLUSIONS SIGLEC1 mRNA levels have potential as a novel predictive biomarker for GD relapse.
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Affiliation(s)
- Koshi Hashimoto
- 1 Department of Preemptive Medicine and Metabolism, Graduate School of Medical and Dental Sciences, Tokyo Medical and Dental University, Tokyo, Japan
| | | | | | - Shunichi Matsumoto
- 4 Department of Medicine and Molecular Science, Gunma University Graduate School of Medicine, Gunma, Japan
| | - Yasuyo Nakajima
- 4 Department of Medicine and Molecular Science, Gunma University Graduate School of Medicine, Gunma, Japan
| | - Kazutaka Tsujimoto
- 5 Molecular Endocrinology and Metabolism, Graduate School of Medical and Dental Sciences, Tokyo Medical and Dental University, Tokyo, Japan
| | - Hajime Yamakage
- 6 Department of Endocrinology, Metabolism, and Hypertension, Clinical Research Institute, National Hospital Organization Kyoto Medical Center, Kyoto, Japan
| | - Noriko Satoh-Asahara
- 6 Department of Endocrinology, Metabolism, and Hypertension, Clinical Research Institute, National Hospital Organization Kyoto Medical Center, Kyoto, Japan
| | | | | | | | - Masatomo Mori
- 4 Department of Medicine and Molecular Science, Gunma University Graduate School of Medicine, Gunma, Japan
| | - Masanobu Yamada
- 4 Department of Medicine and Molecular Science, Gunma University Graduate School of Medicine, Gunma, Japan
| | - Yoshihiro Ogawa
- 5 Molecular Endocrinology and Metabolism, Graduate School of Medical and Dental Sciences, Tokyo Medical and Dental University, Tokyo, Japan
- 7 Department of Medicine and Bioregulatory Science, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan
- 8 Japan Agency for Medical Research and Development , Tokyo, Japan
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The Influence of Juvenile Graves' Ophthalmopathy on Graves' Disease Course. J Ophthalmol 2017; 2017:4853905. [PMID: 29225963 PMCID: PMC5684562 DOI: 10.1155/2017/4853905] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/02/2017] [Revised: 09/26/2017] [Accepted: 10/16/2017] [Indexed: 11/18/2022] Open
Abstract
Purpose To investigate juvenile Graves' ophthalmopathy (GO) signs and compare Graves' disease (GD) course in patients with or without GO. Patients and Methods There were analyzed data (visual acuity, proptosis, palpebral fissure measurements, clinical activity score (CAS), and the course of GD) of 67 children who have been newly diagnosed with GD. 26.9% of patients with GD had signs of ophthalmopathy (GO+), and 73.1% were without ophthalmopathy (GO−). Results Upper eyelid retraction (72.3%), proptosis (66.7%), and soft tissue changes (27.8−38.9%) were in GO+ patients. The palpebral fissure, CAS, and proptosis values were greater in the GO+ group than in the GO− group (p < 0.001). GD course in GO+ patients was longer than that in GO− patients (p < 0.001). The duration of the first remission was longer in GO− than in GO+ patients (p < 0.001). The duration of first remission was longer than one year for 61.2% in GO− and 33.3% in GO+ patients (p < 0.02). Conclusion The common manifestations of juvenile GO patients were upper eyelid retraction, proptosis, and soft tissue involvement. The study demonstrates that pediatric patients with GO are more likely to have a severe course of autoimmune thyroid disease.
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Abstract
BACKGROUND Several studies have reported inconsistent findings on the advantages and disadvantages of long-term treatment with antithyroid drugs (ATD). A systematic review and meta-analysis was undertaken to clarify the numerous aspects of long-term treatment with ATD. METHODS Medline and the Cochrane Library for trials published between 1950 and May 2016 were systematically searched. Studies containing data for long-term (>24 months) ATD treatment were included. Summary estimates of pooled prevalence, odds ratio, and weighted mean difference were calculated with a random effects model. RESULTS Of 587 related articles found, six fulfilled the inclusion criteria. Long-term ATD treatment induced a remission rate of 57% [confidence interval (CI) 45-68%], a rate that was higher in adults than in non-adults (61% vs. 53%). The rate of complications was 19.1% [CI 9.6-30.9%], of which only 1.5% were major complications. The annual remission rate for each year of treatment was 16% [CI 10-27%], which was higher in adults than non-adults (19% vs. 14%). However, it should be noted that this is not a true linear correlation, but a positive relationship can be suggested between time and remission rate. Meta-regression revealed that smoking had a significant lowering effect on remission rate. CONCLUSIONS Long-term ATD treatment is effective and safe, especially in adults, indicating that it should be considered as an alternative treatment for Graves' disease.
