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Yoshimura Noh J, Inoue K, Suzuki N, Yoshihara A, Fukushita M, Matsumoto M, Imai H, Hiruma S, Ichikawa M, Koshibu M, Sankoda A, Hirose R, Watanabe N, Sugino K, Ito K. Dose-dependent incidence of agranulocytosis in patients treated with methimazole and propylthiouracil. Endocr J 2024; 71:695-703. [PMID: 38710619 DOI: 10.1507/endocrj.ej24-0135] [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] [Indexed: 05/08/2024] Open
Abstract
Agranulocytosis is a serious adverse effect of methimazole (MMI) and propylthiouracil (PTU), and although there have been reports suggesting a dose-dependent incidence in relation to both drugs, the evidence has not been conclusive. The objective of our study was to determine whether the incidences of agranulocytosis induced by MMI and PTU exhibit dose-dependency. The subjects were 27,784 patients with untreated Graves' disease, 22,993 of whom were on an antithyroid drug treatment regimen for more than 90 days. Within this subset, 18,259 patients had been treated with MMI, and 4,734 had been treated with PTU. The incidence of agranulocytosis according to dose in the MMI group was 0.13% at 10 mg/day, 0.20% at 15 mg/day, 0.32% at 20 mg/day, and 0.47% at 30 mg/day, revealing a significant dose-dependent increase. In the PTU group, there were 0 cases of agranulocytosis at doses of 125 mg/day and below, 0.33% at 150 mg/day, 0.31% at 200 mg/day, and 0.81% at 300 mg/day, also revealing a significant dose-dependent increase. The incidence of agranulocytosis at MMI 15 mg and PTU 300 mg, i.e., at the same potency in terms of hormone synthesis inhibition, was 0.20% and 0.81%, respectively, and significantly higher in the PTU group. Our findings confirm a dose-dependent increase in the incidence of agranulocytosis with both drugs, but that at comparable thyroid hormone synthesis inhibitory doses PTU has a considerably higher propensity to induce agranulocytosis than MMI does.
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Affiliation(s)
| | - Kosuke Inoue
- Department of Social Epidemiology, Graduate School of Medicine, Kyoto University, Kyoto 606-8315, Japan
| | - Nami Suzuki
- Department of Internal Medicine, Ito Hospital, Tokyo 150-8308, Japan
| | - Ai Yoshihara
- Department of Internal Medicine, Ito Hospital, Tokyo 150-8308, Japan
| | - Miho Fukushita
- Department of Internal Medicine, Ito Hospital, Tokyo 150-8308, Japan
| | - Masako Matsumoto
- Department of Internal Medicine, Ito Hospital, Tokyo 150-8308, Japan
| | - Hideyuki Imai
- Department of Internal Medicine, Ito Hospital, Tokyo 150-8308, Japan
| | - Shigenori Hiruma
- Department of Internal Medicine, Ito Hospital, Tokyo 150-8308, Japan
| | - Masahiro Ichikawa
- Department of Internal Medicine, Ito Hospital, Tokyo 150-8308, Japan
| | - Masakazu Koshibu
- Department of Internal Medicine, Ito Hospital, Tokyo 150-8308, Japan
| | - Akiko Sankoda
- Department of Internal Medicine, Ito Hospital, Tokyo 150-8308, Japan
| | - Rei Hirose
- Department of Internal Medicine, Ito Hospital, Tokyo 150-8308, Japan
| | - Natsuko Watanabe
- Department of Internal Medicine, Ito Hospital, Tokyo 150-8308, Japan
| | | | - Koichi Ito
- Department of Surgery, Ito Hospital, Tokyo 150-8308, Japan
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Schempp V, Cebeci AN, Reinauer C, Woelfle J, Dörr HG, Roosen MT, Gohlke J, Gohlke B. Neutropenia Occurs More Often Under Carbimazole than Under Methimazole Treatment in Pediatric Graves' Disease Patients. Thyroid 2024; 34:735-743. [PMID: 38613811 DOI: 10.1089/thy.2023.0673] [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] [Indexed: 04/15/2024]
Abstract
Background: Agranulocytosis is a rare antithyroid drug treatment (ATD) side effect seen in children suffering from Graves' disease (GD). Neutropenia is a recognized adverse event associated with ATD but has also been reported as pre-treatment neutropenia in GD. Methods: We performed a retrospective cohort study to analyze the longitudinal clinical and biochemical data of 161 pediatric patients with GD who received either methimazole (MMI) or carbimazole (CBZ) as ATD. The inclusion criteria were elevated free thyroxine (fT4 >25 pmol/L), suppressed thyrotropin (TSH <0.05 mlU/mL), and elevated thyrotropin receptor antibodies (TSHRAbs >2.5 IU/L). Absolute neutrophil count (ANC) was used to define neutropenia (ANC <1800/µL) and agranulocytosis (ANC <500/µL). Results: Nine of the 161 patients had neutropenia at diagnosis (ANC: 1348/µL ± 250) without further deterioration under ATD. In this subgroup, we found higher levels of free triiodothyronine (fT3: 31.45 pmol/L ± 3.99) at diagnosis in comparison with those who developed neutropenia (26.29 pmol/L ± 12.96; p = 0.07) and those without neutropenia before and during therapy (23.12 pmol/L ± 13.7; p = 0.003). Thirty-eight patients (23.6%) became neutropenic (ANC: 1479/µL ± 262) while receiving ATD. Neutropenia occurred after a mean of 551.8 (range: 10-1376) days, mostly without further deterioration. Two of these 38 patients developed agranulocytosis and underwent emergency thyroidectomy. The patients with neutropenia were significantly younger (p = 0.031). Neutropenia occurred significantly more often in patients receiving CBZ (50%; n = 20/40) than in those receiving MMI (16.5%; n = 18/110; p = 0.001). The minimum ANC was significantly lower in the CBZ (1971/µL ± 1008) than in the MMI group (2546 ± 959); p = 0.004. Conclusions: Neutropenia occurred significantly more often under CBZ than MMI. As this is potentially due to higher immunogenicity, we suggest that children with GD should be treated with MMI. Frequent measurements of ANC may be needed to detect severe agranulocytosis, although low pre-treatment ANC may not necessarily be a contraindication to ATD treatment. Young age may be potentially associated with an increased risk of reduced ANC. Further investigation is necessary to fully understand risk factors for neutropenia in children with GD.
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Affiliation(s)
- Vera Schempp
- Divisions of Pediatric Endocrinology, University Children's Hospitals, Bonn, Germany
| | - Ayse Nurcan Cebeci
- Divisions of Pediatric Endocrinology, University Children's Hospitals, Erlangen, Germany
| | - Christina Reinauer
- Divisions of Pediatric Endocrinology, University Children's Hospitals, Duesseldorf, Germany
| | - Joachim Woelfle
- Divisions of Pediatric Endocrinology, University Children's Hospitals, Erlangen, Germany
| | - Helmuth-Günther Dörr
- Divisions of Pediatric Endocrinology, University Children's Hospitals, Erlangen, Germany
| | - Marie-Thérèse Roosen
- Divisions of Pediatric Endocrinology, University Children's Hospitals, Bonn, Germany
| | | | - Bettina Gohlke
- Divisions of Pediatric Endocrinology, University Children's Hospitals, Bonn, Germany
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Chaker L, Cooper DS, Walsh JP, Peeters RP. Hyperthyroidism. Lancet 2024; 403:768-780. [PMID: 38278171 DOI: 10.1016/s0140-6736(23)02016-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/06/2023] [Revised: 08/07/2023] [Accepted: 09/16/2023] [Indexed: 01/28/2024]
Abstract
Thyrotoxicosis causes a variety of symptoms and adverse health outcomes. Hyperthyroidism refers to increased thyroid hormone synthesis and secretion, most commonly from Graves' disease or toxic nodular goitre, whereas thyroiditis (typically autoimmune, viral, or drug induced) causes thyrotoxicosis without hyperthyroidism. The diagnosis is based on suppressed serum concentrations of thyroid-stimulating hormone (TSH), accompanied by free thyroxine and total or free tri-iodothyronine concentrations, which are raised (overt hyperthyroidism) or within range (subclinical hyperthyroidism). The underlying cause is determined by clinical assessment, detection of TSH-receptor antibodies and, if necessary, radionuclide thyroid scintigraphy. Treatment options for hyperthyroidism include antithyroid drugs, radioactive iodine, and thyroidectomy, whereas thyroiditis is managed symptomatically or with glucocorticoid therapy. In Graves' disease, first-line treatment is a 12-18-month course of antithyroid drugs, whereas for goitre, radioactive iodine or surgery are preferred for toxic nodules or goitres. Evidence also supports long-term treatment with antithyroid drugs as an option for patients with Graves' disease and toxic nodular goitre.
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Affiliation(s)
- Layal Chaker
- Department of Internal Medicine, Erasmus University Medical Center, Rotterdam, Netherlands; Department of Epidemiology, Erasmus University Medical Center, Rotterdam, Netherlands; Department of Epidemiology, Harvard T H Chan School of Public Health, Boston, MA, USA
| | - David S Cooper
- Department of Medicine, Division of Endocrinology, Diabetes, and Metabolism, The Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - John P Walsh
- Department of Endocrinology & Diabetes, Sir Charles Gairdner Hospital, Nedlands, WA, Australia; Medical School, University of Western Australia, Crawley, WA, Australia
| | - Robin P Peeters
- Department of Internal Medicine, Erasmus University Medical Center, Rotterdam, Netherlands.
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Herb M. NADPH Oxidase 3: Beyond the Inner Ear. Antioxidants (Basel) 2024; 13:219. [PMID: 38397817 PMCID: PMC10886416 DOI: 10.3390/antiox13020219] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/13/2024] [Revised: 02/02/2024] [Accepted: 02/06/2024] [Indexed: 02/25/2024] Open
Abstract
Reactive oxygen species (ROS) were formerly known as mere byproducts of metabolism with damaging effects on cellular structures. The discovery and description of NADPH oxidases (Nox) as a whole enzyme family that only produce this harmful group of molecules was surprising. After intensive research, seven Nox isoforms were discovered, described and extensively studied. Among them, the NADPH oxidase 3 is the perhaps most underrated Nox isoform, since it was firstly discovered in the inner ear. This stigma of Nox3 as "being only expressed in the inner ear" was also used by me several times. Therefore, the question arose whether this sentence is still valid or even usable. To this end, this review solely focuses on Nox3 and summarizes its discovery, the structural components, the activating and regulating factors, the expression in cells, tissues and organs, as well as the beneficial and detrimental effects of Nox3-mediated ROS production on body functions. Furthermore, the involvement of Nox3-derived ROS in diseases progression and, accordingly, as a potential target for disease treatment, will be discussed.
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Affiliation(s)
- Marc Herb
- Institute for Medical Microbiology, Immunology and Hygiene, Faculty of Medicine, University Hospital Cologne, University of Cologne, 50935 Cologne, Germany;
- German Centre for Infection Research, Partner Site Bonn-Cologne, 50931 Cologne, Germany
- Cologne Cluster of Excellence on Cellular Stress Responses in Aging-Associated Diseases (CECAD), 50931 Cologne, Germany
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Kamitani F, Nishioka Y, Koizumi M, Nakajima H, Kurematsu Y, Okada S, Kubo S, Myojin T, Noda T, Imamura T, Takahashi Y. Antithyroid drug-induced leukopenia and G-CSF administration: a long-term cohort study. Sci Rep 2023; 13:19336. [PMID: 37935745 PMCID: PMC10630492 DOI: 10.1038/s41598-023-46307-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2022] [Accepted: 10/30/2023] [Indexed: 11/09/2023] Open
Abstract
Although antithyroid drug (ATD)-induced agranulocytosis is a significant concern, its risks associated with long-term use and re-administration are not fully elucidated. Therefore, we performed this study to determine the incidence of ATD-induced leukopenia and G-CSF administration using administrative claims database. Retrospective cohort study. This study was performed using the DeSC Japanese administrative claims database. A total of 12,491 patients with newly diagnosed Graves' disease (GD) who received methimazole or propylthiouracil between April 2014, and February 2021 among 3.44 million patients in the database were included in the study. We measured the six-year incidence of leukopenia and granulocyte colony-stimulating factor (G-CSF) administration. The incidence of leukopenia and G-CSF administration was 1.34% (168 patients) and 0.30% (38 patients), respectively. Leukopenia had a dose-dependent and biphasic incidence. The incidence of leukopenia and G-CSF administration was 37.2 (0.7%) and 8.0 (0.2%) per 1000 person-years during the first 72 days of ATD initiation, whereas it was 3.1 and 0.7 per 1000 person-years during the subsequent 6 years, respectively. The incidence of both outcomes was comparable between first administration and re-administration of ATD. The incidence of ATD-induced leukopenia and G-CSF administration was high in the first 72 days, with a reduced risk for at least 6 years thereafter. The incidence was similar between first administration and re-administration. ATD, a standard therapy, is often administered for a long period; therefore, our findings can guide the treatment of GD.
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Affiliation(s)
- Fumika Kamitani
- Department of Diabetes and Endocrinology, Nara Medical University, 840, Shijo-Cho, Kashihara, Nara, 634-8522, Japan
| | - Yuichi Nishioka
- Department of Public Health, Health Management and Policy, Nara Medical University, 840, Shijo-Cho, Kashihara, Nara, 634-8521, Japan.
| | - Miyuki Koizumi
- Department of Diabetes and Endocrinology, Nara Medical University, 840, Shijo-Cho, Kashihara, Nara, 634-8522, Japan
| | - Hiroki Nakajima
- Department of Diabetes and Endocrinology, Nara Medical University, 840, Shijo-Cho, Kashihara, Nara, 634-8522, Japan
| | - Yukako Kurematsu
- Department of Diabetes and Endocrinology, Nara Medical University, 840, Shijo-Cho, Kashihara, Nara, 634-8522, Japan
| | - Sadanori Okada
- Department of Diabetes and Endocrinology, Nara Medical University, 840, Shijo-Cho, Kashihara, Nara, 634-8522, Japan
| | - Shinichiro Kubo
- Department of Public Health, Health Management and Policy, Nara Medical University, 840, Shijo-Cho, Kashihara, Nara, 634-8521, Japan
| | - Tomoya Myojin
- Department of Public Health, Health Management and Policy, Nara Medical University, 840, Shijo-Cho, Kashihara, Nara, 634-8521, Japan
| | - Tatsuya Noda
- Department of Public Health, Health Management and Policy, Nara Medical University, 840, Shijo-Cho, Kashihara, Nara, 634-8521, Japan
| | - Tomoaki Imamura
- Department of Public Health, Health Management and Policy, Nara Medical University, 840, Shijo-Cho, Kashihara, Nara, 634-8521, Japan
| | - Yutaka Takahashi
- Department of Diabetes and Endocrinology, Nara Medical University, 840, Shijo-Cho, Kashihara, Nara, 634-8522, Japan
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García Gómez C, Navarro E, Alcázar V, López-Guzmán A, Arrieta F, Anda E, Biagetti B, Guerrero-Pérez F, Villabona C, de Assín Valverde AR, Lamas C, Lecumberri B, Rosado Sierra JA, Sastre J, Díez JJ, Iglesias P. Therapeutic Management and Long-Term Outcome of Hyperthyroidism in Patients with Antithyroid-Induced Agranulocytosis: A Retrospective, Multicenter Study. J Clin Med 2023; 12:6556. [PMID: 37892693 PMCID: PMC10607319 DOI: 10.3390/jcm12206556] [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: 09/13/2023] [Revised: 10/08/2023] [Accepted: 10/10/2023] [Indexed: 10/29/2023] Open
Abstract
BACKGROUND Antithyroid drug-induced agranulocytosis (AIA) (neutrophils <500/µL) is a rare but serious complication in the treatment of hyperthyroidism. METHODOLOGY Adult patients with AIA who were followed up at 12 hospitals in Spain were retrospectively studied. A total of 29 patients were studied. The etiology of hyperthyroidism was distributed as follows: Graves' disease (n = 21), amiodarone-induced thyrotoxicosis (n = 7), and hyperfunctioning multinodular goiter (n = 1). Twenty-one patients were treated with methimazole, as well as six patients with carbimazole and two patients with propylthiouracil. RESULTS The median (IQR) time to development of agranulocytosis was 6.0 (4.0-11.5) weeks. The most common presenting sign was fever accompanied by odynophagia. All of the patients required admission, reverse isolation, and broad-spectrum antibiotics; moreover, G-CSF was administered to 26 patients (89.7%). Twenty-one patients received definitive treatment, thirteen patients received surgery, nine patients received radioiodine, and one of the patients required both treatments. Spontaneous normalization of thyroid hormone values occurred in six patients (four patients with amiodarone-induced thyrotoxicosis and two patients with Graves' disease), and two patients died of septic shock secondary to AIA. CONCLUSIONS AIA is a potentially lethal complication that usually appears around 6 weeks after the initiation of antithyroid therapy. Multiple drugs are required to control hyperthyroidism before definitive treatment; additionally, in a significant percentage of patients (mainly in those treated with amiodarone), hyperthyroidism resolved spontaneously.
