Effect of the combination of dexamethasone and sodium ipodate on serum thyroid hormones in Graves' disease

Development of Graves' disease during drug-free remission of juvenile dermatomyositis

We report a Japanese boy with Graves' disease (GD) which developed during drug-free remission of juvenile dermatomyositis (JDM). He had been diagnosed with JDM at the age of 6 years by typical skin rashes, muscle weakness, elevated serum transaminase levels, and typical findings of both magnetic resonance imaging and muscle biopsy. Although anti-melanoma differentiation antigen 5 autoantibody was positive, there was no complication of interstitial lung disease. He showed good response to methylprednisolone pulse therapy followed by oral prednisolone in combination with weekly methotrexate (MTX) and achieved drug-free remission after 3.5 years of treatment. Nevertheless, serum levels of soluble interleukin-2 receptor (sIL-2R) gradually elevated to 3185 U/ml despite no signs of relapse or malignancy. Hyperactivity and attention deficit was also noted. One year and 3 months after the cessation of MTX, he presented with abdominal pain, tachycardia, and apparent goitre. Laboratory tests showed elevated free triiodothyronine, undetectable thyroid stimulating hormone (TSH), and positive anti-TSH receptor antibodies. 99mTc scintigraphy showed high levels of thyroid uptake. He was diagnosed with GD and treated with 15 mg/day of thiamazole. Although transient drug eruption was observed, his thyroid functions are currently well-controlled on 5 mg/day of thiamazole. In conclusion, to our knowledge, this is the first report in English literature describing complication of GD with JDM. Unexpected elevation of sIL-2R could be a clue to the diagnosis of GD during the follow-up of JDM.

Review of oral cholecystographic agents for the management of hyperthyroidism

OBJECTIVE

Although the use of oral cholecystographic agents (OCAs) had declined due to limited availability, there is literature to suggest it is an effective medication for thyrotoxicosis in appropriate clinical situations.

METHODS

The authors performed a PubMed search and systematically reviewed all the English written case reports, original studies and reviews from 1953 to 2012. Additional information was supplemented from available online pharmacologic databases.

RESULTS

The off-label use of OCAs was reviewed for the management of neonatal and adult Graves' disease, subacute thyroiditis, amiodarone-induced thyroiditis (AIT), exogenous hyperthyroidism, toxic multinodular goiter (TMNG), thyrotropinoma, thyrotoxicosis during pregnancy, rapid pre-operative control of hyperthyroidism, and thyroid storm. Adverse effects were also reviewed.

CONCLUSION

OCAs generally are effective agents in treating thyrotoxicosis in the etiologies reviewed. OCAs are clinically relevant in patients who require rapid control, such as in the pre-operative state or patient who cannot tolerate a thyrotoxicosis state. OCA may also be beneficial in situations where other anti-thyroidal medication would be hazardous or ineffective, such as thionamide allergy or exogenous thyrotoxicosis. Given concern for long-term relapse, OCAs should be considered a short-term bridge to definitive therapy. OCAs are limited in TMNG and should be second line after glucocorticoids in AIT II. OCAs do not preclude the use of radioactive iodine, which can be performed one week after OCA therapy.

Immune manipulation for Graves' disease: re-exploring an unfulfilled promise with modern translational research

Although Graves' disease is the commonest autoimmune thyroid disorder, current therapeutics typically center on the eradication of the antigenic stimulus (i.e. thyroid gland) rather than radically tackling the underlying autoimmune processes. Consequently, it is not a surprising fact that Graves' disease remains essentially a chronic drug-dependent ailment afflicting untold numbers worldwide for decades despite progress in deciphering its autoimmune nature. Addressing the latter is key to a future cure as underscored by appropriate, albeit crude, proof-of-concept scenarios of clinical remissions achieved with hematopoietic stem cell transplantation, immune down-regulation during pregnancy, use of corticosteroids or immunosuppressives, and cytokine biologics in animal models. Ongoing basic and translational research to further elucidate and refine our understanding of the pathogenesis of Graves' disease holds the promise of unraveling novel immune manipulative techniques that will bring the world a step closer to the elusive cure of the underlying autoimmunity amidst skepticisms on the value of the science from the present lack of paralleled advances at the bedside. We review the updated literature and describe the forms of immune manipulation hitherto explored that will offer a route to a future cure, from thionamides, hematopoietic stem cell transplantation to the latest immunomodulatory agents.