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Affiliation(s)
- Fereidoun Azizi
- Endocrine Research Center of Research Institute for Endocrine Sciences, Shahid Beheshti University of Medical Sciences , Tehran, I.R. Iran
| | - Ramin Malboosbaf
- Endocrine Research Center of Research Institute for Endocrine Sciences, Shahid Beheshti University of Medical Sciences , Tehran, I.R. Iran
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26
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Bagir GS, Haydardedeoglu FE, Bakiner OS, Bozkirli E, Ertorer ME. Mean Platelet Volume in Graves' disease: A Sign of Hypermetabolism Rather than Autoimmunity? Pak J Med Sci 2017; 33:871-875. [PMID: 29067056 PMCID: PMC5648955 DOI: 10.12669/pjms.334.12659] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/21/2023] Open
Abstract
Objective: To evaluate the impact of mean platelet volume (MPV) on predicting disease course among patients with Graves’ disease (GD). Methods: This retrospective study was performed between 2013-2016 at the Outpatient Endocrinology Clinic of Baskent University Faculty of Medicine, Adana hospital on 65 patients with GD. Among participants, 30 cases experienced thyrotoxicosis again during the first six months after discontinuing anti-thyroid drug (ATD) sessions that had been carried out for at least 12 months prior to stopping (Relapse group). We also observed 35 patients who exhibited normal thyroid functions within six months following ATD withdrawal (Remission group). MPV levels and thyroid function tests were recorded and total duration of ATD therapy was calculated for all participants. Results: The mean MPV level that was measured at the time of drug withdrawal did not differ between groups, being 8.0±1.2 fL in the Relapse group vs. 8.0±1.0 fL in the Remission group (p=0.81). However, we found that the relapse MPV was higher than the withdrawal MPV in the Relapse group (9.2±1.3 fL) than it was in the Remission group (8.0±1.2 fL, p=0.00). Conclusions: Higher relapse MPV in Relapse group but similar MPV levels in both groups at ATD withdrawal may be attributed to hypermetabolism or hyperthyroidism rather than autoimmunity of GD. Abbreviations: BMI: Body mass index GD: Graves’ disease MPV: Mean platelet volume TSH: Thyroid-stimulating hormone TRAbs: Thyrotropin receptor antibodies ATD: Anti-thyroid drug fT4: Free thyroxine fT3: Free triiodothyronine CBC: Complete blood count PTC: Papillary thyroid carcinoma
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Affiliation(s)
- Gulay Simsek Bagir
- Gulay Simsek Bagir, MD. Baskent University Faculty of Medicine, Division of Endocrinology Adana, Turkey
| | - Filiz Eksi Haydardedeoglu
- Filiz Eksi Haydardedeoglu, MD. Baskent University Faculty of Medicine, Division of Endocrinology Adana, Turkey
| | - Okan Sefa Bakiner
- Okan Sefa Bakiner, Associate Professor of Endocrinology, Baskent University Faculty of Medicine, Division of Endocrinology Adana, Turkey
| | - Emre Bozkirli
- Emre Bozkirli, Associate Professor of Endocrinology, Baskent University Faculty of Medicine, Division of Endocrinology Adana, Turkey
| | - Melek Eda Ertorer
- Melek Eda Ertorer, Professor of Endocrinology, Baskent University Faculty of Medicine, Division of Endocrinology Adana, Turkey
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Léger J, Carel JC. MANAGEMENT OF ENDOCRINE DISEASE: Arguments for the prolonged use of antithyroid drugs in children with Graves' disease. Eur J Endocrinol 2017; 177:R59-R67. [PMID: 28381452 DOI: 10.1530/eje-16-0938] [Citation(s) in RCA: 34] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/15/2016] [Revised: 03/02/2017] [Accepted: 04/05/2017] [Indexed: 11/08/2022]
Abstract
Graves' disease is an autoimmune disorder. It is the leading cause of hyperthyroidism, but is rare in children. Patients are initially managed with antithyroid drugs (ATDs), such as methimazole/carbimazole. A major disadvantage of treatment with ATD is the high risk of relapse, exceeding 70% of children treated for duration of 2 years, and the potential major side effects of the drug reported in exceptional cases. The major advantage of ATD treatment is that normal homeostasis of the hypothalamus-pituitary-thyroid axis may be restored, with periods of drug treatment followed by freedom from medical intervention achieved in approximately 40-50% of cases after prolonged treatment with ATD, for several years, in recent studies. Alternative ablative treatments such as radioactive iodine and, less frequently and mostly in cases of very high volume goiters or in children under the age of 5 years, thyroidectomy, performed by pediatric surgeons with extensive experience should be proposed in cases of non-compliance, intolerance to medical treatment or relapse after prolonged medical treatment. Ablative treatments are effective against hyperthyroidism, but they require the subsequent administration of levothyroxine throughout the patient's life. This review considers data relating to the prognosis for Graves' disease remission in children and explores the limitations of study designs and results; and the emerging proposal for management through the prolonged use of ATD drugs.
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Affiliation(s)
- Juliane Léger
- Assistance Publique-Hôpitaux de Paris, Hôpital Universitaire Robert Debré, Service d'Endocrinologie Diabétologie Pédiatrique, Centre de Référence des Maladies Endocriniennes Rares de la Croissance, Paris, France
- Université Paris Diderot, Sorbonne Paris Cité, Paris, France
- Institut National de la Santé et de la Recherche Médicale (Inserm), Unité 1141, DHU Protect, Paris, France
| | - Jean-Claude Carel
- Assistance Publique-Hôpitaux de Paris, Hôpital Universitaire Robert Debré, Service d'Endocrinologie Diabétologie Pédiatrique, Centre de Référence des Maladies Endocriniennes Rares de la Croissance, Paris, France
- Université Paris Diderot, Sorbonne Paris Cité, Paris, France
- Institut National de la Santé et de la Recherche Médicale (Inserm), Unité 1141, DHU Protect, Paris, France
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Liu J, Fu J, Xu Y, Wang G. Antithyroid Drug Therapy for Graves' Disease and Implications for Recurrence. Int J Endocrinol 2017; 2017:3813540. [PMID: 28529524 PMCID: PMC5424485 DOI: 10.1155/2017/3813540] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/18/2016] [Revised: 03/29/2017] [Accepted: 04/02/2017] [Indexed: 12/12/2022] Open
Abstract
Graves' disease (GD) is the most common cause of hyperthyroidism worldwide. Current therapeutic options for GD include antithyroid drugs (ATD), radioactive iodine, and thyroidectomy. ATD treatment is generally well accepted by patients and clinicians due to some advantages including normalizing thyroid function in a short time, hardly causing hypothyroidism, and ameliorating immune disorder while avoiding radiation exposure and invasive procedures. However, the relatively high recurrence rate is a major concern for ATD treatment, which is associated with multiple influencing factors like clinical characteristics, treatment strategies, and genetic and environmental factors. Of these influencing factors, some are modifiable but some are nonmodifiable. The recurrence risk can be reduced by adjusting the modifiable factors as much as possible. The titration regimen for 12-18 months is the optimal strategy of ATD. Levothyroxine administration after successful ATD treatment was not recommended. The addition of immunosuppressive drugs might be helpful to decrease the recurrence rate of GD patients after ATD withdrawal, whereas further studies are needed to address the safety and efficacy. This paper reviewed the current knowledge of ATD treatment and mainly focused on influencing factors for recurrence in GD patients with ATD treatment.