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Affiliation(s)
- Carlos García Gómez
- Department of Endocrinology and Nutrition, Hospital Universitario Puerta de Hierro Majadahonda, Instituto de Investigación Sanitaria Puerta de Hierro Segovia de Arana (IDIPHISA), 28222 Madrid, Spain; (J.J.D.); (P.I.)
- Department of Medicine, Universidad Autónoma de Madrid, 28046 Madrid, Spain
| | - Elena Navarro
- Department of Endocrinology and Nutrition, Hospital Universitario Virgen del Rocío, 41013 Sevilla, Spain;
| | - Victoria Alcázar
- Department of Endocrinology and Nutrition, Hospital Universitario Severo Ochoa, 28914 Madrid, Spain;
| | - Antonio López-Guzmán
- Department of Endocrinology and Nutrition, Complejo Asistencial de Ávila, 05004 Ávila, Spain;
| | - Francisco Arrieta
- Department of Endocrinology and Nutrition, Hospital Universitario Ramón y Cajal, 28034 Madrid, Spain;
| | - Emma Anda
- Department of Endocrinology and Nutrition, Complejo Hospitalario de Navarra, 31008 Pamplona, Spain;
| | - Betina Biagetti
- Department of Endocrinology and Nutrition, Hospital Universitari Vall d’Hebrón, 08035 Barcelona, Spain;
| | - Fernando Guerrero-Pérez
- Department of Endocrinology and Nutrition, Hospital Universitari de Bellvitge, L’Hospitalet de Llobregat, 08907 Barcelona, Spain; (F.G.-P.); (C.V.)
| | - Carles Villabona
- Department of Endocrinology and Nutrition, Hospital Universitari de Bellvitge, L’Hospitalet de Llobregat, 08907 Barcelona, Spain; (F.G.-P.); (C.V.)
| | - Andrés Ruiz de Assín Valverde
- Department of Endocrinology and Nutrition, Complejo Hospitalario Universitario de Albacete, 02008 Albacete, Spain (C.L.)
| | - Cristina Lamas
- Department of Endocrinology and Nutrition, Complejo Hospitalario Universitario de Albacete, 02008 Albacete, Spain (C.L.)
| | - Beatriz Lecumberri
- Department of Endocrinology and Nutrition, Hospital Universitario La Paz, 28046 Madrid, Spain;
| | | | - Julia Sastre
- Department of Endocrinology and Nutrition, Complejo Hospitalario Universitario de Toledo, 45007 Toledo, Spain;
| | - Juan José Díez
- Department of Endocrinology and Nutrition, Hospital Universitario Puerta de Hierro Majadahonda, Instituto de Investigación Sanitaria Puerta de Hierro Segovia de Arana (IDIPHISA), 28222 Madrid, Spain; (J.J.D.); (P.I.)
- Department of Medicine, Universidad Autónoma de Madrid, 28046 Madrid, Spain
| | - Pedro Iglesias
- Department of Endocrinology and Nutrition, Hospital Universitario Puerta de Hierro Majadahonda, Instituto de Investigación Sanitaria Puerta de Hierro Segovia de Arana (IDIPHISA), 28222 Madrid, Spain; (J.J.D.); (P.I.)
- Department of Medicine, Universidad Autónoma de Madrid, 28046 Madrid, Spain
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7
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Farzameh F, Azadbakht M, Kashi Z, Asgarirad H, Salehifar E, Mirzaee F, Davoodi A, Amirkhanloo S. Evaluation of the therapeutic effect of Descurainia sophia (L.) Webb ex Prantl seed extract on hyperthyroidism: A double-blind placebo-controlled pilot clinical trial. Food Sci Nutr 2023; 11:5918-5927. [PMID: 37823162 PMCID: PMC10563688 DOI: 10.1002/fsn3.3522] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/27/2022] [Revised: 05/21/2023] [Accepted: 06/13/2023] [Indexed: 10/13/2023] Open
Abstract
The seeds of Descurainia sophia (L.) Webb ex Prantl contain goitrogenic glucosinolates, such as gluconapin (3-butenyl glucosinolate). Because of the important role of iodine in the synthesis of thyroid hormones and the inhibitory activity of D. sophia on iodine uptake by the thyroid gland, this study aimed to determine the effects of D. sophia syrup on clinical and biochemical variables of thyrotoxicosis in hyperthyroid patients. In this randomized, double-blind trial, 10 newly diagnosed hyperthyroid female patients were randomly assigned to treatment with (1) methimazole (MMI) plus D. sophia capsules (350 mg/d) or (2) MMI plus placebo capsules. The primary outcomes were clinical and biochemical manifestations of hyperthyroidism after 60 days. Serum levels of FT3 and FT4 significantly decreased (5.9 ± 2.5 vs. 9.4 ± 5.9 and 29.1 ± 3.1 vs. 31.77 ± 3.7, respectively) and the serum thyroid-stimulating hormone (TSH) concentration significantly increased in the D. sophia group contrasted to the placebo group (4.7 ± 0.1 vs. 0.05 ± 0.02). Significant improvement in the thyrotoxicosis clinical symptoms was reported in the D. sophia group contrasted to the placebo group (p < .05). D. sophia can suppress plasma levels of FT3 and FT4 and may be useful as adjunctive therapy for hyperthyroidism.
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Affiliation(s)
- Fatemeh Farzameh
- Department of Pharmacognosy and Biotechnology, Faculty of PharmacyMazandaran University of Medical SciencesSariIran
| | - Mohammad Azadbakht
- Department of Pharmacognosy and Biotechnology, Faculty of PharmacyMazandaran University of Medical SciencesSariIran
| | - Zahra Kashi
- Diabetes Research CenterMazandaran University of Medical SciencesSariIran
| | - Hossein Asgarirad
- Department of Pharmaceutics, Faculty of PharmacyMazandaran University of Medical SciencesSariIran
| | - Ebrahim Salehifar
- Pharmaceutical Sciences Research Center, Hemoglobinopathy InstituteMazandaran University of Medical SciencesSariIran
| | - Fatemeh Mirzaee
- Medicinal Plants Research CenterMazandaran University of Medical SciencesSariIran
| | - Ali Davoodi
- Department of Pharmacognosy and Biotechnology, Faculty of PharmacyMazandaran University of Medical SciencesSariIran
- Medicinal Plants Research CenterMazandaran University of Medical SciencesSariIran
| | - Shervin Amirkhanloo
- Department of Pharmaceutics, Faculty of PharmacyMazandaran University of Medical SciencesSariIran
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Tseng CH, Tseng CL, Chen HS, Chen PL, Huang CJ. Clinical characteristics of neutropenic patients under antithyroid drug: Twelve-year experience in a medical center. J Chin Med Assoc 2023; 86:826-834. [PMID: 37466683 DOI: 10.1097/jcma.0000000000000966] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 07/20/2023] Open
Abstract
BACKGROUND Thionamide-induced agranulocytosis (TiA) is a rare adverse event with a reported incidence of approximately 0.1% to 1.75%. Prompt recognition of TiA is critical to reduce the mortality rate. However, the differential diagnosis between cases of TiA and non-TiA neutropenia can be challenging due to the potential simultaneous involvement of other causes of neutropenia, such as concomitant chemotherapy, liver dysfunction, or infection. The aim of the present study was to investigate the possible factors associated with the development of TiA. METHODS This was a retrospective cohort study of patients treated with antithyroid drugs (ATDs) in Taipei Veterans General Hospital, Taipei, Taiwan, from 2006 to 2018. Patients who developed a neutropenic event during treatment with ATDs were identified from their medical records. The diagnosis of TiA was based on the following: (1) development of neutropenia during treatment or within 7 days after previous exposure to the same ATDs; (2) complete resolution of neutropenia within 1 month after discontinuation of the culprit drug with an absolute neutrophil count (ANC) >1500/μL; and (3) exclusion of other causes of neutropenia. The incidence and risk factors of TiA were analyzed and compared with those of non-TiA neutropenia. RESULTS Among 6644 patients treated with ATDs, 66 (mean age: 53 ± 15 years; 16.2% men) developed a neutropenic event and 20 were diagnosed with TiA (incidence: 0.3%). In the univariate analysis, compared with non-TiA neutropenia, TiA was associated with a lower Charlson Comorbidity Index, shorter treatment duration, lower cumulative ATD dosage, higher ATD dosage, higher ANC, and higher levels of free T4 at the time of the neutropenic event. In the multivariate logistic regression analysis, after adjusting for age, gender and the time to neutropenia, the cumulative ATD dose to neutropenia and ATD dosage at the time of the neutropenic event, Charlson Comorbidity Index, free T4 levels (odds ratio [OR], 4.44; 95% CI, 1.48-13.25), and ANC (OR, 1.00; 95% CI, 1.00-1.01) remained independently associated with TiA. CONCLUSION Patients with TiA were more likely to have higher levels of free T4 and ANC at the time of the neutropenic event vs those with non-TiA neutropenia.
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Affiliation(s)
- Chih-Hsueh Tseng
- Division of Cardiology, Department of Medicine, Taipei Veterans General Hospital, Taipei, Taiwan, ROC
| | - Chi-Lung Tseng
- Faculty of Medicine, School of Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan, ROC
- Division of Gastroenterology, Department of Internal Medicine, Taoyuan General Hospital, Ministry of Health and Welfare, Taoyuan, Taiwan, ROC
| | - Harn-Shen Chen
- Faculty of Medicine, School of Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan, ROC
- Division of Endocrinology and Metabolism, Department of Medicine, Taipei Veterans General Hospital, Taipei, Taiwan, ROC
| | - Pei-Lung Chen
- Department of Medical Genetics, National Taiwan University Hospital, Taipei, Taiwan, ROC
- Graduate Institute of Medical Genomics and Proteomics, National Taiwan University, Taipei, Taiwan, ROC
- Academia Sinica and National Taiwan University, Taipei, Taiwan, ROC
- Division of Endocrinology and Metabolism, Department of Internal Medicine, National Taiwan University Hospital, Taipei, Taiwan, ROC
- Graduate Institute of Clinical Medicine, College of Medicine, National Taiwan University, Taipei, Taiwan, ROC
| | - Chun-Jui Huang
- Faculty of Medicine, School of Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan, ROC
- Division of Endocrinology and Metabolism, Department of Medicine, Taipei Veterans General Hospital, Taipei, Taiwan, ROC
- Institute of Public Health, School of Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan, ROC
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Tizianel I, Sabbadin C, Censi S, Clausi C, Colpo A, Leahu AI, Iacobone M, Mian C, Scaroni C, Ceccato F. Therapeutic Plasma Exchange for the Treatment of Hyperthyroidism: Approach to the Patient with Thyrotoxicosis or Antithyroid-Drugs Induced Agranulocytosis. J Pers Med 2023; 13:jpm13030517. [PMID: 36983698 PMCID: PMC10056870 DOI: 10.3390/jpm13030517] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/10/2023] [Revised: 03/01/2023] [Accepted: 03/09/2023] [Indexed: 03/17/2023] Open
Abstract
Primary hyperthyroidism is an endocrine disorder characterized by excessive thyroid hormone synthesis and secretion by the thyroid gland. Clinical manifestations of hyperthyroidism can vary from subclinical to overt forms. In rare cases, hyperthyroidism may represent a clinical emergency, requiring admission to an intensive care unit due to an acute and severe exacerbation of thyrotoxicosis, known as a thyroid storm. First-line treatment of hyperthyroidism is almost always based on medical therapy (with thioamides, beta-adrenergic blocking agents, glucocorticoids), radioactive iodine or total thyroidectomy, tailored to the patient’s diagnosis. In cases of failure/intolerance/adverse events or contraindication to these therapies, as well as in life-threatening situations, including a thyroid storm, it is necessary to consider an alternative treatment with extracorporeal systems, such as therapeutic plasma exchange (TPE). This approach can promptly resolve severe conditions by removing circulating thyroid hormones. Here we described two different applications of TPE in clinical practice: the first case is an example of thyrotoxicosis due to amiodarone treatment, while the second one is an example of a severe adverse event to antithyroid drugs (agranulocytosis induced by methimazole).
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Affiliation(s)
- Irene Tizianel
- Department of Medicine (DIMED), University of Padova, Via Giustiniani 2, 35128 Padova, Italy
- Endocrinology Unit, Padova University Hospital, Via Ospedale Civile 105, 35128 Padova, Italy
| | - Chiara Sabbadin
- Endocrinology Unit, Padova University Hospital, Via Ospedale Civile 105, 35128 Padova, Italy
| | - Simona Censi
- Department of Medicine (DIMED), University of Padova, Via Giustiniani 2, 35128 Padova, Italy
- Endocrinology Unit, Padova University Hospital, Via Ospedale Civile 105, 35128 Padova, Italy
| | - Cristina Clausi
- Department of Medicine (DIMED), University of Padova, Via Giustiniani 2, 35128 Padova, Italy
- Endocrinology Unit, Padova University Hospital, Via Ospedale Civile 105, 35128 Padova, Italy
| | - Anna Colpo
- Department of Transfusion Medicine, Padua University Hospital, Via Giustiniani 2, 35128 Padova, Italy
| | - Anca Irina Leahu
- Department of Transfusion Medicine, Padua University Hospital, Via Giustiniani 2, 35128 Padova, Italy
| | - Maurizio Iacobone
- Endocrine Surgery Unit, Department of Surgery, Oncology and Gastroenterology (DISCOG), Padua University Hospital, Via Giustiniani 2, 35128 Padova, Italy
| | - Caterina Mian
- Department of Medicine (DIMED), University of Padova, Via Giustiniani 2, 35128 Padova, Italy
- Endocrinology Unit, Padova University Hospital, Via Ospedale Civile 105, 35128 Padova, Italy
| | - Carla Scaroni
- Department of Medicine (DIMED), University of Padova, Via Giustiniani 2, 35128 Padova, Italy
- Endocrinology Unit, Padova University Hospital, Via Ospedale Civile 105, 35128 Padova, Italy
| | - Filippo Ceccato
- Department of Medicine (DIMED), University of Padova, Via Giustiniani 2, 35128 Padova, Italy
- Endocrinology Unit, Padova University Hospital, Via Ospedale Civile 105, 35128 Padova, Italy
- Correspondence: ; Tel.: +39-049-8211323
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Rivkees SA. Approach to the Patient: Management and the Long-term Consequences of Graves' Disease in Children. J Clin Endocrinol Metab 2022; 107:3408-3417. [PMID: 36184734 DOI: 10.1210/clinem/dgac573] [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: 07/21/2022] [Indexed: 02/13/2023]
Abstract
In children, Graves' disease (GD) is the most common cause of hyperthyroidism. Most pediatric patients with GD will not go into lasting remission, even following many years of antidrug therapy. Thus, most pediatric patients will require radioactive iodine (RAI) or surgery. When antithyroid drugs are used, methimazole is the drug of choice. When methimazole is used in children, up to 20% will have minor adverse reactions and serious adverse events occur in up to 1%. RAI is an effective form of therapy when the thyroid size is less than 80 g. Because of concerns of whole-body radiation exposure, it is recommended that RAI be avoided in children under 5 years of age, and dosages less than 10 mCi be used between 5 and 10 years of age. Surgery is an effective treatment in children if performed by a high-volume thyroid surgeon. Because of the scarcity of high-volume pediatric thyroid surgeons, a multidisciplinary approach using pediatric surgeons and endocrine surgeons can be considered. Whereas there is a trend toward long-term antithyroid drug therapy in adults, for several reasons, this approach may not be practical for children. Determining the optimal treatment for the pediatric patient with GD, requires consideration of the risks and benefits relating to age and likelihood of remission.
