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Žarković M, Attanasio R, Nagy EV, Negro R, Papini E, Perros P, Cohen CA, Akarsu E, Alevizaki M, Ayvaz G, Bednarczuk T, Berta E, Bodor M, Borissova AM, Boyanov M, Buffet C, Burlacu MC, Ćirić J, Díez JJ, Dobnig H, Fadeyev V, Field BCT, Fliers E, Frølich JS, Führer D, Galofré JC, Hakala T, Jiskra J, Kopp P, Krebs M, Kršek M, Kužma M, Lantz M, Lazúrová I, Leenhardt L, Luchytskiy V, McGowan A, Melo M, Metso S, Moran C, Morgunova T, Mykola T, Beleslin BN, Niculescu DA, Perić B, Planck T, Poiana C, Puga FM, Robenshtok E, Rosselet P, Ruchala M, Riis KR, Shepelkevich A, Unuane D, Vardarli I, Visser WE, Vrionidou A, Younes YR, Yurenya E, Hegedüs L. Characteristics of specialists treating hypothyroid patients: the "THESIS" collaborative. Front Endocrinol (Lausanne) 2023; 14:1225202. [PMID: 38027187 PMCID: PMC10660282 DOI: 10.3389/fendo.2023.1225202] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/19/2023] [Accepted: 10/16/2023] [Indexed: 12/01/2023] Open
Abstract
Introduction Thyroid specialists influence how hypothyroid patients are treated, including patients managed in primary care. Given that physician characteristics influence patient care, this study aimed to explore thyroid specialist profiles and associations with geo-economic factors. Methods Thyroid specialists from 28 countries were invited to respond to a questionnaire, Treatment of Hypothyroidism in Europe by Specialists: an International Survey (THESIS). Geographic regions were defined according to the United Nations Statistics Division. The national economic status was estimated using World Bank data on the gross national income per capita (GNI per capita). Results 5,695 valid responses were received (response rate 33·0%). The mean age was 49 years, and 65·0% were female. The proportion of female respondents was lowest in Northern (45·6%) and highest in Eastern Europe (77·2%) (p <0·001). Respondent work volume, university affiliation and private practice differed significantly between countries (p<0·001). Age and GNI per capita were correlated inversely with the proportion of female respondents (p<0·01). GNI per capita was inversely related to the proportion of respondents working exclusively in private practice (p<0·011) and the proportion of respondents who treated >100 patients annually (p<0·01). Discussion THESIS has demonstrated differences in characteristics of thyroid specialists at national and regional levels, strongly associated with GNI per capita. Hypothyroid patients in middle-income countries are more likely to encounter female thyroid specialists working in private practice, with a high workload, compared to high-income countries. Whether these differences influence the quality of care and patient satisfaction is unknown, but merits further study.
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Affiliation(s)
- Miloš Žarković
- University of Belgrade Faculty of Medicine, Internal Medicine, Belgrade, Serbia
- Clinic of Endocrinology, Diabetes and Diseases of Metabolism, Thyroid Department, Belgrade, Serbia
| | - Roberto Attanasio
- Associazione Medici Endocrinologi, Scientific Committee, Milan, Italy
| | - Endre V. Nagy
- Division of Endocrinology, Department of Medicine, Faculty of Medicine, University of Debrecen, Debrecen, Hungary
| | - Roberto Negro
- Ospedale Vito Fazzi, Department of Endocrinology, Lecce, Italy
| | - Enrico Papini
- Department of Endocrinology and Metabolism, Regina Apostolorum Hospital, Albano Laziale, Roma, Italy
| | - Petros Perros
- Institute of Translational and Clinical Research, Newcastle University, Newcastle Upon Tyne, United Kingdom
| | | | - Ersin Akarsu
- Department of Internal Medicine, Division of Endocrinology, Faculty of Medicine, Gaziantep University, Gaziantep, Türkiye
| | - Maria Alevizaki
- Endocrine Unit and Diabetes Centre, Department of Clinical Therapeutics, Alexandra Hospital, National and Kapodistrian University of Athens Faculty of Medicine, Athens, Greece
| | - Göksun Ayvaz
- Department of Endocrinology and Metabolism, Koru Ankara Hospital, Ankara, Türkiye
| | - Tomasz Bednarczuk
- Department of Internal Medicine and Endocrinology, Medical University of Warsaw, Warsaw, Poland