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Affiliation(s)
- Jia Liu
- Department of Endocrinology, Beijing Chao-Yang Hospital, Capital Medical University, Beijing 100020, China
| | - Jing Fu
- Department of Endocrinology, Beijing Chao-Yang Hospital, Capital Medical University, Beijing 100020, China
| | - Yuan Xu
- Department of Endocrinology, Beijing Chao-Yang Hospital, Capital Medical University, Beijing 100020, China
| | - Guang Wang
- Department of Endocrinology, Beijing Chao-Yang Hospital, Capital Medical University, Beijing 100020, China
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Nakhjavani M, Abdollahi S, Farzanefar S, Abousaidi M, Esteghamati A, Naseri M, Eftekhari M, Abbasi M. PREDICTION OF RELAPSE FROM HYPERTHYROIDISM FOLLOWING ANTITHYROID MEDICATION WITHDRAWAL USING TECHNETIUM THYROID UPTAKE SCANNING. Endocr Pract 2017; 23:466-470. [PMID: 28437154 DOI: 10.4158/ep161523.or] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
OBJECTIVE Technetium thyroid uptake (TTU) is not inhibited by antithyroid drugs (ATD) and reflects the degree of thyroid stimulation. We intended to predict the relapse rate from hyperthyroidism based on TTU measurement. METHODS Out of 44 initially enrolled subjects, 38 patients aged 41.6 ± 14.6 with Graves disease (duration: 84 ± 78 months) completed the study. TTU was performed with 40-second imaging of the neck and mediastinum 20 minutes after injection of 1 mCi technetium-99m pertechnetate. TTU was measured as the percentage of the count of activity accumulated in the thyroidal region minus the mediastinal background uptake to the count of 1 mCi technetium-99m under the same acquisition conditions. Then methimazole was stopped and patients were followed. The optimal TTU cutoff value for Graves relapse prediction was calculated using Youden's J statistic. RESULTS Hyperthyroidism relapsed in 11 (28.9%) patients 122 ± 96 (range: 15-290) days post-ATD withdrawal. The subjects in remission were followed for 209 ± 81 days (range: 88-390). TTU was significantly higher in patients with forthcoming relapse (12.0 ± 8.0 vs. 3.9 ± 2.0, P = .007). The difference was significant after adjustment for age, sex, history of previous relapse, disease duration, and thyroid-stimulating hormone (TSH) levels before withdrawal. The area under the receiver operative characteristic (ROC) curve was 0.87. The optimal TTU cutoff value for classification of subjects with relapse and remission was 8.7 with sensitivity, specificity, and positive and negative predictive value of 73%, 100%, 100%, and 90%, respectively (odds ratio [OR] = 10.0; 95% confidence interval [CI]: 3.4-29.3). CONCLUSION TTU evaluation in hyperthyroid patients receiving antithyroid medication is an accurate and practical method for predicting relapse after ATD withdrawal. ABBREVIATIONS ATD = antithyroid drugs RIU = radio-iodine uptake TSH = thyroid-stimulating hormone TSI = thyroid-stimulating immunoglobulin TTU = technetium thyroid uptake.
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Kim YA, Cho SW, Choi HS, Moon S, Moon JH, Kim KW, Park DJ, Yi KH, Park YJ, Cho BY. The Second Antithyroid Drug Treatment Is Effective in Relapsed Graves' Disease Patients: A Median 11-Year Follow-Up Study. Thyroid 2017; 27:491-496. [PMID: 28001121 DOI: 10.1089/thy.2016.0056] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/02/2023]
Abstract
BACKGROUND Antithyroid drug (ATD) is a widely used treatment for Graves' disease (GD). However, its long-term efficiency remains unclear. This study investigated the long-term disease prognosis and predictive factors for relapse in ATD-treated GD patients. METHODS Newly diagnosed, ATD-treated GD patients with at least four years of follow-up were recruited (n = 187). Remission was defined as maintaining a euthyroid status for more than one year after ATD withdrawal. RESULTS During 11.1 years (range 4.0-23.7 years) of median follow-up, overall, 51.9% of the newly diagnosed ATD-treated GD patients achieved remission, 32.1% continued ATD treatment, and 13.4% underwent other ablation treatments. The 10-year remission rates were higher in the first (34.2%) and second (25.5%) ATD courses than in any of the other subsequent ATD courses, and decreased as ATD treatments were repeated. The 10-year relapse rate was the highest after the third ATD treatment (71.4%) compared with that after the first (60.5%) and second (58.3%) courses. Longer duration of ATD treatment (odds ratio [OR] = 1.4 [confidence interval (CI) 1.2-1.7], p < 0.001), higher number of relapses (OR = 4.7 [CI 2.3-9.8], p < 0.001), and moderate to severe Graves' ophthalmopathy (OR = 4.1 [CI 1.1-15.2], p = 0.032) were associated with persistent disease status. CONCLUSIONS A second course of ATD can be considered for GD patients after the first relapse because the chance of remission and the relapse rate are similar to the one after the first ATD treatment course. For GD patients with more than two relapses, or with an ATD treatment duration of more than four to five years, low-dose maintenance of ATD or ablative treatment needs to be considered.
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Affiliation(s)
- Ye An Kim
- 1 Department of Internal Medicine, Seoul National University Hospital , Seoul, Korea
- 2 Department of Internal Medicine, Seoul National University Hospital Healthcare System Gangnam Center , Seoul, Korea
| | - Sun Wook Cho
- 1 Department of Internal Medicine, Seoul National University Hospital , Seoul, Korea
| | - Hoon Sung Choi
- 3 Department of Internal Medicine, Kangwon National University School of Medicine , Chuncheon, Korea
| | - Shinje Moon
- 1 Department of Internal Medicine, Seoul National University Hospital , Seoul, Korea
| | - Jae Hoon Moon
- 4 Department of Internal Medicine, Seoul National University Bundang Hospital , Seongnam, Korea
| | - Kyung Won Kim
- 1 Department of Internal Medicine, Seoul National University Hospital , Seoul, Korea
- 2 Department of Internal Medicine, Seoul National University Hospital Healthcare System Gangnam Center , Seoul, Korea
| | - Do Joon Park
- 1 Department of Internal Medicine, Seoul National University Hospital , Seoul, Korea
| | - Ka Hee Yi
- 5 Department of Internal Medicine, Seoul National University Boramae Medical Center , Seoul, Korea
| | - Young Joo Park
- 1 Department of Internal Medicine, Seoul National University Hospital , Seoul, Korea
| | - Bo Youn Cho
- 6 Department of Internal Medicine, Chung-Ang University College of Medicine , Seoul, Korea
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Sundaresh V, Brito JP, Thapa P, Bahn RS, Stan MN. Comparative Effectiveness of Treatment Choices for Graves' Hyperthyroidism: A Historical Cohort Study. Thyroid 2017; 27:497-505. [PMID: 28049375 PMCID: PMC5385429 DOI: 10.1089/thy.2016.0343] [Citation(s) in RCA: 46] [Impact Index Per Article: 6.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
BACKGROUND The optimum therapy for Graves' disease (GD) is chosen following discussion between physician and patient regarding benefits, drawbacks, potential side effects, and logistics of the various treatment options, and it takes into account patient values and preferences. This cohort study aimed to provide useful information for this discussion regarding the usage, efficacy, and adverse-effect profile of radioactive iodine (RAI), antithyroid drugs (ATDs), and thyroidectomy in a tertiary healthcare facility. METHODS The cohort included consecutive adults diagnosed with GD from January 2002 to December 2008, who had complete follow-up after treatment at the Mayo Clinic, Rochester, Minnesota. Data on treatment modalities, disease relapses, and adverse effects were extracted manually and electronically from the electronic medical records. Kaplan-Meier analyses were performed to evaluate the association of treatments with relapse-free survival. RESULTS The cohort included 720 patients with a mean age of 49.3 years followed for a mean of 3.3 years. Of these, 76.7% were women and 17.1% were smokers. The initial therapy was RAI in 75.4%, ATDs in 16.4%, and thyroidectomy in 2.6%, while 5.6% opted for observation. For the duration of follow-up, ATDs had an overall failure rate of 48.3% compared with 8% for RAI (hazard ratio = 7.6; p < 0.0001). Surgery had a 100% success rate; 80% of observed patients ultimately required therapy. Adverse effects developed in 43 (17.3%) patients treated with ATDs, most commonly dysgeusia (4.4%), rash (2.8%), nausea/gastric distress (2.4%), pruritus (1.6%), and urticaria (1.2%). Eight patients treated with RAI experienced radiation thyroiditis (1.2%). Thyroidectomy resulted in one (2.9%) hematoma and one (2.85%) superior laryngeal nerve damage, with no permanent hypocalcemia. CONCLUSIONS RAI was the most commonly used modality within the cohort and demonstrated the best efficacy and safety profile. Surgery was also very effective and relatively safe in the hands of experienced surgeons. While ATDs allow preservation of thyroid function, a high relapse rate combined with a significant adverse-effect profile was documented. These data can inform discussion between physician and patient regarding choice of therapy for GD.