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Affiliation(s)
- Scott A Rivkees
- School of Public Health, Brown University, Providence, RI 02912, USA
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11
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Abstract
Thyroid hormones are primarily responsible for regulating the basal metabolic rate but also make important contributions to reproductive function and fetal development. Both hyper- and hypothyroidism in pregnancy have been associated with increased risks of complications that include preeclampsia and low birth weight, among others. Furthermore, thyroid hormone deficiency in the developing fetus results in neurodevelopmental delay. As the fetus is exclusively reliant on maternal thyroid hormone for most of the first trimester and requires continued maternal supply until birth, identifying maternal thyroid dysfunction is critically important. However, evaluating thyroid function in pregnancy is challenging because of the many physiological changes that affect concentrations of thyroid-related analytes. Increasing plasma human chorionic gonadotropin (hCG) concentrations in the second half of the first trimester elicit a corresponding transient decrease in thyroid-stimulating hormone (TSH), and continually increasing estradiol concentrations throughout pregnancy cause substantial increases in thyroxine-binding globulin (TBG) and total thyroxine (T4) relative to the nonpregnant state. Lastly, free T4 concentrations gradually decrease with increasing gestational age. For these reasons, it is essential to interpret thyroid function test results in the context of trimester-specific reference intervals to avoid misclassification of thyroid status. This review summarizes the effects of thyroid dysfunction prior to conception and during pregnancy and describes considerations for the laboratory assessment of thyroid function in pregnant women.
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Affiliation(s)
- K Aaron Geno
- Department of Pathology, Texas Tech University Health Sciences Center, El Paso, TX, USA
| | - Robert D Nerenz
- Department of Pathology and Laboratory Medicine, Dartmouth-Hitchcock Medical Center, Lebanon, NH, USA.,Geisel School of Medicine, Dartmouth College, Hanover, NH, USA
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12
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Bartalena L, Piantanida E, Gallo D, Ippolito S, Tanda ML. Management of Graves' hyperthyroidism: present and future. Expert Rev Endocrinol Metab 2022; 17:153-166. [PMID: 35287535 DOI: 10.1080/17446651.2022.2052044] [Citation(s) in RCA: 12] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/16/2022] [Accepted: 03/08/2022] [Indexed: 10/18/2022]
Abstract
INTRODUCTION Graves' disease (GD) is an autoimmune disorder due to loss of tolerance to the thyrotropin receptor (TSHR) and ultimately caused by stimulatory TSHR antibodies (TSHR-Ab). GD may be associated with extrathyroidal manifestations, mainly Graves' orbitopathy. Treatment of GD relies on antithyroid drugs (ATDs), radioactive iodine (RAI), thyroidectomy. The major ATD limitation is the high recurrence rate after treatment. The major drawback of RAI and thyroidectomy is the inevitable development of permanent hypothyroidism. AREAS COVERED Original articles, clinical trials, systematic reviews, meta-analyses from 1980 to 2021 were searched using the following terms: Graves' disease, management of Graves' disease, antithyroid drugs, radioactive iodine, thyroidectomy, Graves' orbitopathy, thyroid-eye disease. EXPERT OPINION ATDs are the first-line treatment worldwide, are overall safe and usually given for 18-24 months, long-term treatment may decrease relapses. RAI is safe, although associated with a low risk of GO progression, particularly in smokers. Thyroidectomy requires skilled and high-volume surgeons. Patients play a central role in the choice of treatment within a shared decision-making process. Results from targeted therapies acting on different steps of the autoimmune process, including iscalimab, ATX-GD-59, rituximab, blocking TSHR-Ab, small molecules acting as antagonists of the TSHR, are preliminary or preclinical, but promising in medium-to-long perspective.
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Affiliation(s)
- Luigi Bartalena
- Department of Medicine and Surgery, University of Insubria, Varese, Italy
| | - Eliana Piantanida
- Department of Medicine and Surgery, University of Insubria, Varese, Italy
| | - Daniela Gallo
- Department of Medicine and Surgery, University of Insubria, Varese, Italy
| | - Silvia Ippolito
- Department of Medicine and Surgery, University of Insubria, Varese, Italy
| | - Maria Laura Tanda
- Department of Medicine and Surgery, University of Insubria, Varese, Italy
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13
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Watanabe N, Yoshimura Noh J, Akamizu T, Yamada M. Survey of the actual administration of thiamazole for hyperthyroidism in Japan by the Japan Thyroid Association. Endocr J 2022; 69:35-43. [PMID: 34321366 DOI: 10.1507/endocrj.ej21-0238] [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] [Indexed: 11/23/2022] Open
Abstract
To clarify the actual administration of thiamazole (MMI), the first choice of antithyroid drugs, the actual therapy provided by the Japan Thyroid Association (JTA) members for the following conditions was surveyed. The subjects included adult patients, pregnant women, and pediatric patients with Graves' disease who visited each medical institution from September 2019 to February 2020. Initial doses, frequency of administration, maintenance doses, maximum doses, consultation intervals for pregnant women, and dosages administrated to breastfeeding mothers were surveyed. The total number of cases collected was 11,663. Administration of 15 mg once a day was the most common initial therapy, constituted 74.4% (2,526/3,397 cases) of adults, 33.8% (44/130) of pregnant women, and 50.8% (61/120) of children. The maintenance dose before discontinuation was equivalent to 2.5 mg/day in 52.3% (3,147/6,015). The most common maximum dose for adults and children was 30 mg/day, administrated to 57.5% of adults (223/388) and 59.6% (28/47) of children; for pregnant women, it was 15 mg/day, administrated to 71.1% (27/38). The most common consultation interval for pregnant women was every four weeks (32.1%, 341/1,063). In lactating mothers, the dose was 10 mg/day or less in 366 of 465 cases (78.7%). Breastfeeding was also allowed 4-6 hours after the administration of 15-20 mg/day in 69 patients (14.8%). Breastfeeding was prohibited in 26 patients (5.6%). In conclusion, initial MMI therapy was started with 15 mg once a day in most patients, and MMI was also administrated to lactating mothers following the Graves' disease treatment guidelines by the JTA.
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Litao MKS, Alvarez AG, Shah B. Pre-treatment Neutropenia in Children and Adolescents with Autoimmune Hyperthyroidism. J Clin Res Pediatr Endocrinol 2021; 13:263-268. [PMID: 33261249 PMCID: PMC8388046 DOI: 10.4274/jcrpe.galenos.2020.2020.0184] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/01/2022] Open
Abstract
OBJECTIVE Neutropenia can occur in untreated autoimmune hyperthyroidism (AIH) or in association with treatment with the anti-thyroid drug, methimazole (MMI). Starting MMI in children and adolescents with AIH and pre-existing neutropenia could thus be worrisome. The aim was to describe the prevalence of neutropenia in pediatric AIH, prior to antithyroid drug therapy and to assess the effect of antithyroid drugs on neutrophil count. METHODS Patients with AIH attending a pediatric endocrinology clinic were retrospectively reviewed. Absolute neutrophil count (ANC) data at presentation and during anti-thyroid treatment for up to 24 weeks was collected. AIH was defined as elevated free thyroxine (fT4) or free tri-iodothyronine (fT3), suppressed thyroid stimulating hormone, and positive thyroid autoantibodies. Neutropenia was defined as ANC <1500 cells/μL. RESULTS Thirty-one patients (71% female) were included with a median interquartile range (IQR) age of 14.71 (11.89-17.10) years. Neither fT4 nor fT3 levels correlated with ANC at presentation (rs=0.22, p=0.24 and rs=0.13, p=0.54, respectively). 26/31 (84%) had normal baseline ANC. None developed neutropenia with thionamides. 5/31 (16%) had baseline neutropenia (median ANC 1,200/μL; IQR 874-1200). Four of these five started MMI at diagnosis while one was started on propranolol only but MMI was started one week later. All five normalized ANC within 24 weeks. CONCLUSION In this cohort, 16% of AIH patients had neutropenia at presentation, but this resolved in the short term and did not worsen with thionamides. Thionamides may be used with caution in these patients with close monitoring of blood counts.
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Affiliation(s)
- Melissa Kaori S. Litao
- New York University Faculty of Medicine, Department of Pediatrics, Division of Pediatric Endocrinology, New York, USA
| | - Ana Gutierrez Alvarez
- New York University Faculty of Medicine, Department of Pediatrics, Division of Pediatric Endocrinology, New York, USA
| | - Bina Shah
- New York University Faculty of Medicine, Department of Pediatrics, Division of Pediatric Endocrinology, New York, USA,* Address for Correspondence: New York University Faculty of Medicine, Department of Pediatrics, Division of Pediatric Endocrinology, New York, USA E-mail:
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15
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Lee HG, Yang EM, Kim CJ. Efficacy and adverse events related to the initial dose of methimazole in children and adolescents with Graves' disease. Ann Pediatr Endocrinol Metab 2021; 26:199-204. [PMID: 34610704 PMCID: PMC8505040 DOI: 10.6065/apem.2142046.023] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/26/2021] [Accepted: 05/12/2021] [Indexed: 11/24/2022] Open
Abstract
PURPOSE The first-line antithyroid drug for children and adolescents with Graves' disease (GD) is methimazole (MMI). This study evaluated the relationship between the initial MMI dose and the clinical course of GD after treatment. METHODS We studied the efficacy of the initial MMI dose and the relationship between the initial MMI dose and adverse events (AEs). We retrospectively enrolled 22 males and 77 females and divided those subjects into 3 groups according to the initial dose of MMI: <0.4 mg/kg/day (group A; n=32); 0.4-0.7 mg/kg/day (group B; n=39); and >0.7 mg/kg/day (group C; n=28). RESULTS The mean time to the normalization of free thyroxine (fT4) levels upon initial treatment was 5.64, 8.61, and 7.98 weeks in groups A, B, and C, respectively (P=0.116). The incidence of liver dysfunction, neutropenia, and skin rash was 12.5%, 20.5%, and 42.9% in groups A, B, and C, respectively (P=0.018). Neutropenia, as a severe AE, was absent in group A, but its prevalence was 7.7% in group B and 21.4% in group C (P=0.015). When comparing only groups B and C, the incidences of liver dysfunction and neutropenia were higher in group C (P=0.04 and P=0.021, respectively). CONCLUSION The mean time to the normalization of fT4 levels did not differ among the 3 groups, but the incidence of AEs was higher in the groups that received high MMI doses. High doses of MMI (>0.7 mg/kg/day) should be reconsidered as an initial treatment for children and adolescents with GD.
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Affiliation(s)
- Hyun Gyung Lee
- Department of Pediatrics, Chonnam National University Medical School & Children’s Hospital, Gwangju, Korea
| | - Eun Mi Yang
- Department of Pediatrics, Chonnam National University Medical School & Children’s Hospital, Gwangju, Korea
| | - Chan Jong Kim
- Department of Pediatrics, Chonnam National University Medical School & Children’s Hospital, Gwangju, Korea,Address for correspondence: Chan Jong Kim Department of Pediatrics, Chonnam National University Medical School & Children’s Hospital, 42 Jebong-ro, Dong-gu, Gwangju 61469, Korea
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16
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Liu K, Fu Y, Li T, Liu S, Chen D, Zhao C, Shi Y, Cai Y, Yang T, Zheng X. Clinical efficacy of thyroid-stimulating immunoglobulin detection for diagnosing Graves' disease and predictors of responsiveness to methimazole. Clin Biochem 2021; 97:34-40. [PMID: 34331946 DOI: 10.1016/j.clinbiochem.2021.07.014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/22/2021] [Revised: 06/26/2021] [Accepted: 07/26/2021] [Indexed: 10/20/2022]
Abstract
BACKGROUND As thyroid-stimulating immunoglobulins (TSI) are a sign of Graves' disease (GD), measuring TSI titers is becoming increasingly important for GD diagnosis. This study evaluated the diagnostic accuracy of a new fully automated TSI immunoassay (Immulite™ TSI assay) in GD patients and compared it to the third generation thyroid-stimulating hormone receptor antibody (TRAb) electrochemiluminescence assay (Elecsys Anti-TSHR assay). Additionally, clinical characteristics associated with responsiveness to methimazole in patients with newly diagnosed GD were preliminarily explored. METHODS This study involved 324 subjects, comprising patients with untreated GD (GD-UT), Graves' ophthalmopathy (GO) patients, GD patients who had been treated for > 12 months (GD-T), autoimmune thyroiditis (AIT) patients, and healthy subjects (HS). The Immulite™ TSI and Elecsys Anti-TSHR assay were performed on all samples. According to their responsiveness to methimazole, the GD-UT patients were divided into rapid and slow responder groups, and their clinical characteristics were compared. RESULTS A receiver operating characteristic (ROC) curve analysis of GD-UT patients showed that the optimal TSI cut-off value was 0.57 IU/L. Logistic regression revealed that age and initial FT4 and TSI levels in the middle-dose methimazole group were related to a rapid response, while the initial FT4 level, but not TSI, in the high-dose group was also associated with a rapid response. CONCLUSIONS The clinical diagnostic performance of the Immulite™ TSI assay for diagnosing GD was comparable to that of the Elecsys Anti-TSHR assay. The initial FT4 and TSI levels can be used as predictors of the responsiveness to methimazole in patients with newly diagnosed GD.
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Affiliation(s)
- KunY Liu
- Department of Endocrinology and Metabolism, the First Affiliated Hospital of Nanjing Medical University, Nanjing 210029, China
| | - Yu Fu
- Department of Nuclear Medicine, the First Affiliated Hospital of Nanjing Medical University, Nanjing 210029, China
| | - TianT Li
- Department of Endocrinology and Metabolism, the First Affiliated Hospital of Nanjing Medical University, Nanjing 210029, China; Department of Critical Care Medicine, Nanjing Hospital Affiliated to Nanjing University of Chinese Medicine, Nanjing 210003, China
| | - SunQ Liu
- Department of Endocrinology and Metabolism, the First Affiliated Hospital of Nanjing Medical University, Nanjing 210029, China
| | - DouD Chen
- Department of Endocrinology and Metabolism, the First Affiliated Hospital of Nanjing Medical University, Nanjing 210029, China
| | - ChengC Zhao
- Department of Endocrinology and Metabolism, the First Affiliated Hospital of Nanjing Medical University, Nanjing 210029, China
| | - Yun Shi
- Department of Endocrinology and Metabolism, the First Affiliated Hospital of Nanjing Medical University, Nanjing 210029, China
| | - Yun Cai
- Department of Endocrinology and Metabolism, the First Affiliated Hospital of Nanjing Medical University, Nanjing 210029, China
| | - Tao Yang
- Department of Endocrinology and Metabolism, the First Affiliated Hospital of Nanjing Medical University, Nanjing 210029, China
| | - XuQ Zheng
- Department of Endocrinology and Metabolism, the First Affiliated Hospital of Nanjing Medical University, Nanjing 210029, China.
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Mori Y, Hiromura M, Terasaki M, Kushima H, Ohara M, Fukui T, Takahashi Y, Yamagishi SI. Very rare case of Graves' disease with resistance to methimazole: a case report and literature review. J Int Med Res 2021; 49:300060521996192. [PMID: 33682498 PMCID: PMC7944538 DOI: 10.1177/0300060521996192] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/08/2020] [Accepted: 01/27/2021] [Indexed: 12/27/2022] Open
Abstract
BACKGROUND Methimazole (MMI) is used to treat hyperthyroidism in Graves' disease. It is rare to encounter patients in whom hyperthyroidism cannot be controlled using high doses of MMI.Case presentation: A 21-year-old woman was referred to our hospital because of MMI-resistant Graves' disease. Although her MMI dose had been increased to 120 mg/day, her serum thyroid hormone concentration was too high to be measured. Additional therapy with lithium carbonate, and then with dexamethasone and inorganic iodine, was initiated. After 14 days, the patient's serum thyroid hormone concentration normalized, while she was taking 150 mg/day MMI, 800 mg/day lithium carbonate, 6 mg/day dexamethasone and 306 mg/day inorganic iodine, and total thyroidectomy was then performed. The patient was discharged 8 days after the thyroidectomy and experienced no major complications. CONCLUSIONS We have presented a rare case of Graves' disease that was resistant to high-dose MMI. Combination therapy of MMI with lithium carbonate, dexamethasone and inorganic iodine may represent a therapeutic option for the preoperative preparation of patients with MMI-resistant Graves' disease.