Prevention of relapse of Graves' disease by treatment with an intrathyroid injection of dexamethasone

INTRODUCTION

Antithyroid drugs are widely used in the treatment of Graves' disease (GD), but the relapse rate is very high after therapy withdrawal. We evaluated the reduction effects of intrathyroid injection of dexamethasone (IID) on the relapse rate of hyperthyroidism in patients with newly diagnosed GD.

PATIENTS AND METHODS

A total of 191 patients with GD completed the study. After 6 months of treatment with methimazole (MMI), the patients were randomly assigned to receive either MMI (96 patients) alone or MMI combined with IID (MMI+IID; 95 patients) treatment for 3 months, followed by continuing a dose of MMI that would maintain euthyroidism for the next 9 months in all of the patients. After withdrawal of the medical therapy, patients were followed for 24 months, and the relapse rate of hyperthyroidism was evaluated.

RESULTS

No statistical difference was observed in the levels of serum FT(4), TSH, or TSH receptor antibodies (TR-Ab), the thyroid volume, or the TR-Ab positive rate between the two groups at month 6. After the next 3 months of treatment with MMI+IID or MMI alone, the levels of TSH increased significantly, and the levels of serum TR-Ab, the TR-Ab positive rate, and thyroid volume decreased significantly in the MMI+IID group compared with the MMI group. Seven patients (7.4%) experienced a relapse of overt hyperthyroidism in the MMI+IID group and 49 patients (51%) in MMI group during the 2-yr follow-up period (P < 0.001).

CONCLUSIONS

MMI+IID treatment is helpful to prevent relapse of hyperthyroidism in GD after medical therapy withdrawal.

Successful treatment of hyperthyroidism with amiodarone in a patient with propylthiouracil-induced acute hepatic failure

Acute hepatic failure is a rare and potentially lethal complication of propylthiouracil (PTU) use for hyperthyroidism. We present a 20-year-old woman with Basedow-Graves' disease who developed PTU-induced fulminant hepatitis, which progressed to acute hepatic failure with grade III hepatic encephalopathy. Laboratory evaluation ruled out the most common causes of fulminant hepatitis. We treated her hyperthyroidism with amiodarone (average daily dose, 200 mg) for 3 weeks, achieving rapid and persistent euthyroidism, (triiodothyronine [T(3)] levels ranged between 64 and 109 ng/dL) without side effects. Amiodarone treatment did not abolish the thyroid radioactive iodine uptake (RAIU), allowing for subsequent treatment with radioactive iodine. The clinical course was favorable and the patient achieved full hepatic recovery 3 months after the hepatic failure was detected. After an extensive review of the literature, we believe that this is the first communication of the successful use of amiodarone to control hyperthyroidism in a patient with PTU-induced fulminant hepatitis.

The use of oral radiographic contrast agents in the management of hyperthyroidism

Oral iodinated radiographic contrast agents such as ipodate and iopanoic acid form an important part of the armamentarium used to treat hyperthyroidism. They rapidly and dramatically reduce serum triiodothyronine (T3) levels by inhibiting conversion of thyroxine (T4) to T3 in the periphery and by blocking secretion from the thyroid. Potential risks from the large iodine load resulting from their use limit their widespread applicability. In addition, they are ineffective when used alone on a long-term basis. However, these agents may be especially useful in treating thyrotoxic patients preoperatively, in neonatal Graves' disease, in massive levothyroxine ingestion, and when other conventional antithyroid drugs are unsuccessful or contraindicated.

Sodium ipodate and methimazole in the long-term treatment of hyperthyroid Graves' disease

A prospective study was conducted to evaluate the effect of prolonged treatment of hyperthryoid Graves' disease with methimazole (MMI) for 12 months or Na ipodate for only 6.6 +/- 1.1 months, since the drug had to be discontinued because of persistent or recurrent hyperthyroidism during treatment. The eight patients who were treated with MMI alone for 12 months became euthyroid, and seven remained in remission for at least 6 months after MMI was discontinued. In contrast, only two of 10 patients treated with Na ipodate alone became euthyroid and remained so during therapy. No ipodate was discontinued in the eight patients who did not respond, and they were then treated with MMI. One patient had recurrent hyperthyrodism after NA ipodate was discontinued, and she was then treated with MMI. MMI was efficacious in treating these nine patients, and all patients were euthyroid by the third month of MMI administration. Five of these nine patients remained euthyroid for at least 6 months after MMI was discontinued, a remission rate that was not significantly different from that observed in the eight patients treated only and initially with MMI (Fisher's Exact Test). There was no significant change in serum thyroid peroxidase antibodies during treatment with MMI alone, Na ipodate alone, or Na ipodate followed by MMI.(ABSTRACT TRUNCATED AT 250 WORDS)

Rapid preoperative preparation in hyperthyroidism

OBJECTIVE

We have evaluated an alternative method of preparation of hyperthyroid patients for surgery, using betamethasone, iopanoic acid and propranolol.