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Affiliation(s)
- Vishnu Sundaresh
- Division of Endocrinology, Metabolism, and Diabetes, University of Utah, Salt Lake City, Utah
- Geriatrics and Primary Care Internal Medicine, Mayo Clinic, Rochester, Minnesota
| | - Juan P. Brito
- Division of Endocrinology, Mayo Clinic, Rochester, Minnesota
- Knowledge and Evaluation Research Unit in Endocrinology (KER_Endo), Mayo Clinic, Rochester, Minnesota
| | - Prabin Thapa
- Department of Health Sciences Research, Division of Biostatistics, Mayo Clinic, Rochester, Minnesota
| | - Rebecca S. Bahn
- Division of Endocrinology, Mayo Clinic, Rochester, Minnesota
| | - Marius N. Stan
- Division of Endocrinology, Mayo Clinic, Rochester, Minnesota
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Struja T, Kaeslin M, Boesiger F, Jutzi R, Imahorn N, Kutz A, Bernasconi L, Mundwiler E, Mueller B, Christ-Crain M, Meienberg F, Ebrahimi F, Henzen C, Fischli S, Kraenzlin M, Meier C, Schuetz P. External validation of the GREAT score to predict relapse risk in Graves' disease: results from a multicenter, retrospective study with 741 patients. Eur J Endocrinol 2017; 176:413-419. [PMID: 28100628 DOI: 10.1530/eje-16-0986] [Citation(s) in RCA: 31] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/01/2016] [Revised: 01/11/2017] [Accepted: 01/17/2017] [Indexed: 11/08/2022]
Abstract
CONTEXT First-line treatment in Graves' disease is often done with antithyroid agents (ATD), but relapse rates remain high making definite treatment necessary. Predictors for relapse risk help guiding initial treatment decisions. OBJECTIVE We aimed to externally validate the prognostic accuracy of the recently proposed Graves' Recurrent Events After Therapy (GREAT) score to predict relapse risk in Graves' disease. DESIGN, SETTING AND PARTICIPANTS We retrospectively analyzed data (2004-2014) of patients with a first episode of Graves' hyperthyroidism from four Swiss endocrine outpatient clinics. MAIN OUTCOME MEASURES Relapse of hyperthyroidism analyzed by multivariate Cox regression. RESULTS Of the 741 included patients, 371 experienced a relapse (50.1%) after a mean follow-up of 25.6 months after ATD start. In univariate regression analysis, higher serum free T4, higher thyrotropin-binding inhibitor immunoglobulin (TBII), younger age and larger goiter were associated with higher relapse risk. We found a strong increase in relapse risk with more points in the GREAT score from 33.8% in patients with GREAT class I (0-1 points), 59.4% in class II (2-3 points) with a hazard ratio of 1.79 (95% CI: 1.42-2.27, P < 0.001) and 73.6% in class III (4-6 points) with a hazard ratio of 2.24 (95% CI: 1.64-3.06, P < 0.001). CONCLUSIONS Based on this retrospective analysis within a large patient population from a multicenter study, the GREAT score shows good external validity and can be used for assessing the risk for relapse in Graves' disease, which influence the initial treatment decisions.
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Affiliation(s)
- Tristan Struja
- Medical University DepartmentClinic for Endocrinology, Diabetes & Metabolism
| | - Marina Kaeslin
- Medical University DepartmentClinic for Endocrinology, Diabetes & Metabolism
| | - Fabienne Boesiger
- Medical University DepartmentClinic for Endocrinology, Diabetes & Metabolism
| | - Rebecca Jutzi
- Medical University DepartmentClinic for Endocrinology, Diabetes & Metabolism
| | - Noemi Imahorn
- Medical University DepartmentClinic for Endocrinology, Diabetes & Metabolism
| | - Alexander Kutz
- Medical University DepartmentClinic for Endocrinology, Diabetes & Metabolism
| | - Luca Bernasconi
- Department of Laboratory MedicineKantonsspital Aarau, Aarau, Switzerland
| | - Esther Mundwiler
- Department of Laboratory MedicineKantonsspital Aarau, Aarau, Switzerland
| | - Beat Mueller
- Medical University DepartmentClinic for Endocrinology, Diabetes & Metabolism
- Medical Faculty of the University of BaselBasel, Switzerland
| | - Mirjam Christ-Crain
- Medical Faculty of the University of BaselBasel, Switzerland
- Clinic for EndocrinologyDiabetes & Metabolism, University Hospital of Basel, Basel, Switzerland
| | - Fabian Meienberg
- Clinic for EndocrinologyDiabetes & Metabolism, University Hospital of Basel, Basel, Switzerland
| | - Fahim Ebrahimi
- Clinic for EndocrinologyDiabetes & Metabolism, University Hospital of Basel, Basel, Switzerland
| | - Christoph Henzen
- Medical Faculty of the University of BaselBasel, Switzerland
- Clinic for EndocrinologyDiabetes & Metabolism, Kantonsspital Luzern, Luzern, Switzerland
| | - Stefan Fischli
- Clinic for EndocrinologyDiabetes & Metabolism, Kantonsspital Luzern, Luzern, Switzerland
| | - Marius Kraenzlin
- Medical Faculty of the University of BaselBasel, Switzerland
- Clinic for EndocrinologyDiabetes & Metabolism, University Hospital of Basel, Basel, Switzerland
| | - Christian Meier
- Medical Faculty of the University of BaselBasel, Switzerland
- Clinic for EndocrinologyDiabetes & Metabolism, University Hospital of Basel, Basel, Switzerland
| | - Philipp Schuetz
- Medical University DepartmentClinic for Endocrinology, Diabetes & Metabolism
- Medical Faculty of the University of BaselBasel, Switzerland
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Ferrari SM, Fallahi P, Antonelli A, Benvenga S. Environmental Issues in Thyroid Diseases. Front Endocrinol (Lausanne) 2017; 8:50. [PMID: 28373861 PMCID: PMC5357628 DOI: 10.3389/fendo.2017.00050] [Citation(s) in RCA: 91] [Impact Index Per Article: 13.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/20/2017] [Accepted: 03/03/2017] [Indexed: 02/06/2023] Open
Abstract
Environmental factors are determinant for the appearance of autoimmune thyroid diseases (AITD) in susceptible subjects. Increased iodine intake, selenium, and vitamin D deficiency, exposure to radiation, from nuclear fallout or due to medical radiation, are environmental factors increasing AITD. Cigarette smoking is associated with Graves' disease and Graves' ophthalmopathy, while it decreases the risk of hypothyroidism and thyroid autoimmunity. Viral infections are important environmental factors in the pathogenesis of AITD, too, particularly human parvovirus B19 (EVB19) and hepatitis C virus. Among the many chemical contaminants, halogenated organochlorines and pesticides variably disrupt thyroid function. Polychlorinated biphenyls and their metabolites and polybrominated diethyl ethers bind to thyroid transport proteins, such as transthyretin, displace thyroxine, and disrupt thyroid function. Among drugs, interferon- and iodine-containing drugs have been associated with AITD. Moreover intestinal dysbiosis causes autoimmune thyroiditis. To reduce the risk to populations and also in each patient, it is necessary to comprehend the association between environmental agents and thyroid dysfunction.