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Affiliation(s)
- Yusaku Mori
- Anti-glycation Research Section, Division of Diabetes, Metabolism and Endocrinology, Department of Internal Medicine, Showa University School of Medicine, Tokyo, Japan
| | - Munenori Hiromura
- Division of Diabetes, Metabolism and Endocrinology, Department of Internal Medicine, Showa University School of Medicine, Tokyo, Japan
| | - Michishige Terasaki
- Division of Diabetes, Metabolism and Endocrinology, Department of Internal Medicine, Showa University School of Medicine, Tokyo, Japan
| | - Hideki Kushima
- Division of Diabetes, Metabolism and Endocrinology, Department of Internal Medicine, Showa University School of Medicine, Tokyo, Japan
| | - Makoto Ohara
- Division of Diabetes, Metabolism and Endocrinology, Department of Internal Medicine, Showa University School of Medicine, Tokyo, Japan
| | - Tomoyasu Fukui
- Division of Diabetes, Metabolism and Endocrinology, Department of Internal Medicine, Showa University School of Medicine, Tokyo, Japan
| | - Yasuyoshi Takahashi
- Division of Diabetes, Metabolism and Endocrinology, Department of Internal Medicine, Showa University School of Medicine, Tokyo, Japan
| | - Sho-ichi Yamagishi
- Division of Diabetes, Metabolism and Endocrinology, Department of Internal Medicine, Showa University School of Medicine, Tokyo, Japan
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Kahaly GJ. Management of Graves Thyroidal and Extrathyroidal Disease: An Update. J Clin Endocrinol Metab 2020; 105:5905591. [PMID: 32929476 PMCID: PMC7543578 DOI: 10.1210/clinem/dgaa646] [Citation(s) in RCA: 79] [Impact Index Per Article: 19.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/10/2020] [Accepted: 09/11/2020] [Indexed: 12/14/2022]
Abstract
CONTEXT Invited update on the management of systemic autoimmune Graves disease (GD) and associated Graves orbitopathy (GO). EVIDENCE ACQUISITION Guidelines, pertinent original articles, systemic reviews, and meta-analyses. EVIDENCE SYNTHESIS Thyrotropin receptor antibodies (TSH-R-Abs), foremost the stimulatory TSH-R-Abs, are a specific biomarker for GD. Their measurement assists in the differential diagnosis of hyperthyroidism and offers accurate and rapid diagnosis of GD. Thyroid ultrasound is a sensitive imaging tool for GD. Worldwide, thionamides are the favored treatment (12-18 months) of newly diagnosed GD, with methimazole (MMI) as the preferred drug. Patients with persistently high TSH-R-Abs and/or persistent hyperthyroidism at 18 months, or with a relapse after completing a course of MMI, can opt for a definitive therapy with radioactive iodine (RAI) or total thyroidectomy (TX). Continued long-term, low-dose MMI administration is a valuable and safe alternative. Patient choice, both at initial presentation of GD and at recurrence, should be emphasized. Propylthiouracil is preferred to MMI during the first trimester of pregnancy. TX is best performed by a high-volume thyroid surgeon. RAI should be avoided in GD patients with active GO, especially in smokers. Recently, a promising therapy with an anti-insulin-like growth factor-1 monoclonal antibody for patients with active/severe GO was approved by the Food and Drug Administration. COVID-19 infection is a risk factor for poorly controlled hyperthyroidism, which contributes to the infection-related mortality risk. If GO is not severe, systemic steroid treatment should be postponed during COVID-19 while local treatment and preventive measures are offered. CONCLUSIONS A clear trend towards serological diagnosis and medical treatment of GD has emerged.
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Affiliation(s)
- George J Kahaly
- Department of Medicine I, Johannes Gutenberg University (JGU) Medical Center, Mainz, Germany
- Correspondence and Reprint Requests: George J. Kahaly, MD, PhD, JGU Medical Center, Mainz 55101, Germany. E-mail:
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Okamura K, Bandai S, Fujikawa M, Sato K, Kitazono T. Clinical experience of treating Graves' hyperthyroidism complicated with malignancy-The possible role of potassium iodide for avoiding the risk of thionamide-associated neutropenia. Endocr J 2020; 67:751-758. [PMID: 32238669 DOI: 10.1507/endocrj.ej20-0016] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
The treatment of Graves' hyperthyroidism (GD) complicated with malignancy is challenging, as anti-thyroid thionamide drugs (ATDs) and anti-cancer chemotherapy are both associated with a risk of neutropenia. Treatment with conventional ATDs, radioactive iodine (RAI) or potassium iodide (KI) was attempted in 8 patients with malignancy (34-80 years of age; 2 males and 6 females) in whom GD had been fortuitously diagnosed during a detailed systematic examination. Three patients requiring surgery were initially treated conventionally with methylmercaptoimidazole (MMI), MMI and KI or RAI (group A; one patient each). The patients became euthyroid on days 17-31 and underwent surgery on days 25-47. RAI therapy was administered to one patient after surgery. The patients were then treated with KI during chemotherapy. Five other patients who did not require surgery were initially treated with 100 mg KI monotherapy (group B). The serum free T4 level declined immediately in all of these patients, and they became euthyroid on days 7-18, remaining almost entirely euthyroid for more than 120 days. Anti-cancer chemotherapy was successfully completed for three of the patients while taking KI, despite the patients experiencing repeated episodes of anti-cancer chemotherapy-induced neutropenia. Our present findings suggest that, in patients with GD and malignancy, MMI + KI or RAI may be required if immediate surgery is scheduled, but KI monotherapy may be worth trying, if anti-cancer chemotherapy is scheduled, thus avoiding the possibility of thionamide-induced neutropenia.
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Affiliation(s)
- Ken Okamura
- Department of Medicine and Clinical Science, Graduate School of Medical Sciences, Kyushu University, Fukuoka 812-8582, Japan
| | - Sachiko Bandai
- Department of Medicine and Clinical Science, Graduate School of Medical Sciences, Kyushu University, Fukuoka 812-8582, Japan
| | - Megumi Fujikawa
- Department of Medicine and Clinical Science, Graduate School of Medical Sciences, Kyushu University, Fukuoka 812-8582, Japan
| | - Kaori Sato
- Department of Medicine and Clinical Science, Graduate School of Medical Sciences, Kyushu University, Fukuoka 812-8582, Japan
| | - Takanari Kitazono
- Department of Medicine and Clinical Science, Graduate School of Medical Sciences, Kyushu University, Fukuoka 812-8582, Japan
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Francis T, Francis N, Lazarus JH, Okosieme OE. Safety of antithyroid drugs in pregnancy: update and therapy implications. Expert Opin Drug Saf 2020; 19:565-576. [PMID: 32223355 DOI: 10.1080/14740338.2020.1748007] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Abstract
Introduction: The thionamide antithyroid drugs, methimazole (MMI), its pro-drug derivative carbimazole (CMZ), and propylthiouracil (PTU) are the mainstay of treatment for hyperthyroidism in pregnancy. However, antithyroid drugs carry risks of adverse effects that can affect fetal and maternal well-being.Areas covered: This review provides an update on the safety of antithyroid drugs in pregnancy, focusing on the most serious concerns of severe liver disease and congenital anomalies.Expert opinion: PTU-induced liver disease is uncommon but can run a catastrophic course in pregnancy with a risk of liver failure and threats to maternal or fetal survival. Acute pancreatitis is a relatively rare occurrence that has been linked to thionamide use in a handful of reports in non-pregnant individuals. Observational studies on the risk of birth defects with antithyroid drug exposure in pregnancy overall show an increase in birth defect risk with exposure to CMZ/MMI, and to a lesser extent, PTU. Further studies are required to determine whether the currently recommended approach of switching between thionamide drugs in pregnancy improves outcomes. Ultimately, a preventative strategy of offering definitive therapy to hyperthyroid women of childbearing potential offers the best approach to truly reduce the risks of antithyroid drug adverse effects in pregnancy.
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Affiliation(s)
- Thanuya Francis
- Endocrinology and Diabetes Department, Prince Charles Hospital, Cwm Taf University Health Board, Merthyr Tydfil, UK
| | - Niroshan Francis
- Endocrinology and Diabetes Department, Prince Charles Hospital, Cwm Taf University Health Board, Merthyr Tydfil, UK
| | - John H Lazarus
- Thyroid Research Group, School of Medicine, Cardiff University, Cardiff, UK
| | - Onyebuchi E Okosieme
- Endocrinology and Diabetes Department, Prince Charles Hospital, Cwm Taf University Health Board, Merthyr Tydfil, UK.,Thyroid Research Group, School of Medicine, Cardiff University, Cardiff, UK
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Lane LC, Cheetham T. Graves' disease: developments in first-line antithyroid drugs in the young. Expert Rev Endocrinol Metab 2020; 15:59-69. [PMID: 32133893 DOI: 10.1080/17446651.2020.1735359] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/09/2019] [Accepted: 02/24/2020] [Indexed: 10/24/2022]
Abstract
Introduction: First-line treatment for most young people with Graves' disease (GD) will include the administration of a thionamide antithyroid medication (ATD); Carbimazole (CBZ), Methimazole (MMZ), or rarely, propylthiouracil (PTU). GD is a challenge for families and clinicians because the likelihood of remission following a course of ATD is lower in young people when compared to adults, yet the risk of adverse events is higher. An overall consensus regarding the optimal ATD treatment regimen is lacking; how ATD are prescribed, for how long and how the associated risk of adverse events is managed varies between clinicians, units and nations. This partly reflects clinician and family uncertainty regarding outcomes.Areas covered: This review will focus on some of the key articles published in the field of thionamide ATD in children. It will highlight key issues that need to be discussed with families as well as addressing the approach and controversies in the treatment of GD. This article does not reflect a formal systematic review of the literature.Expert opinion: New strategies in areas such as immunomodulation may see the development of new antithyroid drug treatments that, either in isolation or in combination with thionamide therapy, may increase the likelihood of long-term remission.
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Affiliation(s)
- Laura C Lane
- Translational and Clinical Research Institute, Newcastle University, Newcastle-Upon-Tyne, UK
- Department of Paediatric Endocrinology, The Great North Children's Hospital, Newcastle-Upon-Tyne, UK
| | - Tim Cheetham
- Translational and Clinical Research Institute, Newcastle University, Newcastle-Upon-Tyne, UK
- Department of Paediatric Endocrinology, The Great North Children's Hospital, Newcastle-Upon-Tyne, UK
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22
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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: 9] [Impact Index Per Article: 2.3] [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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24
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Arts P, Simons A, AlZahrani MS, Yilmaz E, AlIdrissi E, van Aerde KJ, Alenezi N, AlGhamdi HA, AlJubab HA, Al-Hussaini AA, AlManjomi F, Alsaad AB, Alsaleem B, Andijani AA, Asery A, Ballourah W, Bleeker-Rovers CP, van Deuren M, van der Flier M, Gerkes EH, Gilissen C, Habazi MK, Hehir-Kwa JY, Henriet SS, Hoppenreijs EP, Hortillosa S, Kerkhofs CH, Keski-Filppula R, Lelieveld SH, Lone K, MacKenzie MA, Mensenkamp AR, Moilanen J, Nelen M, Ten Oever J, Potjewijd J, van Paassen P, Schuurs-Hoeijmakers JHM, Simon A, Stokowy T, van de Vorst M, Vreeburg M, Wagner A, van Well GTJ, Zafeiropoulou D, Zonneveld-Huijssoon E, Veltman JA, van Zelst-Stams WAG, Faqeih EA, van de Veerdonk FL, Netea MG, Hoischen A. Exome sequencing in routine diagnostics: a generic test for 254 patients with primary immunodeficiencies. Genome Med 2019; 11:38. [PMID: 31203817 PMCID: PMC6572765 DOI: 10.1186/s13073-019-0649-3] [Citation(s) in RCA: 44] [Impact Index Per Article: 8.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/10/2019] [Accepted: 05/17/2019] [Indexed: 12/18/2022] Open
Abstract
BACKGROUND Diagnosis of primary immunodeficiencies (PIDs) is complex and cumbersome yet important for the clinical management of the disease. Exome sequencing may provide a genetic diagnosis in a significant number of patients in a single genetic test. METHODS In May 2013, we implemented exome sequencing in routine diagnostics for patients suffering from PIDs. This study reports the clinical utility and diagnostic yield for a heterogeneous group of 254 consecutively referred PID patients from 249 families. For the majority of patients, the clinical diagnosis was based on clinical criteria including rare and/or unusual severe bacterial, viral, or fungal infections, sometimes accompanied by autoimmune manifestations. Functional immune defects were interpreted in the context of aberrant immune cell populations, aberrant antibody levels, or combinations of these factors. RESULTS For 62 patients (24%), exome sequencing identified pathogenic variants in well-established PID genes. An exome-wide analysis diagnosed 10 additional patients (4%), providing diagnoses for 72 patients (28%) from 68 families altogether. The genetic diagnosis directly indicated novel treatment options for 25 patients that received a diagnosis (34%). CONCLUSION Exome sequencing as a first-tier test for PIDs granted a diagnosis for 28% of patients. Importantly, molecularly defined diagnoses indicated altered therapeutic options in 34% of cases. In addition, exome sequencing harbors advantages over gene panels as a truly generic test for all genetic diseases, including in silico extension of existing gene lists and re-analysis of existing data.