| | - Eszter Berta
- Division of Endocrinology, Department of Medicine, Faculty of Medicine, University of Debrecen, Debrecen, Hungary
| | - Miklos Bodor
- Division of Endocrinology, Department of Medicine, Faculty of Medicine, University of Debrecen, Debrecen, Hungary
| | - Anna Maria Borissova
- Sofia University Saint Kliment Ohridski, Medical Faculty, Clinic of Endocrinology and Metabolism, University Hospital “Sofiamed”, Sofia, Bulgaria
| | - Mihail Boyanov
- University Hospital Alexandrovska, Clinic of Endocrinology and Metabolism, Medical University-Sofia, Internal Medicine, Sofia, Bulgaria
| | - Camille Buffet
- GRC n 16, GRC Thyroid Tumors, Thyroid Disease and Endocrine Tumor Department, AP-HP, Hôpital Pitié Salpêtrière, Sorbonne University, Paris, France
| | - Maria-Cristina Burlacu
- Department of Endocrinology and Nutrition, Cliniques Universitaires St-Luc, Université Catholique De Louvain, Brussels, Belgium
| | - Jasmina Ćirić
- University of Belgrade Faculty of Medicine, Internal Medicine, Belgrade, Serbia
- Clinic of Endocrinology, Diabetes and Diseases of Metabolism, Thyroid Department, Belgrade, Serbia
| | - Juan J. Díez
- Department of Endocrinology, Hospital Universitario Puerta De Hierro Majadahonda, Madrid, Spain
- Instituto De Investigación Sanitaria Puerta De Hierro Segovia De Arana, Majadahonda, Madrid, Spain
- Department of Medicine, Universidad Autónoma De Madrid, Madrid, Spain
| | - Harald Dobnig
- Thyroid Endocrinology, Osteoporosis Institute Dobnig, Graz, Austria
| | - Valentin Fadeyev
- Department of Endocrinology No. 1, N.V. Sklifosovsky Institute of Clinical Medicine, I.M. Sechenov First Moscow State Medical University, Moscow, Russia
| | - Benjamin C. T. Field
- University of Surrey Faculty of Health and Medical Sciences, Section of Clinical Medicine, Prague, United Kingdom
| | - Eric Fliers
- Department of Endocrinology & Metabolism, Amsterdam UMC, University of Amsterdam, Amsterdam, Netherlands
| | | | - Dagmar Führer
- University Hospital Essen, Department of Endocrinology, Diabetes and Metabolism, University-Duisburg-Essen, Essen, Germany
| | - Juan Carlos Galofré
- Departmento De Endocrinologia e Nutrición, Clínica Universidad De Navarra, Pamplona, Spain
| | - Tommi Hakala
- Department of Surgery, Tampere University Hospital, Tampere, Finland
| | - Jan Jiskra
- 3rd Department of Medicine, 1st Faculty of Medicine, Charles University, General University Hospital, Prague, Czechia
| | - Peter Kopp
- Division of Endocrinology, Diabetology and Metabolism, University of Lausanne, Lausanne, Switzerland
| | - Michael Krebs
- Department of Medicine III, Division of Endocrinology, Medical University of Vienna, Vienna, Austria
| | - Michal Kršek
- 3rd Department of Medicine, 1st Faculty of Medicine, Charles University, General University Hospital, Prague, Czechia
| | - Martin Kužma
- 5th Department of Internal Medicine, Medical Faculty of Commenius University and University Hospital, Bratislava, Slovakia
| | - Mikael Lantz
- Department of Endocrinology, Skåne University Hospital, Malmö, Sweden
| | - Ivica Lazúrová
- P. J. Šafárik University Košice, 1st Department of Internal Medicine of the Medical Faculty, Košice, Slovakia
| | - Laurence Leenhardt
- Hopital Pitie-Salpetriere, Thyroid and Endocrine Tumors Unit, Institut of Endocrinology, Sorbonne University, Paris, France
| | - Vitaliy Luchytskiy
- Department of Reproductive Endocrinogy, Institute of Endocrinology and Metabolism named after V.P. Komissarenko, National Academy of Medical Science of Ukraine, Kyiv, Ukraine
| | - Anne McGowan
- Robert Graves Institute, Tallaght University Hospital, Dublin, Ireland
| | - Miguel Melo
- Department of Endocrinology, Diabetes and Metabolism, Medical Faculty, University of Coimbra, Coimbra, Portugal
| | - Saara Metso
- Department of Internal Medicine, Tampere University Hospital, Tampere, Finland
| | - Carla Moran
- Diabetes & Endocrinology Section, Beacon Hospital, Dublin, Ireland
- School of Medicine, University College Dublin, Dublin, Ireland
| | - Tatyana Morgunova
- Department of Endocrinology No. 1, N.V. Sklifosovsky Institute of Clinical Medicine, I.M. Sechenov First Moscow State Medical University, Moscow, Russia