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Affiliation(s)
| | - Poupak Fallahi
- Department of Clinical and Experimental Medicine, University of Pisa, Pisa, Italy
| | - Alessandro Antonelli
- Department of Clinical and Experimental Medicine, University of Pisa, Pisa, Italy
- *Correspondence: Alessandro Antonelli,
| | - Salvatore Benvenga
- Department of Clinical and Experimental Medicine, University of Messina School of Medicine, Messina, Italy
- Master Program of Childhood, Adolescence and Women’s Endocrine Health, University of Messina School of Medicine, Messina, Italy
- Interdepartmental Program of Molecular & Clinical Endocrinology, and Women’s Endocrine Health, University Hospital, Policlinico G. Martino, Messina, Italy
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Langenstein C, Schork D, Badenhoop K, Herrmann E. Relapse prediction in Graves´ disease: Towards mathematical modeling of clinical, immune and genetic markers. Rev Endocr Metab Disord 2016; 17:571-581. [PMID: 27638651 DOI: 10.1007/s11154-016-9386-8] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/13/2023]
Abstract
PROBLEM Graves' disease (GD) is an important and prevalent thyroid autoimmune disorder. Standard therapy for GD consists of antithyroid drugs (ATD) with treatment periods of around 12 months but relapse is frequent. Since predictors for relapse are difficult to identify the individual decision making for optimal treatment is often arbitrary. METHODS After reviewing the literature on this topic we summarize important factors involved in GD and with respect to their potential for relapse prediction from markers before and after treatment. This information was used to design a mathematical model integrating thyroid hormone parameters, thyroid size, antibody titers and a complex algorithm encompassing genetic predisposition, environmental exposures and current immune activity in order to arrive at a prognostic index for relapse risk after treatment. CONCLUSION In the search for a tool to analyze and predict relapse in GD mathematical modeling is a promising approach. In analogy to mathematical modeling approaches in other diseases such as viral infections, we developed a differential equation model on the basis of published clinical trials in patients with GD. Although our model needs further evaluation to be applicable in a clinical context, it provides a perspective for an important contribution to a final statistical prediction model.
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Affiliation(s)
- Christoph Langenstein
- Institute of Biostatistics and Mathematical Modeling - Department of Medicine, Goethe University Frankfurt, Theodor-Stern-Kai 7, Frankfurt am Main, 60590, Germany.
| | - Diana Schork
- Department of Medicine 1 - Division of Endocrinology & Diabetes, Goethe University Hospital Frankfurt, Frankfurt am Main, Germany
| | - Klaus Badenhoop
- Department of Medicine 1 - Division of Endocrinology & Diabetes, Goethe University Hospital Frankfurt, Frankfurt am Main, Germany
| | - Eva Herrmann
- Institute of Biostatistics and Mathematical Modeling - Department of Medicine, Goethe University Frankfurt, Theodor-Stern-Kai 7, Frankfurt am Main, 60590, Germany
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Abstract
Hyperthyroidism is characterised by increased thyroid hormone synthesis and secretion from the thyroid gland, whereas thyrotoxicosis refers to the clinical syndrome of excess circulating thyroid hormones, irrespective of the source. The most common cause of hyperthyroidism is Graves' disease, followed by toxic nodular goitre. Other important causes of thyrotoxicosis include thyroiditis, iodine-induced and drug-induced thyroid dysfunction, and factitious ingestion of excess thyroid hormones. Treatment options for Graves' disease include antithyroid drugs, radioactive iodine therapy, and surgery, whereas antithyroid drugs are not generally used long term in toxic nodular goitre, because of the high relapse rate of thyrotoxicosis after discontinuation. β blockers are used in symptomatic thyrotoxicosis, and might be the only treatment needed for thyrotoxicosis not caused by excessive production and release of the thyroid hormones. Thyroid storm and hyperthyroidism in pregnancy and during the post-partum period are special circumstances that need careful assessment and treatment.