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Affiliation(s)
- Peer Arts
- Department of Human Genetics, Radboud University Medical Center, Nijmegen, The Netherlands
- Department of Genetics and Molecular Pathology, Centre for Cancer Biology, SA Pathology and the University of South Australia, Adelaide, South Australia, Australia
| | - Annet Simons
- Department of Human Genetics, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Mofareh S AlZahrani
- Department of Pediatrics, Children's specialist Hospital, King Fahad Medical City, Riyadh, Saudi Arabia
| | - Elanur Yilmaz
- Department of Human Genetics, Radboud University Medical Center, Nijmegen, The Netherlands
- Department of Medical Biology, Faculty of Medicine, Akdeniz University, Antalya, Turkey
| | - Eman AlIdrissi
- Department of Pediatrics, Children's specialist Hospital, King Fahad Medical City, Riyadh, Saudi Arabia
| | - Koen J van Aerde
- Department of Pediatric immunology, Pediatrics, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Njood Alenezi
- Department of Pediatrics, Children's specialist Hospital, King Fahad Medical City, Riyadh, Saudi Arabia
| | - Hamza A AlGhamdi
- Department of Pediatrics, Children's specialist Hospital, King Fahad Medical City, Riyadh, Saudi Arabia
| | - Hadeel A AlJubab
- Department of Pediatrics, Children's specialist Hospital, King Fahad Medical City, Riyadh, Saudi Arabia
| | - Abdulrahman A Al-Hussaini
- Department of Pediatrics, Children's specialist Hospital, King Fahad Medical City, Riyadh, Saudi Arabia
| | - Fahad AlManjomi
- Department of Pediatric Hematology and Oncology, Comprehensive Cancer center, King Fahad Medical City, Riyadh, Saudi Arabia
| | - Alaa B Alsaad
- Department of Pediatrics, Children's specialist Hospital, King Fahad Medical City, Riyadh, Saudi Arabia
| | - Badr Alsaleem
- Department of Pediatrics, Children's specialist Hospital, King Fahad Medical City, Riyadh, Saudi Arabia
| | - Abdulrahman A Andijani
- Department of Pediatrics, Children's specialist Hospital, King Fahad Medical City, Riyadh, Saudi Arabia
| | - Ali Asery
- Department of Pediatrics, Children's specialist Hospital, King Fahad Medical City, Riyadh, Saudi Arabia
| | - Walid Ballourah
- Department of Pediatric Hematology and Oncology, Comprehensive Cancer center, King Fahad Medical City, Riyadh, Saudi Arabia
| | - Chantal P Bleeker-Rovers
- Radboud Expertise Center for Immunodeficiency and Autoinflammation, Department of Internal Medicine, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Marcel van Deuren
- Radboud Expertise Center for Immunodeficiency and Autoinflammation, Department of Internal Medicine, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Michiel van der Flier
- Department of Pediatric immunology, Pediatrics, Radboud University Medical Center, Nijmegen, The Netherlands
- Department of Pediatric Infectious Diseases and Immunology, Wilhelmina Children's Hospital, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Erica H Gerkes
- Department of Genetics, University of Groningen, University Medical Center Groningen, Groningen, the Netherlands
| | - Christian Gilissen
- Department of Human Genetics, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Murad K Habazi
- Department of Pediatrics, Children's specialist Hospital, King Fahad Medical City, Riyadh, Saudi Arabia
| | - Jayne Y Hehir-Kwa
- Department of Human Genetics, Radboud University Medical Center, Nijmegen, The Netherlands
- Princess Máxima Center for Pediatric Oncology, Utrecht, the Netherlands
| | - Stefanie S Henriet
- Department of Pediatric immunology, Pediatrics, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Esther P Hoppenreijs
- Department of Pediatric Rheumatology, Pediatrics, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Sarah Hortillosa
- Department of Pediatrics, Children's specialist Hospital, King Fahad Medical City, Riyadh, Saudi Arabia
| | - Chantal H Kerkhofs
- Department of Clinical Genetics, Maastricht University Medical Center+, Maastricht, The Netherlands
| | - Riikka Keski-Filppula
- PEDEGO Research Unit and Medical Research Center Oulu, University of Oulu, Oulu, Finland
- Department of Clinical Genetics, Oulu University Hospital, Oulu, Finland
| | - Stefan H Lelieveld
- Department of Human Genetics, Radboud University Medical Center, Nijmegen, The Netherlands
- Princess Máxima Center for Pediatric Oncology, Utrecht, the Netherlands
| | - Khurram Lone
- Department of Pediatrics, Children's specialist Hospital, King Fahad Medical City, Riyadh, Saudi Arabia
| | - Marius A MacKenzie
- Department of Hematology, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Arjen R Mensenkamp
- Department of Human Genetics, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Jukka Moilanen
- PEDEGO Research Unit and Medical Research Center Oulu, University of Oulu, Oulu, Finland
- Department of Clinical Genetics, Oulu University Hospital, Oulu, Finland
| | - Marcel Nelen
- Department of Human Genetics, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Jaap Ten Oever
- Radboud Expertise Center for Immunodeficiency and Autoinflammation, Department of Internal Medicine, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Judith Potjewijd
- Department of Clinical Immunology, Maastricht University Medical Center, Maastricht, The Netherlands
| | - Pieter van Paassen
- Department of Clinical Immunology, Maastricht University Medical Center, Maastricht, The Netherlands
| | | | - Anna Simon
- Radboud Expertise Center for Immunodeficiency and Autoinflammation, Department of Internal Medicine, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Tomasz Stokowy
- Department of Clinical Science, Department of Informatics, Computational Biology Unit, University of Bergen, 5020, Bergen, Norway
| | - Maartje van de Vorst
- Department of Human Genetics, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Maaike Vreeburg
- Department of Clinical Genetics, Maastricht University Medical Center+, Maastricht, The Netherlands
| | - Anja Wagner
- Department of Clinical Genetics, Erasmus MC, University Medical Center, Rotterdam, The Netherlands
| | - Gijs T J van Well
- Department of Pediatrics, School for Nutrition and Translational Research in Metabolism (NUTRIM), Maastricht University Medical Center+, Maastricht University, Maastricht, The Netherlands
| | - Dimitra Zafeiropoulou
- Department of Human Genetics, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Evelien Zonneveld-Huijssoon
- Department of Genetics, University of Groningen, University Medical Center Groningen, Groningen, the Netherlands
| | - Joris A Veltman
- Department of Human Genetics, Radboud University Medical Center, Nijmegen, The Netherlands
- Institute of Genetic Medicine, Newcastle University, Newcastle-upon-Tyne, UK
| | | | - Eissa A Faqeih
- Department of Pediatrics, Children's specialist Hospital, King Fahad Medical City, Riyadh, Saudi Arabia
| | - Frank L van de Veerdonk
- Radboud Expertise Center for Immunodeficiency and Autoinflammation, Department of Internal Medicine, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Mihai G Netea
- Radboud Expertise Center for Immunodeficiency and Autoinflammation, Department of Internal Medicine, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Alexander Hoischen
- Department of Human Genetics, Radboud University Medical Center, Nijmegen, The Netherlands.
- Radboud Expertise Center for Immunodeficiency and Autoinflammation, Department of Internal Medicine, Radboud University Medical Center, Nijmegen, The Netherlands.
- Department of Human Genetics and Department of Internal Medicine, Radboud University Medical Center, P.O. Box 9101, 6500, HB, Nijmegen, The Netherlands.
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Gershinsky M, Saliba W, Lavi I, Shapira C, Gronich N. Increased Risk of Antithyroid Drug Agranulocytosis Associated with Amiodarone-Induced Thyrotoxicosis: A Population-Based Cohort Study. Thyroid 2019; 29:193-201. [PMID: 30648930 DOI: 10.1089/thy.2018.0274] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Abstract
BACKGROUND Agranulocytosis occurs in 0.2-0.5% of patients treated with the antithyroid drugs (ATDs) methimazole and propylthiouracil. The objectives of this study were to evaluate the risk of ATD-related agranulocytosis in patients with amiodarone-induced thyrotoxicosis (AIT), and to compare it with the agranulocytosis risk in patients with thyrotoxicosis due to other etiologies treated with ATDs. METHODS This was a retrospective cohort study. Participants were 14,781 adult patients with thyrotoxicosis, newly treated with an ATD between January 1, 2002, and December 31, 2015. Among them were 593 patients treated by ATDs due to AIT. The main outcome measures were incidence rates and crude and adjusted hazard ratios using univariate and multivariable Cox regression models for ATD-related agranulocytosis within one year of treatment initiation, in association with AIT. RESULTS Agranulocytosis occurred in 28 (0.19%) of patients newly treated with methimazole or propylthiouracil during the first year of follow-up. Of these 28 patients, 8/593 (1.35%) were AIT patients and 20/14,188 (0.14%) were thyrotoxic patients that was not AIT related (p < 0.001). Incidence rates were 22 (9.47-43.36) cases/1000 person-years of follow-up in AIT, and 1.79 (1.09-2.76)/1000 person-years of follow-up in non-AIT thyrotoxicosis (p < 0.0001). In univariate Cox regression analysis, risk for ATD agranulocytosis associated with AIT was 9.71 (4.28-22.05) compared to the risk in non-AIT thyrotoxicosis. In a multivariable model, adjusting for age, sex, body mass index, smoking history, year of cohort entry, diabetes mellitus, hypertension, renal failure, beta blockers, calcium channel blockers, anti-aggregants, and dose of ATDs, the risk associated with AIT was 5.70 (2.14-15.21). In a model adjusted for a propensity score to receive amiodarone, risk for ATD agranulocytosis associated with AIT was 6.32 (1.22-32.70). CONCLUSIONS ATD use is associated with a higher risk for agranulocytosis in patients with AIT.
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Affiliation(s)
- Michal Gershinsky
- 1 Departments of Endocrinology and Diabetes, Lady Davis Carmel Medical Center and Linn Medical Center, Haifa, Israel
- 2 Ruth and Bruce Rappaport Faculty of Medicine, Technion-Israel Institute of Technology, Haifa, Israel
| | - Walid Saliba
- 2 Ruth and Bruce Rappaport Faculty of Medicine, Technion-Israel Institute of Technology, Haifa, Israel
- 3 Department of Community Medicine and Epidemiology, Clalit Health Services, Haifa, Israel
| | - Idit Lavi
- 3 Department of Community Medicine and Epidemiology, Clalit Health Services, Haifa, Israel
| | - Chen Shapira
- 2 Ruth and Bruce Rappaport Faculty of Medicine, Technion-Israel Institute of Technology, Haifa, Israel
| | - Naomi Gronich
- 3 Department of Community Medicine and Epidemiology, Clalit Health Services, Haifa, Israel
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Delitala AP, Capobianco G, Cherchi PL, Dessole S, Delitala G. Thyroid function and thyroid disorders during pregnancy: a review and care pathway. Arch Gynecol Obstet 2018; 299:327-338. [PMID: 30569344 DOI: 10.1007/s00404-018-5018-8] [Citation(s) in RCA: 27] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/19/2018] [Accepted: 12/12/2018] [Indexed: 12/28/2022]
Abstract
PURPOSE To review the literature on thyroid function and thyroid disorders during pregnancy. METHODS A detailed literature research on MEDLINE, Cochrane library, EMBASE, NLH, ClinicalTrials.gov, and Google Scholar databases was done up to January 2018 with restriction to English language about articles regarding thyroid diseases and pregnancy. RESULTS Thyroid hormone deficiencies are known to be detrimental for the development of the fetus. In particular, the function of the central nervous system might be impaired, causing low intelligence quotient, and mental retardation. Overt and subclinical dysfunctions of the thyroid disease should be treated appropriately in pregnancy, aiming to maintain euthyroidism. Thyroxine (T4) replacement therapy should reduce thyrotropin (TSH) concentration to the recently suggested fixed upper limits of 2.5 mU/l (first and second trimester) and 3.0 mU/l (third trimester). Overt hyperthyroidism during pregnancy is relatively uncommon but needs prompt treatment due to the increased risk of preterm delivery, congenital malformations, and fetal death. The use of antithyroid drug (methimazole, propylthiouracil, carbimazole) is the first choice for treating overt hyperthyroidism, although they are not free of side effects. Subclinical hyperthyroidism tends to be asymptomatic and no pharmacological treatment is usually needed. Gestational transient hyperthyroidism is a self-limited non-autoimmune form of hyperthyroidism with negative antibody against TSH receptors, that is related to hCG-induced thyroid hormone secretion. The vast majority of these patients does not require antithyroid therapy, although administration of low doses of β-blocker may by useful in very symptomatic patients. CONCLUSIONS Normal maternal thyroid function is essential in pregnancy to avoid adverse maternal and fetal outcomes.
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Affiliation(s)
- Alessandro P Delitala
- Azienda Ospedaliero-Universitaria Di Sassari, Clinica Medica, Viale San Pietro 8, 07100, Sassari, Italy.
| | - Giampiero Capobianco
- Department of Medical, Surgical and Experimental Sciences, University of Sassari, 07100, Sassari, Italy
| | - Pier Luigi Cherchi
- Department of Medical, Surgical and Experimental Sciences, University of Sassari, 07100, Sassari, Italy
| | - Salvatore Dessole
- Department of Medical, Surgical and Experimental Sciences, University of Sassari, 07100, Sassari, Italy
| | - Giuseppe Delitala
- Department of Medical, Surgical and Experimental Sciences, University of Sassari, 07100, Sassari, Italy
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27
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Abstract
The thionamide antithyroid drugs were discovered in large part following serendipitous observations by a number of investigators in the 1940s who found that sulfhydryl-containing compounds were goitrogenic in animals. This prompted Prof. Edwin B Astwood to pioneer the use of these compounds to treat hyperthyroidism in the early 1940s and to develop the more potent and less toxic drugs that are used today. Despite their simple molecular structure and ease of use, many uncertainties remain, including their mechanism(s) of action, clinical role, optimal use in pregnancy and the prediction and prevention of rare but potentially life-threatening adverse reactions. In this review, we summarize the history of the development of these drugs and outline their current role in the clinical management of patients with hyperthyroidism.
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Affiliation(s)
- Henry B Burch
- National Institute of Diabetes and Digestive and Kidney Diseases, National Institutes of Health, Bethesda, Maryland, USA
| | - David S Cooper
- Division of Endocrinology, Diabetes, and Metabolism, The Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
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Kauff DW, Staubitz JI, Musholt TJ, Lang H. Synchronous Antithyroid Drug-Induced Agranulocytosis and Fournier Gangrene. AACE Clin Case Rep 2018. [DOI: 10.4158/ep171801.cr] [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] Open
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Korevaar TIM, Medici M, Visser TJ, Peeters RP. Thyroid disease in pregnancy: new insights in diagnosis and clinical management. Nat Rev Endocrinol 2017; 13:610-622. [PMID: 28776582 DOI: 10.1038/nrendo.2017.93] [Citation(s) in RCA: 219] [Impact Index Per Article: 31.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
Adequate thyroid hormone availability is important for an uncomplicated pregnancy and optimal fetal growth and development. Overt thyroid disease is associated with a wide range of adverse obstetric and child development outcomes. An increasing number of studies now indicate that milder forms of thyroid dysfunction are also associated with these adverse pregnancy outcomes. The definitions of both overt and subclinical thyroid dysfunction have changed considerably over the past few years, as new data indicate that the commonly used fixed upper limits of 2.5 mU/l or 3.0 mU/l for thyroid-stimulating hormone (TSH) are too low to define an abnormal thyroid function. Furthermore, some studies now show that the reference ranges are not necessarily the best cut-off for identifying pregnancies at high risk of adverse outcomes. In addition, data suggest that thyroid peroxidase autoantibody positivity and high or low concentrations of human chorionic gonadotropin seem to have a more prominent role in the interpretation of thyroid dysfunction than previously thought. Data on the effects of thyroid disease treatment are lacking, but some studies indicate that clinicians should be aware of the potential for overtreatment with levothyroxine. Here, we put studies from the past decade on reference ranges for TSH, determinants of thyroid dysfunction, risks of adverse outcomes and options for treatment into perspective. In addition, we provide an overview of the current views on thyroid physiology during pregnancy and discuss strategies to identify high-risk individuals who might benefit from levothyroxine treatment.
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Affiliation(s)
- Tim I M Korevaar
- Department of Internal Medicine, Erasmus Medical Center, Postbus 2040, 3000 CA, Rotterdam, The Netherlands
- Academic Center for Thyroid Diseases, Erasmus Medical Center, Postbus 2040, 3000 CA, Rotterdam, The Netherlands
| | - Marco Medici
- Department of Internal Medicine, Erasmus Medical Center, Postbus 2040, 3000 CA, Rotterdam, The Netherlands
- Academic Center for Thyroid Diseases, Erasmus Medical Center, Postbus 2040, 3000 CA, Rotterdam, The Netherlands
| | - Theo J Visser
- Department of Internal Medicine, Erasmus Medical Center, Postbus 2040, 3000 CA, Rotterdam, The Netherlands
- Academic Center for Thyroid Diseases, Erasmus Medical Center, Postbus 2040, 3000 CA, Rotterdam, The Netherlands
| | - Robin P Peeters
- Department of Internal Medicine, Erasmus Medical Center, Postbus 2040, 3000 CA, Rotterdam, The Netherlands
- Academic Center for Thyroid Diseases, Erasmus Medical Center, Postbus 2040, 3000 CA, Rotterdam, The Netherlands
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Association of HLA-B and HLA-DRB1 polymorphisms with antithyroid drug-induced agranulocytosis in a Han population from northern China. Sci Rep 2017; 7:11950. [PMID: 28931918 PMCID: PMC5607267 DOI: 10.1038/s41598-017-12350-2] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/09/2017] [Accepted: 09/07/2017] [Indexed: 01/15/2023] Open
Abstract
Antithyroid drug (ATD)-induced agranulocytosis is associated with human leukocyte antigen (HLA) and nearby genes in Southeast Asian and European populations. The susceptibility of the Han population from northern China to ATD-induced agranulocytosis has not been reported. We evaluated the associations of genetic variants at the HLA-B and HLA-DRB1 loci and 32 candidate single nucleotide polymorphisms (SNPs) with agranulocytosis in 29 patients with ATD-induced agranulocytosis and in 140 patients with Graves’ disease (GD) as controls. All subjects were of Han descent from northern China. HLA-B*27:05 (P = 1.10 × 10−4), HLA-B*38:02 (P = 2.41 × 10−4) and HLA-DRB1*08:03 (P = 1.57 × 10−3) were susceptibility HLA variants for ATD-induced agranulocytosis. All subjects carrying the HLA-B*27:05 allele had agranulocytosis. The odds ratios (ORs) comparing allele carriers to non-carriers were 66.24 (95% confidence interval (CI): 3.54–1239.66) for HLA-B*27:05, 7.525 (95% CI: 2.294–24.68) for HLA-B*38:02 and 4.316 (95% CI: 1.56–11.93) for HLA-DRB1*08:03. Two SNPs, rs2596487 (OR = 4.196, 95% CI = 2.086–8.441, P = 2.08 × 10−5) and rs2228391 (OR = 3.621, 95% CI = 1.596–8.217, P = 1.2 × 10−3), were independently associated with ATD-induced agranulocytosis. Subjects carrying the ‘A’ allele of rs1811197 or HLA-B*38:02 showed lower minimum granulocyte counts than non-carriers (P = 4.74 × 10−4 and P = 7.39 × 10−4, respectively). Our findings support the association between genetic variations of HLA-B and HLA-DRB1 with ATD-induced agranulocytosis in a Han population from northern China.