DESIGN

Betamethasone (0.5 mg every 6 hours), iopanoic acid (500 mg every 6 hours) and propranolol (40 mg every 8 hours) were given orally for 5 days; thyroidectomy was performed on the 6th day. We analysed patient acceptability, clinical and hormonal effects, ease of surgery and final outcome.

PATIENTS

Thirteen females and 1 male, aged 16-59 years, ten with diffuse goitre and four with nodular goitre were submitted to subtotal thyroidectomy because antithyroid drugs had failed to control thyrotoxicosis or because hyperthyroidism coexisted with other conditions (pregnancy, hypertensive disease).

MEASUREMENTS

Daily clinical assessments were made together with T3, T4 and rT3 serum concentrations before and while on drug treatment, during the surgical procedure and post-operatively.

RESULTS

Daily assessment showed progressive clinical improvement so that on day 5 the patients were considered clinically euthyroid. Serum levels of T3 (mean +/- SD) showed significant decrease (by 38.2 +/- 24.9%, P less than 0.01) as early as 24 hours after medication was started, reaching almost euthyroid levels on day 3; on the day of operation T3 had diminished by 64.5 +/- 16.6% (P less than 0.0001). Serum T4 concentration showed a slight but significant decrement only from day 4 on and never reached euthyroid levels. Serum rT3 values exhibited a brisk increment at 24 hours (+333 +/- 194%, P less than 0.0001) and remained elevated between 8 and 10 nmol/l until medication was stopped. Drug tolerance was considered as excellent since no serious side-effects were noted, even in pregnant patients. There were no anaesthetic incidents or postoperative complications and patients were discharged 48-72 hours after operation. The final outcome has been satisfactory and pregnant patients continued their pregnancies without incident, bearing normal children.

CONCLUSIONS

Pharmacological combination of betamethasone, iopanoic acid and propranolol has proved to be safe and effective and is of low cost. Provided there is adequate supervision of the patients, it may be used in patients requiring urgent thyroidectomy or in those who for reasons of non-compliance need a short preoperative regime.

Effects of amiodarone on serum T3 and T4 concentrations in hyperthyroid patients treated with propylthiouracil

Amiodarone (Cordarone) has been proven to be useful in the management of atrial fibrillation. However, because of a large iodine content, this drug is not used in this complication of thyrotoxicosis. We previously have observed a greater fall in serum T3 and T4 concentrations in hyperthyroid patients treated with amiodarone and methimazole than with methimazole alone. In the present study, we determined whether the addition of amiodarone to propylthiouracil (PTU) could improve the levels of circulating thyroid hormones in hyperthyroid patients, and we assessed the release of iodide from amiodarone by measuring the 24 h urinary iodine excretion. Twelve hyperthyroid patients were treated either with PTU, 600 mg daily for 10 days (group PTU), or with amiodarone (A), 1200 mg daily for 3 days in addition to PTU (group A-PTU). Basal serum T4, T3, and rT3 concentrations (mean +/- SEM) were respectively 206 +/- 13 nmol/L, 5.13 +/- 0.8 nmol/L, and 81 +/- 7 ng/dL for group PTU and 238 +/- 39 nmol/L, 4.73 +/- 1.06 nmol/L, and 84 +/- 12 ng/dL for group A-PTU (NS). In group A-PTU, plasma amiodarone peaked on day 3 (mean +/- SEM: 0.48 +/- 0.11 mg/L), and urinary iodine reached 5.27 +/- 1.28 mg/day on day 5. The fall in serum T3 and the increase in serum rT3 concentrations were significantly greater in group A-PTU than in group PTU (ANOVA, p less than 0.05). In group A-PTU, the minimal serum T3 concentration was observed on day 5 of treatment (28 +/- 6% of the pretreatment values).(ABSTRACT TRUNCATED AT 250 WORDS)

The effect of amiodarone on the control of hyperthyroidism by propylthiouracil

We studied the efficacy of amiodarone (800, 600, 400 and 200 mg orally daily during weeks 1, 2, 3 and 4, respectively) plus propylthiouracil (PTU, 100 mg orally every 8 h) in comparison to PTU alone in the early treatment (28 days) of Graves' disease patients. Circulating T3 and T4 decreased earlier and more markedly in the amiodarone plus PTU-treated group. An initial rise of circulating rT3 above the base-line value followed by a gradual decline was observed in the former group while only a decline below the base-line values was observed in the latter group. The resting pulse rate decreased and body weight increased significantly in the amiodarone plus PTU-treated group. In the PTU-treated group, significant weight gain was observed later in the course of treatment while no significant reduction in pulse rate was observed. No major side-effects of amiodarone were observed during the course of treatment. This study suggested that the combination of amiodarone and PTU was more efficacious than PTU alone in reducing circulating T3, T4 and clinical hyperthyroidism early in the course of treatment of patients with Graves' disease. This regimen has an additional potential advantage because of the antiarrhythmic property of amiodarone, especially in situations when a beta-blocker is contraindicated.