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Affiliation(s)
- Simone De Leo
- Endocrine Unit, Fondazione IRCCS Cà Granda, Milan, Italy (S De Leo MD); Department of Clinical Sciences and Community Health, University of Milan, Milan, Italy (S De Leo); and Section of Endocrinology, Diabetes and Nutrition, Boston University School of Medicine, Boston, MA, USA (S De Leo, S Y Lee MD, Prof L E Braverman MD)
| | - Sun Y Lee
- Endocrine Unit, Fondazione IRCCS Cà Granda, Milan, Italy (S De Leo MD); Department of Clinical Sciences and Community Health, University of Milan, Milan, Italy (S De Leo); and Section of Endocrinology, Diabetes and Nutrition, Boston University School of Medicine, Boston, MA, USA (S De Leo, S Y Lee MD, Prof L E Braverman MD)
| | - Lewis E Braverman
- Endocrine Unit, Fondazione IRCCS Cà Granda, Milan, Italy (S De Leo MD); Department of Clinical Sciences and Community Health, University of Milan, Milan, Italy (S De Leo); and Section of Endocrinology, Diabetes and Nutrition, Boston University School of Medicine, Boston, MA, USA (S De Leo, S Y Lee MD, Prof L E Braverman MD)
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Perricone C, Versini M, Ben-Ami D, Gertel S, Watad A, Segel MJ, Ceccarelli F, Conti F, Cantarini L, Bogdanos DP, Antonelli A, Amital H, Valesini G, Shoenfeld Y. Smoke and autoimmunity: The fire behind the disease. Autoimmun Rev 2016; 15:354-74. [DOI: 10.1016/j.autrev.2016.01.001] [Citation(s) in RCA: 95] [Impact Index Per Article: 11.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/05/2015] [Accepted: 12/31/2015] [Indexed: 12/14/2022]
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Singhal N, Praveen VP, Bhavani N, Menon AS, Menon U, Abraham N, Kumar H, JayKumar RV, Nair V, Sundaram S, Sundaram P. Technetium uptake predicts remission and relapse in Grave's disease patients on antithyroid drugs for at least 1 year in South Indian subjects. Indian J Endocrinol Metab 2016; 20:157-161. [PMID: 27042408 PMCID: PMC4792013 DOI: 10.4103/2230-8210.176360] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
Abstract
CONTEXT Most of the information on remission related factors in Grave's disease are derived from Western literature. It is likely that there may be additional prognostic factors and differences in the postdrug treatment course of Grave's disease in India. AIM To study factors which predict remission/relapse in Grave's disease patients from South India. Also to establish if technetium (Tc) uptake has a role in predicting remission. SUBJECTS AND METHODS Records of 174 patients with clinical, biochemical, and scintigraphic criteria consistent with Grave's disease, seen in our Institution between January 2006 and 2014 were analyzed. Patient factors, drug-related factors, Tc-99m uptake and other clinical factors were compared between the remission and nonremission groups. STATISTICAL ANALYSIS USED Mann-Whitney U-test and Chi-square tests were used when appropriate to compare the groups. RESULTS Fifty-seven (32.7%) patients attained remission after at least 1 year of thionamide therapy. Of these, 11 (19.2%) patients relapsed within 1 year. Age, gender, goiter, and presence of extrathyroidal manifestations were not associated with remission. Higher values of Tc uptake were positively associated with remission (P- 0.02). Time to achievement of normal thyroid function and composite dose: Time scores were significantly associated with remission (P - 0.05 and P - 0.01, respectively). Patients with lower FT4 at presentation had a higher chance of remission (P - 0.01). The relapse rates were lower than previously reported in the literature. A higher Tc uptake was found to be significantly associated with relapse also (P - 0.009). CONCLUSION The prognostic factors associated with remission in Graves's disease in this South Indian study are not the same as that reported in Western literature. Tc scintigraphy may have an additional role in identifying people who are likely to undergo remission and thus predict the outcome of Grave's disease.
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Affiliation(s)
- Neha Singhal
- Department of Endocrine, Amrita Institute of Medical Sciences, Amrita Vishwa Vidyapeetham, Kochi, Kerala, India
| | - V. P. Praveen
- Department of Endocrine, Amrita Institute of Medical Sciences, Amrita Vishwa Vidyapeetham, Kochi, Kerala, India
| | - Nisha Bhavani
- Department of Endocrine, Amrita Institute of Medical Sciences, Amrita Vishwa Vidyapeetham, Kochi, Kerala, India
| | - Arun S. Menon
- Department of Endocrine, Amrita Institute of Medical Sciences, Amrita Vishwa Vidyapeetham, Kochi, Kerala, India
| | - Usha Menon
- Department of Endocrine, Amrita Institute of Medical Sciences, Amrita Vishwa Vidyapeetham, Kochi, Kerala, India
| | - Nithya Abraham
- Department of Endocrine, Amrita Institute of Medical Sciences, Amrita Vishwa Vidyapeetham, Kochi, Kerala, India
| | - Harish Kumar
- Department of Endocrine, Amrita Institute of Medical Sciences, Amrita Vishwa Vidyapeetham, Kochi, Kerala, India
| | - R. V. JayKumar
- Department of Endocrine, Amrita Institute of Medical Sciences, Amrita Vishwa Vidyapeetham, Kochi, Kerala, India
| | - Vasantha Nair
- Department of Endocrine, Amrita Institute of Medical Sciences, Amrita Vishwa Vidyapeetham, Kochi, Kerala, India
| | - Shanmugha Sundaram
- Department of Nuclear Medicine, Amrita Institute of Medical Sciences, Amrita Vishwa Vidyapeetham, Kochi, Kerala, India
| | - Padma Sundaram
- Department of Nuclear Medicine, Amrita Institute of Medical Sciences, Amrita Vishwa Vidyapeetham, Kochi, Kerala, India
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Jarusaitiene D, Verkauskiene R, Jasinskas V, Jankauskiene J. Predictive Factors of Development of Graves' Ophthalmopathy for Patients with Juvenile Graves' Disease. Int J Endocrinol 2016; 2016:8129497. [PMID: 27413373 PMCID: PMC4928005 DOI: 10.1155/2016/8129497] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/07/2016] [Accepted: 05/12/2016] [Indexed: 12/14/2022] Open
Abstract
Background. Due to low incidence of Graves' ophthalmopathy (GO) among children, the manifestation is poorly analyzed, posing a risk to late identification of insidious disease. Purposes. To identify predictive factors that may influence the development of GO in pediatric and young patients with Graves' disease (GD). Methods. A cross-sectional study of patients newly diagnosed with pediatric or juvenile GD during 2002-2012 was conducted at the Hospital of Lithuanian University of Health Sciences. Ocular evaluation was based on European Group on Graves' Orbitopathy survey. The ocular manifestations were analyzed in relation to demographic, environmental, and clinical factors. Results. In total, 130 patients with juvenile GD were included; 29.2% had GO. Median age at GD onset was 17 yrs (IQR 4-29). Main symptoms of GO were eyelids retraction (73.7%), proptosis (65.8%), injection of conjunctiva (42.1%), and eyeball motility disturbance (21.1%). Major significant and independent risk factors for GO development were high initial concentration of FT4 (OR = 5.963), TTHAb (OR = 6.358), stress (OR = 6.030), and smoking (OR = 7.098). Conclusion. The major factors that could influence GO development were smoking, stress, and increased levels of initial TRAb, FT4. Slight proptosis, retraction of eyelids, and conjunctive injection were found as predominant ophthalmological symptoms in juvenile GO.