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Bukhari S, Khan M, Kumar N, Mohan V. Increased risk for thionamide-induced agranulocytosis in elderly patients: a case presentation and literature review. BMJ Case Rep 2017; 2017:bcr-2017-220924. [PMID: 28716776 DOI: 10.1136/bcr-2017-220924] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
Thionamides, such as methimazole and propylthiouracil, are used for the management of hyperthyroidism. Agranulocytosis is a rare adverse effect of thionamides and elderly patients are especially vulnerable. Here we discuss a case of an 80-year-old woman who developed agranulocytosis and pneumonia approximately 4 weeks after starting low dose methimazole therapy. Despite aggressive treatment with broad-spectrum antibiotics and granulocyte colony stimulating factor, she developed multiorgan failure and died. Our goals are to identify risk factors common to elderly patients and hopefully improve outcomes in this population when prescribed thionamides.
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Affiliation(s)
- Sumera Bukhari
- Department of Internal Medicine, St Francis Medical Center, Seton Hall University, Trenton, New Jersey, USA
| | - Muhammad Khan
- Department of Internal Medicine, St Francis Medical Center, Seton Hall University, Trenton, New Jersey, USA
| | - Naresh Kumar
- Department of Internal Medicine, St Francis Medical Center, Seton Hall University, Trenton, New Jersey, USA
| | - Vinuta Mohan
- Department of Endocrinology, St Francis Medical Center, Seton Hall University, Trenton, New Jersey, USA
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Plantinga TS, Arts P, Knarren GH, Mulder AH, Wakelkamp IM, Hermus AR, Joosten LA, Netea MG, Bisschop PH, de Herder WW, Beijers HJ, de Bruin IJ, Gilissen C, Veltman JA, Hoischen A, Smit JW, Netea-Maier RT. Rare NOX3 Variants Confer Susceptibility to Agranulocytosis During Thyrostatic Treatment of Graves' Disease. Clin Pharmacol Ther 2017; 102:1017-1024. [PMID: 28486791 DOI: 10.1002/cpt.733] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/15/2017] [Revised: 04/12/2017] [Accepted: 05/01/2017] [Indexed: 01/12/2023]
Abstract
Agranulocytosis is a rare and serious adverse effect of antithyroid drugs, with unknown etiology. The present study aimed to uncover genetic susceptibility and underlying mechanisms of antithyroid drug-induced agranulocytosis (ATDAC). We studied two independent families with familial Graves' disease, of which several members developed ATDAC. In addition, six sporadic ATDAC patients with Graves' disease were investigated. Whole exome sequencing analysis of affected and unaffected family members was performed to identify genetic susceptibility variants for ATDAC, followed by functional characterization of primary granulocytes from patients and unrelated healthy controls. Whole exome sequencing, cosegregation analysis, and stringent selection criteria of candidate gene variants identified NOX3 as a genetic factor related to ATDAC. Functional studies revealed increased apoptosis of methimazole-treated granulocytes from patients carrying NOX3 variants. In conclusion, genetic variants in NOX3 may confer susceptibility to antithyroid drug-induced apoptosis of granulocytes. These findings contribute to the understanding of the mechanisms underlying ATDAC.
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Affiliation(s)
- T S Plantinga
- Department of Internal Medicine, Division of Endocrinology, Radboud University Medical Center, Nijmegen, The Netherlands
| | - P Arts
- Department of Human Genetics, Radboud University Medical Center, Nijmegen, The Netherlands
| | - G H Knarren
- Department of Internal Medicine, Slingeland Hospital, Doetinchem, The Netherlands
| | - A H Mulder
- Department of Internal Medicine, Slingeland Hospital, Doetinchem, The Netherlands
| | - I M Wakelkamp
- Department of Internal Medicine, St Antonius Hospital, Nieuwegein, The Netherlands
| | - A R Hermus
- Department of Internal Medicine, Division of Endocrinology, Radboud University Medical Center, Nijmegen, The Netherlands
| | - L A Joosten
- Department of Internal Medicine, Division of Endocrinology, Radboud University Medical Center, Nijmegen, The Netherlands
| | - M G Netea
- Department of Internal Medicine, Division of Endocrinology, Radboud University Medical Center, Nijmegen, The Netherlands
| | - P H Bisschop
- Department of Endocrinology and Metabolism, Academic Medical Centre, Amsterdam, The Netherlands
| | - W W de Herder
- Department of Internal Medicine, Division of Endocrinology, Erasmus Medical Center, Rotterdam, The Netherlands
| | - H J Beijers
- Department of Internal Medicine, Division of Endocrinology, Radboud University Medical Center, Nijmegen, The Netherlands
| | - I J de Bruin
- Department of Internal Medicine, Division of Endocrinology, Radboud University Medical Center, Nijmegen, The Netherlands
| | - C Gilissen
- Department of Human Genetics, Radboud University Medical Center, Nijmegen, The Netherlands
| | - J A Veltman
- Department of Human Genetics, Radboud University Medical Center, Nijmegen, The Netherlands
| | - A Hoischen
- Department of Human Genetics, Radboud University Medical Center, Nijmegen, The Netherlands
| | - J W Smit
- Department of Internal Medicine, Division of Endocrinology, Radboud University Medical Center, Nijmegen, The Netherlands
| | - R T Netea-Maier
- Department of Internal Medicine, Division of Endocrinology, Radboud University Medical Center, Nijmegen, The Netherlands
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He Y, Li J, Zheng J, Khan Z, Qiang W, Gao F, Zhao Y, Shi B. Emphasis on the early diagnosis of antithyroid drug-induced agranulocytosis: retrospective analysis over 16 years at one Chinese center. J Endocrinol Invest 2017; 40:733-740. [PMID: 28236218 DOI: 10.1007/s40618-017-0626-x] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/16/2016] [Accepted: 01/24/2017] [Indexed: 01/06/2023]
Abstract
PURPOSE Antithyroid drug (ATD)-induced agranulocytosis is a rare but life-threatening adverse drug reaction that occurs in patients during the treatment of Graves' disease. We aimed to comprehensively examine data for patients with this rare complication and to improve the clinical safety of ATDs. METHODS We retrospectively reviewed the medical records of 64 hospitalized patients diagnosed with ATD-induced agranulocytosis between 2000 and 2015. RESULTS Agranulocytosis occurred in 52 (81.3%) patients within the first 3 months after initiation of ATD therapy. Fever (84.4%) and sore throat (82.8%) were the most common symptoms. Although they experienced symptoms, 30 (46.9%) patients did not seek treatment immediately and delayed their diagnosis of agranulocytosis. The minimum granulocyte count was lower in the patients diagnosed after the appearance of symptoms than in those diagnosed before the appearance of symptoms (0.01 × 109/L (0 × 109/L - 0.06 × 109/L) versus 0.26 × 109/L (0.05 × 109/L - 0.40 × 109/L), P < 0.001). The interval days from the appearance of symptoms to the diagnosis of agranulocytosis were negatively correlated with the minimum granulocyte count (r = -0.348, P = 0.005). In addition, a lower minimum granulocyte count was associated with a longer recovery time (β = -11.899, 95% CI -15.304 to -8.496). CONCLUSIONS Our findings have demonstrated that delayed diagnosis of ATD-induced agranulocytosis is common in our population. Delayed diagnosis is associated with severe agranulocytosis and may prolong the recovery time from agranulocytosis. Monitoring of the white blood cell and granulocyte counts may be an effective way to establish an early diagnosis and prevent progression to severe agranulocytosis.
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Affiliation(s)
- Y He
- Department of Endocrinology, The First Affiliated Hospital of Xi'an Jiaotong University School of Medicine, Xi'an, 710061, Shaanxi, People's Republic of China
| | - J Li
- Department of Rheumatology, The Fifth Hospital of Xi'an, Xi'an, Shaanxi, People's Republic of China
| | - J Zheng
- Clinical Research Center, The First Affiliated Hospital of Xi'an Jiaotong University School of Medicine, Xi'an, Shaanxi, People's Republic of China
| | - Z Khan
- Department of Endocrinology, The First Affiliated Hospital of Xi'an Jiaotong University School of Medicine, Xi'an, 710061, Shaanxi, People's Republic of China
| | - W Qiang
- Department of Endocrinology, The First Affiliated Hospital of Xi'an Jiaotong University School of Medicine, Xi'an, 710061, Shaanxi, People's Republic of China
| | - F Gao
- Clinical Research Center, The First Affiliated Hospital of Xi'an Jiaotong University School of Medicine, Xi'an, Shaanxi, People's Republic of China
| | - Y Zhao
- Department of Endocrinology, The First Affiliated Hospital of Xi'an Jiaotong University School of Medicine, Xi'an, 710061, Shaanxi, People's Republic of China
| | - B Shi
- Department of Endocrinology, The First Affiliated Hospital of Xi'an Jiaotong University School of Medicine, Xi'an, 710061, Shaanxi, People's Republic of China.
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Choi HS, Yoo WS. Free Thyroxine, Anti-Thyroid Stimulating Hormone Receptor Antibody Titers, and Absence of Goiter Were Associated with Responsiveness to Methimazole in Patients with New Onset Graves' Disease. Endocrinol Metab (Seoul) 2017; 32:281-287. [PMID: 28685517 PMCID: PMC5503874 DOI: 10.3803/enm.2017.32.2.281] [Citation(s) in RCA: 4] [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] [Received: 02/14/2017] [Revised: 04/21/2017] [Accepted: 04/24/2017] [Indexed: 11/17/2022] Open
Abstract
BACKGROUND Anti-thyroid drug therapy is considered a treatment of choice for Graves' disease; however, treatment response varies among individuals. Although several studies have reported risk factors for relapse after initial treatment, few have assessed responsiveness during the early treatment period. Our study aimed to identify the clinical characteristics for responsiveness to methimazole. METHODS We included 99 patients diagnosed with Graves' disease for the first time. Drug responsiveness was defined as the correlation coefficients between decreasing rates of free thyroxine level per month and methimazole exposure dose. According to their responsiveness to treatment, the patients were classified into rapid or slow responder groups, and age, sex, free thyroxine level, and thyrotropin binding inhibiting immunoglobulin (TBII) titers were compared between groups. RESULTS The mean patient age was 44.0±13.5 years and 40 patients were male (40%). The mean TBII titer was 36.6±74.4 IU/L, and the mean free thyroxine concentration was 48.9±21.9 pmol/L. The rapid responder group showed higher TBII titer and free thyroxine level at diagnosis, while age, sex, smoking, and presence of goiter did not differ between the two groups. Logistic regression analyses revealed that high level of serum thyroxine, high titer of TBII, and absence of goiter were significantly associated with a rapid response, while age, sex, and smoking were not significant factors for the prediction of responsiveness. CONCLUSION In patients with new onset Graves' disease, high level of free thyroxine, high titer of TBII, and absence of goiter were associated with rapid responsiveness to methimazole treatment.
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Affiliation(s)
- Hoon Sung Choi
- Department of Internal Medicine, Kangwon National University Hospital, Kangwon National University School of Medicine, Chuncheon, Korea
| | - Won Sang Yoo
- Department of Internal Medicine, Dankook University Hospital, Dankook University College of Medicine, Cheonan, Korea.
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Hussain YS, Hookham JC, Allahabadia A, Balasubramanian SP. Epidemiology, management and outcomes of Graves' disease-real life data. Endocrine 2017; 56:568-578. [PMID: 28478488 PMCID: PMC5435772 DOI: 10.1007/s12020-017-1306-5] [Citation(s) in RCA: 50] [Impact Index Per Article: 7.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/09/2017] [Accepted: 04/17/2017] [Indexed: 01/19/2023]
Abstract
PURPOSE Treatment options in Graves' disease are clearly defined, but management practices and the perceptions of success are varied. The outcomes of treatment in large consecutive cohorts of Graves' disease have not been well characterised. The study describes the epidemiology, management strategies and medium term outcomes following anti-thyroid drug treatment, radio-iodine ablation and surgery in Graves' disease. METHODS All patients (n = 659) who received treatment for a new diagnosis of Graves' disease in secondary care over a 5 year period were included with a median (interquartile range) follow-up of 42.9 (29-57.5) months. RESULTS The age adjusted incidence of adult onset Graves' disease in Sheffield, UK was 24.8 per 100,000 per year. Excluding 35 patients lost to follow-up, 93.1% (n = 581) were controlled on anti-thyroid drug treatment. Of these, 73.6% went into remission following withdrawal of anti-thyroid drugs; 5.2% were still undergoing initial therapy; 13.3% lost control whilst on anti-thyroid drugs; and 7.9% went on to have either surgery or radio-iodine ablation whilst controlled on anti-thyroid drugs. Of the 428 patients who achieved remission, 36.7% relapsed. Of 144 patients who had radio-iodine ablation treatment, 5.6% relapsed and needed further treatment. Of 119 patients having surgery, 5.2% had long-term hypoparathyroidism and none had documented long-term recurrent laryngeal nerve palsy. CONCLUSIONS In the follow-up, 39.9% of patients underwent surgery or radio-iodine ablation with little morbidity. Up to two-thirds of patients who achieved remission did not relapse. Data on effectiveness and risks of treatments for Graves' disease presented in this study will help clinicians and patients in decision making.
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Affiliation(s)
- Y S Hussain
- Endocrine Surgery Unit, Directorate of General Surgery, Sheffield Teaching Hospitals NHS Foundation Trust, Sheffield, UK
| | - J C Hookham
- Endocrine Surgery Unit, Directorate of General Surgery, Sheffield Teaching Hospitals NHS Foundation Trust, Sheffield, UK
| | - A Allahabadia
- Directorate of Diabetes and Endocrinology, Sheffield Teaching Hospitals NHS Foundation Trust, Sheffield, UK
| | - S P Balasubramanian
- Endocrine Surgery Unit, Directorate of General Surgery, Sheffield Teaching Hospitals NHS Foundation Trust, Sheffield, UK.
- Department of Oncology and Metabolism, University of Sheffield, Sheffield, UK.
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Minamitani K, Sato H, Ohye H, Harada S, Arisaka O. Guidelines for the treatment of childhood-onset Graves' disease in Japan, 2016. Clin Pediatr Endocrinol 2017; 26:29-62. [PMID: 28458457 PMCID: PMC5402306 DOI: 10.1297/cpe.26.29] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/03/2016] [Accepted: 12/02/2016] [Indexed: 12/12/2022] Open
Abstract
Purpose behind developing these guidelines: Over one decade ago, the “Guidelines for the
Treatment of Graves’ Disease with Antithyroid Drug, 2006” (Japan Thyroid Association
(JTA)) were published as the standard drug therapy protocol for Graves’ disease. The
“Guidelines for the Treatment of Childhood-Onset Graves’ Disease with Antithyroid Drug in
Japan, 2008” were published to provide guidance on the treatment of pediatric patients.
Based on new evidence, a revised version of the “Guidelines for the Treatment of Graves’
Disease with Antithyroid Drug, 2006” (JTA) was published in 2011, combined with the
“Handbook of Radioiodine Therapy for Graves’ Disease 2007” (JTA). Subsequently, newer
findings on pediatric Graves’ disease have been reported. Propylthiouracil (PTU)-induced
serious hepatopathy is an important problem in pediatric patients. The American Thyroid
Association’s guidelines suggest that, in principle, physicians must not administer PTU to
children. On the other hand, the “Guidelines for the Treatment of Graves’ Disease with
Antithyroid Drug, 2011” (JTA) state that radioiodine therapy is no longer considered a
“fundamental contraindication” in children. Therefore, the “Guidelines for the Treatment
of Childhood-Onset Graves’ Disease with Antithyroid Drug in Japan, 2008” required
revision.