Comparison of methimazole, methimazole and sodium ipodate, and methimazole and saturated solution of potassium iodide in the early treatment of hyperthyroid Graves' disease

We have evaluated three regimens for the rapid control (10 days' therapy) of thyrotoxicosis in hyperthyroid Graves' disease: methimazole (MMI, 40 mg/day), MMI and sodium ipodate (MMI + Na Ipodate, 1 g/day and MMI and saturated solution of potassium iodide (MMI + SSKI, 6 drops twice daily). When serum T4 and T3 concentrations were analysed as the percent change from pre-treatment values, the following results were observed. Serum T4 concentration decreased in the three treatment groups and the decrease was similar in the MMI and MMI + SSKI groups but significantly lower than in the MMI + Na ipodate group. The serum T3 concentration decreased to the normal range in all seven MMI + Na Ipodate treated patients by the fourth day of treatment and the per cent decrease in serum T3 from pre-treatment values was significantly greater than in the MMI and MMI + SSKI treated patients. The decrease in serum T3 was similar in the latter two groups. Heart rate decreased in all three groups, but the decrease was significantly more in the MMI + Na Ipodate-treated patients. The present findings suggest that the rapid control of hyperthyroid Graves' disease is similar in patients treated with MMI and MMI + SSKI and that the combination of MMI + Na Ipodate is more efficacious since the decrease in serum T3 concentrations and heart rate was significantly greater in the MMI + Na ipodate-treated patients.

Effect of amiodarone on serum T4 and T3 levels in hyperthyroid patients treated with methimazole

We investigated the course of thyroid hormones levels in the serum of hyperthyroid patients acutely treated with amiodarone. Ten patients were treated either with amiodarone, 3 X 400 mg daily for 3 days in addition to methimazole, 3 X 20 mg daily for 10 days (Group I; n = 5) or with a placebo plus methimazole at the same doses (Group II; n = 5). Basal T3, T4 and rT3 serum concentrations were: 297 ng/dl, 16.6 micrograms/dl and 507 pg/dl, respectively in Group I and 377 ng/dl, 17.6 micrograms/dl and 362 pg/dl in Group II (NS). Compared with basal values, the drop in serum T3 concentration became significant on Day 1 in Group I, but not until day 5 in Group II. The decrease in serum T3 concentration was significantly higher in Group I than in Group II from Day 1 to Day 7. In Group I, T4 concentration was significantly lower on Days 2, 4 and 6; the percentage drop in T4 calculated from the areas under the curves was higher and the T3/T4 ratio lower on Days 3-5, 7 and 9; rT3 was higher on Days 4 and 5 and its rise was significant on Days 1, 3 and 4. During the follow-up period a transient rise in T4 and T3 concentrations was observed in two patients in Group I when the methimazole dosage was tapered or stopped because of agranulocytosis. In conclusion, in our hyperthyroid patients, amiodarone in conjunction with methimazole induced a greater fall in T3 and T4 than did methimazole alone.

Iopanoic acid is of minimal benefit in the treatment of severe hyperthyroidism: conclusions from a case study

Iopanoic acid (1 g/d) was used together with propylthiouracil (1200 mg/d) in the treatment of a patient with very severe hyperthyroidism and associated cardiac failure. Although serum total T3 decreased by 75% within 48 h and reached normal after 72 h, free T3 levels did not fall to normal. Total and free T4 remained markedly elevated and features of hyperthyroidism persisted. Estimations of theoretical in vivo occupancy of nuclear thyroid hormone receptors, based on serum free T4 and free T3, suggest that the marked decrease in total T3 would not result in a corresponding decrease in thyroid hormone action. Hence, estimates of potential benefit from oral cholecystographic contrast agents, based only on measurements of total T3, may be unduly optimistic. When temporary agranulocytosis developed in this patient, the prior use of iopanoic acid, by markedly reducing thyroidal iodine uptake, restricted the therapeutic options. Caution should, therefore, be exercised in the use of iodine-containing contrast media as adjunctive antithyroid agents.