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Affiliation(s)
- Dalia Jarusaitiene
- Eye Clinic, Medical Academy, Lithuanian University of Health Sciences, A. Mickevičiaus 9, LT-44307 Kaunas, Lithuania
- *Dalia Jarusaitiene:
| | - Rasa Verkauskiene
- Institute of Endocrinology, Medical Academy, Lithuanian University of Health Sciences, Eiveniu 2, LT-50009 Kaunas, Lithuania
| | - Vytautas Jasinskas
- Eye Clinic, Medical Academy, Lithuanian University of Health Sciences, A. Mickevičiaus 9, LT-44307 Kaunas, Lithuania
| | - Jurate Jankauskiene
- Eye Clinic, Medical Academy, Lithuanian University of Health Sciences, A. Mickevičiaus 9, LT-44307 Kaunas, Lithuania
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Piantanida E, Lai A, Sassi L, Gallo D, Spreafico E, Tanda ML, Bartalena L. Outcome Prediction of Treatment of Graves' Hyperthyroidism with Antithyroid Drugs. Horm Metab Res 2015. [PMID: 26197855 DOI: 10.1055/s-0035-1555759] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
Graves' disease is the most common cause of hyperthyroidism in iodine-replete areas and is ultimately due to antibodies interacting with the TSH receptor on thyroid follicular cells [TSH-receptor antibody (TRAb)]. Antithyroid drugs (ATDs) belonging to the family of thionamides are the first-line treatment in Europe. ATD treatment is commonly continued for 18-24 months. Its major limitation is the high rate of relapses after drug withdrawal. Factors particularly bound to subsequent relapses are the large thyroid volume, smoking habit, persistence of TRAb in the circulation at the end of treatment, and the post-partum period. Under these conditions, consideration should be given to a definitive therapy for hyperthyroidism (radioiodine treatment, thyroidectomy), particularly if the patient is at risk of cardiovascular complications that might be exacerbated by persistence or recurrence of hyperthyroidism.
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Affiliation(s)
- E Piantanida
- Department of Clinical and Experimental Medicine, University of Insubria, Varese, Italy
| | - A Lai
- Department of Clinical and Experimental Medicine, University of Insubria, Varese, Italy
| | - L Sassi
- Department of Clinical and Experimental Medicine, University of Insubria, Varese, Italy
| | - D Gallo
- Department of Clinical and Experimental Medicine, University of Insubria, Varese, Italy
| | - E Spreafico
- Department of Clinical and Experimental Medicine, University of Insubria, Varese, Italy
| | - M L Tanda
- Department of Clinical and Experimental Medicine, University of Insubria, Varese, Italy
| | - L Bartalena
- Department of Clinical and Experimental Medicine, University of Insubria, Varese, Italy
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Liu X, Qiang W, Liu X, Liu L, Liu S, Gao A, Gao S, Shi B. A second course of antithyroid drug therapy for recurrent Graves' disease: an experience in endocrine practice. Eur J Endocrinol 2015; 172:321-6. [PMID: 25468954 PMCID: PMC4321192 DOI: 10.1530/eje-14-0704] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
OBJECTIVE There are scarce reports regarding the prognosis of a second course of antithyroid drug (ATD) therapy on recurrent Graves' disease (GD). The aim of this study was to assess the long-term remission rate after a second ATD therapy and verify significant clinical predictors of a remission. DESIGN A prospective randomized clinical trial with long-term follow-up was conducted to evaluate the effects of a second course of ATD therapy. METHODS A total of 128 recurrent GD patients who had finished a first regular ATD therapy were enrolled in this study, and prescribed methimazole (MMI) treatment with titration regimen. The patients were randomly assigned to two groups when the drug doses were reduced to 2.5 mg daily (qd). Group 1 was discontinued with 2.5 mg qd after about 5 months. Group 2 was continuously reduced to 2.5 mg every other day (qod) after 5 months and then discontinued with 2.5 mg qod after about a further 5 months. The patients were followed for 48 months after drug withdrawal. RESULTS Of the total number of patients, 97 cases (75.78%) achieved permanent remission at the end of follow-up, with the recurrence of 31 cases (24.22%). The remission rate of group 2 (84.62%) was significantly higher than that of group 1 (66.67%) (P=0.024). Cox regression showed that the hazard ratio for recurrence decreased under a high or high normal TSH level at drug withdrawal. CONCLUSION A second course of ATD therapy can bring about a satisfying long-term remission on recurrent GD. The drug dose of 2.5 mg qod and a high or high normal TSH level at drug withdrawal may increase the likelihood of permanent remission.
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Affiliation(s)
- Xiaomei Liu
- Department of EndocrinologyFirst Affiliated Hospital of Xi'an Jiaotong University, No. 277 Yanta West Road, Xi'an, Shaanxi 710061, China
| | - Wei Qiang
- Department of EndocrinologyFirst Affiliated Hospital of Xi'an Jiaotong University, No. 277 Yanta West Road, Xi'an, Shaanxi 710061, China
| | - Xingjun Liu
- Department of EndocrinologyFirst Affiliated Hospital of Xi'an Jiaotong University, No. 277 Yanta West Road, Xi'an, Shaanxi 710061, China
| | - Lianye Liu
- Department of EndocrinologyFirst Affiliated Hospital of Xi'an Jiaotong University, No. 277 Yanta West Road, Xi'an, Shaanxi 710061, China
| | - Shu Liu
- Department of EndocrinologyFirst Affiliated Hospital of Xi'an Jiaotong University, No. 277 Yanta West Road, Xi'an, Shaanxi 710061, China
| | - Aibo Gao
- Department of EndocrinologyFirst Affiliated Hospital of Xi'an Jiaotong University, No. 277 Yanta West Road, Xi'an, Shaanxi 710061, China
| | - Shan Gao
- Department of EndocrinologyFirst Affiliated Hospital of Xi'an Jiaotong University, No. 277 Yanta West Road, Xi'an, Shaanxi 710061, China
| | - Bingyin Shi
- Department of EndocrinologyFirst Affiliated Hospital of Xi'an Jiaotong University, No. 277 Yanta West Road, Xi'an, Shaanxi 710061, China
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Laurberg P, Krejbjerg A, Andersen SL. Relapse following antithyroid drug therapy for Graves' hyperthyroidism. Curr Opin Endocrinol Diabetes Obes 2014; 21:415-21. [PMID: 25111942 DOI: 10.1097/med.0000000000000088] [Citation(s) in RCA: 36] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
PURPOSE OF REVIEW In most patients with hyperthyroidism caused by Graves' disease, antithyroid drug (ATD) therapy is followed by a gradual amelioration of the autoimmune abnormality, but about half of the patients will experience relapse of hyperthyroidism when the ATDs are withdrawn after a standard 1 to 2 years of therapy. This is a major drawback of ATD therapy, and a major concern to patients. We review current knowledge on how to predict and possibly reduce the risk of such relapse. RECENT FINDINGS Several patient and disease characteristics, as well as environmental factors and duration of ATD therapy, may influence the risk of relapse after ATD withdrawal. Depending on the presence of such factors, the risk of relapse after ATD withdrawal may vary from around 10 to 90%. Risk factors for relapse should be taken into account when choosing between therapeutic modalities in a patient with newly diagnosed disease, and also when discussing duration of ATD therapy. SUMMARY Prolonged low-dose ATD therapy may be feasible in patients with high risk of relapse, such as children and patients with active Graves' orbitopathy, and in patients with previous relapse who prefer such therapy rather than surgery or radioiodine.