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Affiliation(s)
| | - Kanshi Minamitani
- Department of Pediatrics, Teikyo University Chiba Medical Center, Chiba, Japan
| | | | - Hidemi Ohye
- Department of Internal Medicine, Ito Hospital, Tokyo, Japan
| | - Shohei Harada
- Division of Neonatal Screening, National Center for Child Health and Development, Tokyo, Japan
| | - Osamu Arisaka
- Department of Pediatrics, Dokkyo Medical University, Tochigi, Japan
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Yasuda K, Miyoshi Y, Tachibana M, Namba N, Miki K, Nakata Y, Takano T, Ozono K. Relationship between dose of antithyroid drugs and adverse events in pediatric patients with Graves' disease. Clin Pediatr Endocrinol 2017; 26:1-7. [PMID: 28203042 PMCID: PMC5295245 DOI: 10.1297/cpe.26.1] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/23/2016] [Accepted: 11/22/2016] [Indexed: 12/03/2022] Open
Abstract
Graves’ disease (GD) accounts for a large proportion of pediatric hyperthyroidism, and
the first-line treatment is antithyroid drug (ATD) therapy. Methimazole (MMI) is effective
in most patients but is associated with significant adverse events (AEs). We reviewed the
medical records of GD patients (n = 56) with onset age of <15 yr and investigated the
relationship between MMI dose and AEs. The study population comprised 11 male and 45
female patients and the median age at diagnosis was 11 yr. All patients were initially
treated with ATDs. Among the 52 patients initially treated with MMI, 20 received a low
dose, and 32 received a high dose of MMI (< 0.7 vs ≥ 0.7 mg/kg/day,
respectively). AEs occurred in 20% of the patients in the low-dose MMI group, and in 50%
patients in the high-dose MMI group (p = 0.031). A greater variety of AEs was observed in
the high-dose group. Neutropenia and rash were observed in both groups. With treatment
transition to low-dose MMI according to the Japanese Society for Pediatric Endocrinology
guidelines, we expect a decrease in the incidence of AEs in future. However, we should be
careful as neutropenia and rash can occur independently of the MMI dose.
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Affiliation(s)
- Kie Yasuda
- Department of Pediatrics, Osaka University Graduate School of Medicine, Osaka, Japan
| | - Yoko Miyoshi
- Department of Pediatrics, Osaka University Graduate School of Medicine, Osaka, Japan
| | - Makiko Tachibana
- Department of Pediatrics, Osaka University Graduate School of Medicine, Osaka, Japan
| | - Noriyuki Namba
- Department of Pediatrics, Osaka University Graduate School of Medicine, Osaka, Japan; Department of Pediatrics, Japan Community Health Care Organization Osaka Hospital, Osaka, Japan
| | - Kazunori Miki
- Department of Pediatrics, Osaka University Graduate School of Medicine, Osaka, Japan; Department of Pediatrics, Itami Municipal Hospital, Hyogo, Japan
| | - Yukiko Nakata
- Department of Metabolic Medicine, Osaka University Graduate School of Medicine, Osaka, Japan
| | - Toru Takano
- Department of Metabolic Medicine, Osaka University Graduate School of Medicine, Osaka, Japan
| | - Keiichi Ozono
- Department of Pediatrics, Osaka University Graduate School of Medicine, Osaka, Japan
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Nakamura H, Ide A, Kudo T, Nishihara E, Ito M, Miyauchi A. Periodic Granulocyte Count Measuring Is Useful for Detecting Asymptomatic Agranulocytosis in Antithyroid Drug-Treated Patients with Graves' Disease. Eur Thyroid J 2016; 5:253-260. [PMID: 28101490 PMCID: PMC5216194 DOI: 10.1159/000448586] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/10/2016] [Revised: 07/21/2016] [Indexed: 12/27/2022] Open
Abstract
OBJECTIVE Finding agranulocytosis (AG) at an early stage is important to improve outcome, but periodic granulocyte count monitoring is not generally recommended for patients with Graves' disease, because AG develops suddenly. METHOD At the Kuma Hospital, Graves' patients under antithyroid drug (ATD) treatment in an outpatient clinic have a granulocyte count examination during each visit, and if it is <1,000/μl, a warning is immediately sent to the patient's physician. We evaluated the usefulness of this system. RESULTS We investigated 25 AG and 33 granulocytopenia (GP) cases over a recent 5-year period, excluding patients who developed AG or GP at another hospital and were referred to us for treatment. Among the 25 AG patients, 16 patients (64%; 9 asymptomatic and 7 very mild symptomatic cases) were discovered by the periodic granulocyte count examination at an outpatient clinic. The remaining 9 patients visited the Kuma Hospital or other hospitals because of infection symptoms. Most of the AG patients were given granulocyte colony-stimulating factor injections immediately and were admitted if a prompt increase in granulocytes could not be obtained. The final treatments for Graves' disease were 131I-radioisotope therapy (19 patients), thyroidectomy (2 patients), inorganic iodine (1 patient), or another ATD (1 patient). Among the 33 GP patients, 31 (94%), including 20 asymptomatic cases, were discovered during periodic granulocyte count monitoring. Most of them stopped ATD, and other treatments for Graves' disease were selected. CONCLUSION Periodic monitoring of granulocyte counts is useful for identifying AG and GP patients with no or minimum infection symptoms.
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Affiliation(s)
- Hirotoshi Nakamura
- *Dr. Hirotoshi Nakamura, Department of Medicine, Kuma Hospital, 8-2-35 Shimoyamate-dori, Chuo-ku, Kobe 650-0011 (Japan), E-Mail
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Puthenpura V, Desai K, Bauer A, Marshall I. Delayed methimazole-induced agranulocytosis in a 6-year old patient with Graves’ disease. INTERNATIONAL JOURNAL OF PEDIATRIC ENDOCRINOLOGY 2016; 2016:16. [PMID: 27605984 PMCID: PMC5013617 DOI: 10.1186/s13633-016-0034-6] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 07/05/2016] [Accepted: 08/24/2016] [Indexed: 11/10/2022]
Abstract
Background Agranulocytosis is regarded as a rare side effect of methimazole (MMI) therapy that occurs in a dose dependent manner and that usually develops within the first 3–6 months of treatment. Although delayed development beyond this timeline has been documented in adults, very few children have been reported with this presentation. Case presentation We present a 6-year old patient who developed agranulocytosis 18 months after the start of MMI therapy. Conclusions This is an unusual case of a 6-year old patient who developed this serious side effect on stable MMI therapy well beyond the typical timeline. Our review of the literature revealed that there really is inconclusive data on the incidence, time, and dose-dependency of MMI-induced agranulocytosis in the pediatric Graves’ disease population.
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Bartalena L, Chiovato L, Vitti P. Management of hyperthyroidism due to Graves' disease: frequently asked questions and answers (if any). J Endocrinol Invest 2016; 39:1105-14. [PMID: 27319009 DOI: 10.1007/s40618-016-0505-x] [Citation(s) in RCA: 38] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/30/2016] [Accepted: 06/11/2016] [Indexed: 02/03/2023]
Abstract
Graves' disease is the most common cause of hyperthyroidism in iodine-replete areas. Although progress has been made in our understanding of the pathogenesis of the disease, no treatment targeting pathogenic mechanisms of the disease is presently available. Therapies for Graves' hyperthyroidism are largely imperfect because they are bound to either a high rate of relapsing hyperthyroidism (antithyroid drugs) or lifelong hypothyroidism (radioiodine treatment or thyroidectomy). Aim of the present article is to offer a practical guidance to the reader by providing evidence-based answers to frequently asked questions in clinical practice.
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Affiliation(s)
- L Bartalena
- Endocrine Unit, Department of Clinical and Experimental Medicine, ASST dei Sette Laghi, Ospedale di Circolo, University of Insubria, Viale Borri, 57, Varese, Italy.
| | - L Chiovato
- Fondazione Salvatore Maugeri and University of Pavia, Pavia, Italy
| | - P Vitti
- Department of Clinical and Experimental Medicine, University of Pisa, Pisa, Italy
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Ross DS, Burch HB, Cooper DS, Greenlee MC, Laurberg P, Maia AL, Rivkees SA, Samuels M, Sosa JA, Stan MN, Walter MA. 2016 American Thyroid Association Guidelines for Diagnosis and Management of Hyperthyroidism and Other Causes of Thyrotoxicosis. Thyroid 2016; 26:1343-1421. [PMID: 27521067 DOI: 10.1089/thy.2016.0229] [Citation(s) in RCA: 1315] [Impact Index Per Article: 164.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
BACKGROUND Thyrotoxicosis has multiple etiologies, manifestations, and potential therapies. Appropriate treatment requires an accurate diagnosis and is influenced by coexisting medical conditions and patient preference. This document describes evidence-based clinical guidelines for the management of thyrotoxicosis that would be useful to generalist and subspecialty physicians and others providing care for patients with this condition. METHODS The American Thyroid Association (ATA) previously cosponsored guidelines for the management of thyrotoxicosis that were published in 2011. Considerable new literature has been published since then, and the ATA felt updated evidence-based guidelines were needed. The association assembled a task force of expert clinicians who authored this report. They examined relevant literature using a systematic PubMed search supplemented with additional published materials. An evidence-based medicine approach that incorporated the knowledge and experience of the panel was used to update the 2011 text and recommendations. The strength of the recommendations and the quality of evidence supporting them were rated according to the approach recommended by the Grading of Recommendations, Assessment, Development, and Evaluation Group. RESULTS Clinical topics addressed include the initial evaluation and management of thyrotoxicosis; management of Graves' hyperthyroidism using radioactive iodine, antithyroid drugs, or surgery; management of toxic multinodular goiter or toxic adenoma using radioactive iodine or surgery; Graves' disease in children, adolescents, or pregnant patients; subclinical hyperthyroidism; hyperthyroidism in patients with Graves' orbitopathy; and management of other miscellaneous causes of thyrotoxicosis. New paradigms since publication of the 2011 guidelines are presented for the evaluation of the etiology of thyrotoxicosis, the management of Graves' hyperthyroidism with antithyroid drugs, the management of pregnant hyperthyroid patients, and the preparation of patients for thyroid surgery. The sections on less common causes of thyrotoxicosis have been expanded. CONCLUSIONS One hundred twenty-four evidence-based recommendations were developed to aid in the care of patients with thyrotoxicosis and to share what the task force believes is current, rational, and optimal medical practice.
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Affiliation(s)
- Douglas S Ross
- 1 Massachusetts General Hospital , Boston, Massachusetts
| | - Henry B Burch
- 2 Endocrinology - Metabolic Service, Walter Reed National Military Medical Center , Bethesda, Maryland
| | - David S Cooper
- 3 Division of Endocrinology, Diabetes, and Metabolism, The Johns Hopkins University School of Medicine , Baltimore, Maryland
| | | | - Peter Laurberg
- 5 Departments of Clinical Medicine and Endocrinology, Aalborg University and Aalborg University Hospital , Aalborg, Denmark
| | - Ana Luiza Maia
- 6 Thyroid Section, Hospital de Clinicas de Porto Alegre, Federal University of Rio Grande do Sul , Porto Alegre, Brazil
| | - Scott A Rivkees
- 7 Pediatrics - Chairman's Office, University of Florida College of Medicine , Gainesville, Florida
| | - Mary Samuels
- 8 Division of Endocrinology, Diabetes and Clinical Nutrition, Oregon Health & Science University , Portland, Oregon
| | - Julie Ann Sosa
- 9 Section of Endocrine Surgery, Duke University School of Medicine , Durham, North Carolina
| | - Marius N Stan
- 10 Division of Endocrinology, Mayo Clinic , Rochester, Minnesota
| | - Martin A Walter
- 11 Institute of Nuclear Medicine, University Hospital Bern , Switzerland
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Ha J, Jo K, Kang B, Kim MH, Lim DJ. Cholestyramine Use for Rapid Reversion to Euthyroid States in Patients with Thyrotoxicosis. Endocrinol Metab (Seoul) 2016; 31:476-479. [PMID: 27469067 PMCID: PMC5053062 DOI: 10.3803/enm.2016.31.3.476] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/25/2016] [Revised: 06/09/2016] [Accepted: 06/13/2016] [Indexed: 11/13/2022] Open
Abstract
Cholestyramine (CS) is an ion exchange resin, which binds to iodothyronines and would lower serum thyroid hormone level. The use of CS added to conventional antithyroid drugs to control thyrotoxicosis has been applied since 1980's, and several studies indicate that using CS in combination with methimazole (MZ) produces a more rapid decline in serum thyroid hormones than with only MZ treatment. Our recent retrospective review of five patients taking high dose MZ and CS, compared to age-, gender-, initial free thyroxine (T4) level-, and MZ dose-matched 12 patients with MZ use only, showed more rapid decline of both free T4 and triiodothyronine levels without more adverse events. CS could be safely applicable short-term adjunctive therapy when first-line antithyroid medications are not enough to adequately control severe thyrotoxicosis or side effects of antithyroid drug would be of great concern.
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Affiliation(s)
- Jeonghoon Ha
- Division of Endocrinology and Metabolism, Department of Internal Medicine, Seoul St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, Korea
| | - Kwanhoon Jo
- Division of Endocrinology and Metabolism, Department of Internal Medicine, Seoul St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, Korea
| | - Borami Kang
- Division of Endocrinology and Metabolism, Department of Internal Medicine, Seoul St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, Korea
| | - Min Hee Kim
- Division of Endocrinology and Metabolism, Department of Internal Medicine, Seoul St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, Korea
| | - Dong Jun Lim
- Division of Endocrinology and Metabolism, Department of Internal Medicine, Seoul St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, Korea.
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Sarker T, Özgönenel B, Gadgeel M, Buck S, Adhikari A, Ravindranath Y. Methimazole Induced Total Myeloid Aplasia with Delayed Recovery Despite Granulocyte Colony Stimulating Factor (G-CSF): Marrow Progenitor Recovery Kinetics. Indian J Hematol Blood Transfus 2016; 32:214-8. [PMID: 27408395 DOI: 10.1007/s12288-015-0595-1] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/09/2015] [Accepted: 09/08/2015] [Indexed: 11/24/2022] Open
Abstract
An eighteen-year-old female with Graves thyrotoxicosis presented with methimazole-induced agranulocytosis and total myeloid aplasia. The bone marrow at presentation showed complete absence of myeloid precursors and striking plasmacytosis. 16 days later, myeloid precursors were still absent morphologically; however bone marrow flow cytometry and cell culture detected an improvement in myelogenesis, which was soon followed by clinical recovery of agranulocytosis. Neutrophil recovery was delayed until day 22 after cessation of methimazole despite G-CSF use, consistent with a direct toxic effect on committed myeloid cells. Our findings suggest that cell culture and flow cytometric evaluation of bone marrow myeloid progenitors can be used as a guide to anticipate neutrophil recovery.
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Affiliation(s)
- Tania Sarker
- Division of Hematology/Oncology, Carman Ann Adams Children's Hospital of Michigan, Wayne State University, 3901 Beaubien Blvd., Detroit, MI 48201 USA
| | - Bülent Özgönenel
- Division of Hematology/Oncology, Carman Ann Adams Children's Hospital of Michigan, Wayne State University, 3901 Beaubien Blvd., Detroit, MI 48201 USA
| | - Manisha Gadgeel
- Division of Hematology/Oncology, Carman Ann Adams Children's Hospital of Michigan, Wayne State University, 3901 Beaubien Blvd., Detroit, MI 48201 USA
| | - Steven Buck
- Division of Hematology/Oncology, Carman Ann Adams Children's Hospital of Michigan, Wayne State University, 3901 Beaubien Blvd., Detroit, MI 48201 USA
| | - Amita Adhikari
- Division of Endocrinology, Carman Ann Adams Children's Hospital of Michigan, Wayne State University, Detroit, MI USA
| | - Yaddanapudi Ravindranath
- Division of Hematology/Oncology, Carman Ann Adams Children's Hospital of Michigan, Wayne State University, 3901 Beaubien Blvd., Detroit, MI 48201 USA
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Chaudhry LA, Mauzen KF, Ba-Essa E, Robert AA. Antithyroid drug induced a granulocytosis: what still we need to learn? Pan Afr Med J 2016; 23:27. [PMID: 27200132 PMCID: PMC4856502 DOI: 10.11604/pamj.2016.23.27.8365] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/04/2015] [Accepted: 12/01/2015] [Indexed: 11/18/2022] Open
Abstract
Antithyroid drugs (ATDs) induced agranulocytosis is a rare but life threatening condition. We report a 29 years Filipino female diagnosed as having hyperthyroidism with normal base line blood counts, liver and renal profile. She was started on maximum 60mg (20mg TID) oral dose of carbimazole since one month by her treating physician. Exactly after one month of treatment she presented to emergency room (ER) with fever, sore throat and generalized weakness for several days.
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Affiliation(s)
- Liaqat Ali Chaudhry
- Department of Internal Medicine, Pulmonary Division, Sultan Bin Abdulaziz Humanitarian City, Riyadh, Saudi Arabia
| | - Khalid Fouad Mauzen
- Department of Anesthesia & Intensive Care Unit, Sultan Bin Abdulaziz Humanitarian City, Riyadh, Saudi Arabia
| | - Ebtesam Ba-Essa
- Department of Medicine & Endocrinology, Dammam Medical Complex (MOH), Saudi Arabia
| | - Asirvatham Alwin Robert
- Department of Endocrinology and Diabetes, Diabetes Treatment Center, Prince Sultan Military Medical City, Riyadh, Saudi Arabia
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Yang J, Zhu YJ, Zhong JJ, Zhang J, Weng WW, Liu ZF, Xu Q, Dong MJ. Characteristics of Antithyroid Drug-Induced Agranulocytosis in Patients with Hyperthyroidism: A Retrospective Analysis of 114 Cases in a Single Institution in China Involving 9690 Patients Referred for Radioiodine Treatment Over 15 Years. Thyroid 2016; 26:627-33. [PMID: 26867063 DOI: 10.1089/thy.2015.0439] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/12/2022]
Abstract
BACKGROUND Antithyroid drug (ATD)-induced agranulocytosis is a rare but life-threatening disease. Clinical features of ATD-induced agranulocytosis and outcomes remain incompletely understood. METHOD Patients with clinically diagnosed ATD-induced agranulocytosis were retrospectively studied, involving 9690 patients who were referred for radioiodine treatment during a 15-year period (2000-2015) in China. There were 114 cases of agranulocytosis attributable to ATD included, and their clinical characteristics and therapy outcomes were analyzed. RESULTS The female-to-male ratio of ATD-induced agranulocytosis was 10.4:1. The mean age (±standard deviation) of the patients with ATD-induced agranulocytosis was 41.7 ± 12.3 years. The methimazole and propylthiouracil doses given at the onset were 22.9 ± 8.0 mg/day and 253.6 ± 177.5 mg/day, respectively. ATD-induced agranulocytosis occurred in 45.1%, 74.3%, and 88.5% of patients within 4, 8, and 12 weeks of the onset of ATD therapy, respectively. Fever (78.9%) and sore throat (72.8%) were the most common symptoms when agranulocytosis was diagnosed. The mean recovery time of agranulocytosis was 13.41 ± 7.14 days. Recovery time in the granulocyte colony-stimulating factor (G-CSF)-treated group (12.7 ± 6.0 days) did not differ from that in the group not treated with G-CSF (16.4 ± 10.6 days; p = 0.144). Treatment with (131)I was successful in 87/98 patients (88.8%). The success rate of (131)I was equivalent (p = 1.000) between the groups receiving methimazole (88.2%, 75/85) and propylthiouracil (92.3%, 12/13). CONCLUSIONS This largest single-institution study in China shows that ATD-induced agranulocytosis tends to occur within the first 12 weeks after the onset of ATD therapy. For patients with ATD-induced agranulocytosis, G-CSF does not improve the recovery time of agranulocytosis, and (131)I is an optimal treatment approach.
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Affiliation(s)
- Jun Yang
- 1 Department of Nuclear Medicine, First Affiliated Hospital, College of Medicine, Zhejiang University , Hangzhou, People's Republic of China
| | - Yang-Jun Zhu
- 1 Department of Nuclear Medicine, First Affiliated Hospital, College of Medicine, Zhejiang University , Hangzhou, People's Republic of China
| | - Ji-Jun Zhong
- 2 Department of Nuclear Medicine, Taizhou Central Hospital , Taizhou, People's Republic of China
| | - Jun Zhang
- 1 Department of Nuclear Medicine, First Affiliated Hospital, College of Medicine, Zhejiang University , Hangzhou, People's Republic of China
| | - Wan-Wen Weng
- 1 Department of Nuclear Medicine, First Affiliated Hospital, College of Medicine, Zhejiang University , Hangzhou, People's Republic of China
| | - Zhen-Feng Liu
- 3 PET Center, First Affiliated Hospital, College of Medicine, Zhejiang University , Hangzhou, People's Republic of China
| | - Qin Xu
- 1 Department of Nuclear Medicine, First Affiliated Hospital, College of Medicine, Zhejiang University , Hangzhou, People's Republic of China
| | - Meng-Jie Dong
- 1 Department of Nuclear Medicine, First Affiliated Hospital, College of Medicine, Zhejiang University , Hangzhou, People's Republic of China
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Kubota S. Successful Re-administration of Low-dose of Methimazole (MMI) in Graves' Disease Patients Who Experienced Allergic Cutaneous Reactions to MMI at Initial Treatment and Had Received Long-term Propylthiouracil (PTU). Intern Med 2016; 55:3235-3237. [PMID: 27853063 PMCID: PMC5173488 DOI: 10.2169/internalmedicine.55.7281] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
Abstract
Objective When patients with Graves' disease show severe allergic cutaneous reactions, physicians often suggest that they undergo radioiodine therapy instead of receiving propylthiouracil (PTU), another antithyroid drug, because anti-neutrophil cytoplasmic antibody (ANCA) -related vasculitis can occur with PTU, especially with long-term use. However, some patients refuse radioiodine therapy and chose PTU. Sometimes PTU treatment may be prolonged. Since the frequency of adverse effects of methimazole (MMI) is dose-related, there is a possibility that we can re-administer a low dose without adverse effects to patients well-controlled with PTU who once experienced an allergic reaction to MMI. Methods I prospectively re-administered a low dose of MMI to patients who previously experienced an allergic reaction to MMI at initial treatment. The dose of re-administered MMI ranged from 5 mg twice a week to 5 mg daily. Patients Nine patients with Graves' disease who developed urticaria at initial treatment with MMI and had been treated with PTU for 6 to 21 years were recruited. Results Eight of the 9 patients were successfully controlled with MMI without allergic cutaneous reactions. Only one patient felt itchiness 2 days after switching to MMI. However, skin change was not observed. Conclusion If the patients show allergic cutaneous reactions as a side effect of MMI at the initial treatment for Graves' disease, then there is a strong possibility that such patients can tolerate a low dose of MMI without adverse effects after the disease activity has subsided.
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Kim HK, Yoon JH, Jeon MJ, Kim TY, Shong YK, Lee MJ, Kim BH, Kim IJ, Joung JY, Kim SW, Chung JH, Kang HC. Characteristics of Korean Patients with Antithyroid Drug-Induced Agranulocytosis: A Multicenter Study in Korea. Endocrinol Metab (Seoul) 2015; 30:475-80. [PMID: 26394729 PMCID: PMC4722401 DOI: 10.3803/enm.2015.30.4.475] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/14/2015] [Revised: 01/30/2015] [Accepted: 06/08/2015] [Indexed: 11/11/2022] Open
Abstract
BACKGROUND Antithyroid drugs (ATDs) can lead to the development of agranulocytosis, which is the most serious adverse effect. Characteristics of ATD-induced agranulocytosis (AIA) have seldom been reported due to the rarity. In this study, we characterized the clinical features for AIA in Korean patients. METHODS We retrospectively reviewed data from patients with AIA diagnosed between 1997 and 2014 at four tertiary hospitals. Agranulocytosis was defined as an absolute neutrophil count (ANC) below 500/mm³. RESULTS The mean age of the patients (11 males, 43 females) was 38.2±14.9 years. Forty-eight patients (88.9%) with AIA had fever and sore throat on initial presentation, 20.4% of patients developed AIA during the second course of treatment, and 75.9% of patients suffered AIA within 3 months after initiation of ATD. The patients taking methimazole (n=39) showed lower levels of ANC and more frequent use of granulocyte-macrophage colony-stimulating factor than propylthiouracil (n=15) users. The median duration of agranulocytosis was 5.5 days (range, 1 to 20). No differences were observed between the long (≥6 days) and short recovery time (≤5 days) groups in terms of age, gender, ATDs, duration of ATDs, or initial ANC levels. Four patients (7.4%) who were taking ATDs for less than 2 months died of sepsis on the first or second day of hospitalization. CONCLUSION The majority of AIA incidents occur in the early treatment period. Considering the high fatality rate of AIA, an early aggressive therapeutic approach is critical and patients should be well informed regarding the warning symptoms of the disease.
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Affiliation(s)
- Hee Kyung Kim
- Department of Internal Medicine, Chonnam National University Medical School, Gwangju, Korea
| | - Jee Hee Yoon
- Department of Internal Medicine, Chonnam National University Medical School, Gwangju, Korea
| | - Min Ji Jeon
- Department of Internal Medicine, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Tae Yong Kim
- Department of Internal Medicine, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Young Kee Shong
- Department of Internal Medicine, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Min Jin Lee
- Department of Internal Medicine, Pusan National University School of Medicine, Busan, Korea
| | - Bo Hyun Kim
- Department of Internal Medicine, Pusan National University School of Medicine, Busan, Korea
| | - In Joo Kim
- Department of Internal Medicine, Pusan National University School of Medicine, Busan, Korea
| | - Ji Young Joung
- 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
| | - Jae Hoon Chung
- 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.
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Xing H, Guan X. Necrotizing gingivostomatitis and osteonecrosis associated with antithyroid drug propylthiouracil therapy. Oral Surg Oral Med Oral Pathol Oral Radiol 2015; 119:e65-8. [PMID: 25577420 DOI: 10.1016/j.oooo.2014.11.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/30/2014] [Revised: 10/27/2014] [Accepted: 11/02/2014] [Indexed: 10/24/2022]
Abstract
A 43-year-old Chinese female had been diagnosed with hyperthyroidism 15 years ago. She was recently administered 150 mg/day propylthiouracil (PTU). After 3 weeks of PTU administration, she developed necrotizing stomatitis and osteonecrosis, most likely due to secondary effects from the PTU treatment. Her neutrophil count was reduced below normal to 0.24×10(9)/L but normalized after withdrawal of PTU therapy. About 1 month after onset, the patient came to our hospital and began to receive intravenous treatments of metronidazole and amoxicillin. Following review of her medical history and a series of clinical and laboratory examinations, the patient was diagnosed with secondary necrotizing gingivostomatitis and osteonecrosis possibly associated with PTU-induced agranulocytosis. One-year after treatment, the patient's oral manifestations remained unchanged. This case demonstrates the need for dental practitioners to more closely monitor oral symptoms in patients with hyperthyroidism treated with antithyroid drugs.
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Affiliation(s)
- Haixia Xing
- Attending physician, Department of Oral Medicine, Beijing Stomatological Hospital, Capital Medical University, Beijing, China
| | - Xiaobing Guan
- Chief physician, Department of Oral Medicine, Beijing Stomatological Hospital, Capital Medical University, Beijing, China.
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Sato S, Noh JY, Sato S, Suzuki M, Yasuda S, Matsumoto M, Kunii Y, Mukasa K, Sugino K, Ito K, Nagataki S, Taniyama M. Comparison of efficacy and adverse effects between methimazole 15 mg+inorganic iodine 38 mg/day and methimazole 30 mg/day as initial therapy for Graves' disease patients with moderate to severe hyperthyroidism. Thyroid 2015; 25:43-50. [PMID: 25178068 DOI: 10.1089/thy.2014.0084] [Citation(s) in RCA: 31] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/12/2022]
Abstract
BACKGROUND Methimazole (MMI) is usually used at an initial dose of 30 mg/day for severe Graves' disease (GD) hyperthyroidism, but adverse effects are more frequent at this dose than at MMI 15 mg/day. OBJECTIVES We designed a regimen to address the lack of a primary therapeutic effect of the MMI 15 mg/day by combining it with inorganic iodine at 38.2 mg/day. Our aim was to compare the two regimens (MMI 15 mg+inorganic iodine at 38.2 mg/day (M15+I) vs. MMI 30 mg/day (M30)) in terms of therapeutic effect, adverse effects, and remission rate. DESIGN AND PATIENTS In a prospective study, 310 patients with untreated GD (serum free thyroxine (fT4) ≥5 ng/dL) were assigned to one of the two regimens. Potassium iodide was discontinued in the M15+I group as soon as the serum fT4 level was within the reference range (0.8-1.6 ng/dL). RESULTS Percentages of patients achieving an fT4 level within reference range in ≤30, ≤60, or 90 days on the study treatment regimens were 45.3%, 73.9%, and 82.0% respectively for the M15+I group, and 24.8%, 63.1%, and 75.2% respectively for the M30 group. Hence, the proportions of patients achieving this goal in ≤30 or ≤60 days were significantly larger in the M15+I group. Adverse effects that required discontinuation of MMI were more frequent in the M30-treated than in the M15+I-treated group (14.8% vs. 7.5%; p=0.0387). The remission rates in the M15+I and M30 groups were 19.9% and 14.8%-higher in the former, but the difference did not reach statistical significance. CONCLUSION The results of this study raise the possibility that M15+I is superior to M30 as a primary treatment for moderate to severe hyperthyroidism caused by GD.
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Affiliation(s)
- Shotaro Sato
- 1 Department of Internal Medicine, Ito Hospital , Tokyo, Japan
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50
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Zheng R, Liu K, Chen K, Cao W, Cao L, Zhang H, Sun H, Liu C. Lithium Carbonate in the Treatment of Graves' Disease with ATD-Induced Hepatic Injury or Leukopenia. Int J Endocrinol 2015; 2015:694023. [PMID: 26576153 PMCID: PMC4630389 DOI: 10.1155/2015/694023] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/07/2015] [Accepted: 10/05/2015] [Indexed: 11/18/2022] Open
Abstract
Objective. GD with ATD-induced hepatic injury or leukopenia occurs frequently in clinical practice. The purpose of the present study was to observe the clinical effect of lithium carbonate on hyperthyroidism in patients with GD with hepatic injury or leukopenia. Methods. Fifty-one patients with GD with hepatic injury or leukopenia participated in the study. All patients were treated with lithium carbonate, in addition to hepatoprotective drugs or drugs that increase white blood cell count. Thyroid function, liver function, and white blood cells were measured. Clinical outcomes were observed after a 1-year follow-up. Results. After treatment for 36 weeks, symptoms of hyperthyroidism and the level of thyroid hormones were improved and liver function, and white blood cells returned to a normal level. Twelve patients (23.5%) obtained clinical remission, 6 patients (11.8%) relapsed after withdrawal, 25 patients (49.0%) received radioiodine therapy, and 8 patients (15.7%) underwent surgical procedures after lithium carbonate treatment. Conclusion. Lithium carbonate has effects on the treatment of mild-to-moderate hyperthyroidism caused by GD, and it is particularly suitable for patients with ATD-induced hepatic injury or leukopenia.
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Affiliation(s)
- Rendong Zheng
- Department of Endocrinology and Metabolism, Jiangsu Province Hospital on Integration of Chinese and Western Medicine, Nanjing University of Traditional Chinese Medicine, 100 Shizi Street, Hongshan Road, Nanjing, Jiangsu 210028, China
| | - Kemian Liu
- Department of Endocrinology and Metabolism, Jiangsu Province Hospital on Integration of Chinese and Western Medicine, Nanjing University of Traditional Chinese Medicine, 100 Shizi Street, Hongshan Road, Nanjing, Jiangsu 210028, China
| | - Kun Chen
- Department of Endocrinology and Metabolism, Jiangsu Province Hospital on Integration of Chinese and Western Medicine, Nanjing University of Traditional Chinese Medicine, 100 Shizi Street, Hongshan Road, Nanjing, Jiangsu 210028, China
| | - Wen Cao
- Department of Endocrinology and Metabolism, Jiangsu Province Hospital on Integration of Chinese and Western Medicine, Nanjing University of Traditional Chinese Medicine, 100 Shizi Street, Hongshan Road, Nanjing, Jiangsu 210028, China
| | - Lin Cao
- Department of Endocrinology and Metabolism, Jiangsu Province Hospital on Integration of Chinese and Western Medicine, Nanjing University of Traditional Chinese Medicine, 100 Shizi Street, Hongshan Road, Nanjing, Jiangsu 210028, China
| | - Huifeng Zhang
- Department of Endocrinology and Metabolism, Jiangsu Province Hospital on Integration of Chinese and Western Medicine, Nanjing University of Traditional Chinese Medicine, 100 Shizi Street, Hongshan Road, Nanjing, Jiangsu 210028, China
| | - Hongping Sun
- Department of Endocrinology and Metabolism, Jiangsu Province Hospital on Integration of Chinese and Western Medicine, Nanjing University of Traditional Chinese Medicine, 100 Shizi Street, Hongshan Road, Nanjing, Jiangsu 210028, China
| | - Chao Liu
- Department of Endocrinology and Metabolism, Jiangsu Province Hospital on Integration of Chinese and Western Medicine, Nanjing University of Traditional Chinese Medicine, 100 Shizi Street, Hongshan Road, Nanjing, Jiangsu 210028, China
- *Chao Liu:
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