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Affiliation(s)
- Peter Laurberg
- aDepartment of Endocrinology, Aalborg University Hospital bDepartment of Clinical Medicine, Aalborg University, Aalborg, Denmark
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Muldoon BT, Mai VQ, Burch HB. Management of Graves' disease: an overview and comparison of clinical practice guidelines with actual practice trends. Endocrinol Metab Clin North Am 2014; 43:495-516. [PMID: 24891174 DOI: 10.1016/j.ecl.2014.02.001] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
Over the last century, much has been learned about the pathogenesis, manifestations, and management of Graves' disease leading to the establishment of evidence-based clinical practice guidelines. The joint clinical practice guidelines from the American Thyroid Association and the American Association of Clinical Endocrinologists give recommendations on both the diagnosis and treatment of hyperthyroidism. A survey of clinicians performed that same year, however, revealed that current practices diverge from these recently published guidelines in multiple areas. These differences will need to be assessed serially to determine the impact of the guidelines on future clinical practice and perhaps vice versa.
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Affiliation(s)
- Becky T Muldoon
- Endocrinology Service, Department of Medicine, Walter Reed National Military Medical Center, 8901 Wisconsin Avenue, Building 19, 5th Floor, Bethesda, MD 20889-5600, USA; Department of Medicine, Uniformed Services University of the Health Sciences, 4301 Jones Bridge Road, Bethesda, MD 20814, USA
| | - Vinh Q Mai
- Endocrinology Service, Department of Medicine, Walter Reed National Military Medical Center, 8901 Wisconsin Avenue, Building 19, 5th Floor, Bethesda, MD 20889-5600, USA; Department of Medicine, Uniformed Services University of the Health Sciences, 4301 Jones Bridge Road, Bethesda, MD 20814, USA
| | - Henry B Burch
- Endocrinology Service, Department of Medicine, Walter Reed National Military Medical Center, 8901 Wisconsin Avenue, Building 19, 5th Floor, Bethesda, MD 20889-5600, USA; Endocrinology Division, Uniformed Services University of the Health Sciences, 4301 Jones Bridge Road, Bethesda, MD 20814, USA.
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Gao G, Dai J, Qian Y, Ma F. Meta-analysis of methylprednisolone pulse therapy for Graves' ophthalmopathy. Clin Exp Ophthalmol 2014; 42:769-77. [PMID: 24617953 DOI: 10.1111/ceo.12317] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/15/2013] [Accepted: 02/20/2014] [Indexed: 01/23/2023]
Abstract
A meta-analysis was performed to evaluate the efficacy of methylprednisolone pulse therapy for Graves' ophthalmopathy. Eight studies involving 376 patients were included. A higher effective rate was found for patients treated with intravenous glucocorticoids (IVGC) over oral glucocorticoids (OGC) (risk ratio [RR] = 1.48; 95% confidence interval [CI] = 1.18-1.86). The combined IVGC and orbital radiotherapy (OR) was markedly more effective than OGC+OR (RR = 1.40; 95% CI = 1.11-1.77). IVGC resulted in an obvious reduction of clinical activity score (CAS) compared with OGC, with a weighted mean difference (WMD) of 0.86 (95% CI = 0.53-1.18). The WMD for the reduction of the CAS between IVGC+OR and OGC+OR was 0.66 (95% CI = 0.30-1.02). IVGC is an effective treatment and cause fewer adverse events. Limiting the total cumulative dose of methylprednisolone, careful patient selection and monitoring the condition of patients during treatment are necessary.
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Affiliation(s)
- Guohong Gao
- Department of Ophthalmology, Eye and ENT Hospital Affiliated with Fudan University, Shanghai, China; Key Laboratory of Myopia, Ministry of Health PR China, Shanghai, China
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Mohlin E, Filipsson Nyström H, Eliasson M. Long-term prognosis after medical treatment of Graves' disease in a northern Swedish population 2000-2010. Eur J Endocrinol 2014; 170:419-27. [PMID: 24366943 DOI: 10.1530/eje-13-0811] [Citation(s) in RCA: 38] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
OBJECTIVE To investigate the long-term prognosis of patients with Graves' disease (GD) after antithyroid drug (ATD) treatment and follow-up outside of highly specialised care. DESIGN AND METHODS Medical records of all patients diagnosed with first-time GD in 2000-2010 with at least 6 months ATD treatment at a central hospital and follow-up in primary health care in the county of Norrbotten in northern Sweden were retrospectively reviewed. Patients were followed for relapse until 31st December 2012. We included 219 patients (mean age 46 years, 82.5% women) with follow-up of maximum 10 years and 829 observed patient years. Data were analysed using Kaplan-Meier estimates and log-rank test. RESULTS During the observation period, 43.5% of the patients had relapsed into active GD. The cumulative relapse rates were 22.6, 30.2, 36.9 and 41.5% after 6 months, 1, 3 and 5 years respectively. The presence of goitre (P=0.014) predicted relapse. Previous smoking was protective against relapse (P=0.003). The levels of free thyroxine or free tri-iodothyronine, age, gender, current smoking and ophthalmopathy did not predict relapse. Agranulocytosis was found in 1.7% (95% CI 0.7-4.0%). CONCLUSION A long-term remission of 56.5%, in an iodine-sufficient area where ATD is offered to most patients in the real world of central and district hospitals, is higher than in most studies. Relapse was most common during the first year, and prognosis was excellent after 4 years without relapse. The protective effect of previous smoking merits further research.
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Affiliation(s)
- Eric Mohlin
- Sunderby Research Unit, Department of Public Health and Clinical Medicine, Umeå University, Umeå, Sweden
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