| | - Tronko Mykola
- Institute of Endocrinology and Metabolism named after V.P. Komissarenko, National Academy of Medical Science of Ukraine, Kyiv, Ukraine
| | - Biljana Nedeljković Beleslin
- University of Belgrade Faculty of Medicine, Internal Medicine, Belgrade, Serbia
- Clinic of Endocrinology, Diabetes and Diseases of Metabolism, Thyroid Department, Belgrade, Serbia
| | - Dan Alexandru Niculescu
- Department of Endocrinology, Carol Davila University of Medicine and Pharmacy, Bucharest, Romania
| | - Božidar Perić
- Department of Endocrinology, Diabetes and Metabolic Diseases “Mladen Sekso”, University Hospital Center “Sisters of Mercy”, Zagreb, Croatia
| | - Tereza Planck
- Department of Endocrinology, Skåne University Hospital, Malmö, Sweden
| | - Catalina Poiana
- Department of Endocrinology, Carol Davila University of Medicine and Pharmacy, Bucharest, Romania
| | - Francisca Marques Puga
- Endocrinology, Diabetes and Metabolism Service, Porto Hospital and University Centre, Porto, Portugal
| | - Eyal Robenshtok
- Endocrinology Institute, Rabin Medical Center, Tel Aviv University Sackler Faculty of Medicine, Tel Aviv, Israel
| | | | - Marek Ruchala
- Department of Endocrinology, Metabolism and Internal Medicine, Poznan University of Medical Sciences, Poznan, Poland
| | - Kamilla Ryom Riis
- Department of Endocrinology, Odense University Hospital, Odense, Denmark
| | - Alla Shepelkevich
- Department of Endocrinology, Belarusian State Medical University, Minsk, Belarus
| | - David Unuane
- Department of Internal Medicine, Endocrine Unit, UZ Brussel, Vrije Universiteit Brussel, Brussel, Belgium
| | - Irfan Vardarli
- Department of Medicine I, Klinikum Vest GmbH, Knappschaftskrankenhaus Recklinghausen, Recklinghausen, Germany
- 5th Medical Department, Division of Endocrinology and Diabetes, Medical Faculty Mannheim, Heidelberg University, Mannheim, Germany
| | - W. Edward Visser
- Rotterdam Thyroid Center, Department of Internal Medicine, Erasmus MC, Rotterdam, Netherlands
| | - Andromachi Vrionidou
- Department of Endocrinology and Diabetes Centre, Hellenic Red Cross Hospital, Athens, Greece
| | - Younes R. Younes
- East Surrey Hospital, Surrey & Sussex Healthcare NHS Trust, Redhill, Surrey, United Kingdom
| | | | - Laszlo Hegedüs
- Department of Endocrinology, Odense University Hospital, Odense, Denmark
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Mourik JEM, Derks M, Te Beek ET, Ten Broek MRJ. Gamma camera-specific reference standards for radioactive iodine uptake measurements. EJNMMI Phys 2023; 10:55. [PMID: 37702889 PMCID: PMC10499732 DOI: 10.1186/s40658-023-00575-2] [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: 01/31/2023] [Accepted: 09/05/2023] [Indexed: 09/14/2023] Open
Abstract
BACKGROUND Current guidelines of the radioiodine uptake (RAIU) test allow the use of different equipment, isotopes, activity and region-of-interest (ROI). We evaluated presence and extent of these differences in clinical practice and evaluated the effect of some of these variations on RAIU outcomes. Also, gamma camera-specific reference standards were calculated and retrospectively compared with measurements obtained during clinical RAIU tests. MATERIALS AND METHODS First, questionnaires were sent to Dutch nuclear medicine departments requesting information about equipment usage, isotope, isotope formulation, activity and measurement techniques. Secondly, a neck phantom containing a range of activities in capsule or water-dissolved formulation was scanned. Counts were measured using automatic ROI, square box ROI or all counts in the image. Thirdly, clinical RAIU data were collected during 2015-2018 using three different gamma cameras. Reference standards for each scanner were calculated using regression analysis between reference activity and measured counts. Uptake measurements using this gamma camera-specific reference standard were compared with original measurements. RESULTS The survey demonstrated significant differences in isotope, isotope formulation, activity, use of neck phantoms, frequency and duration of reference measurements, distance to collimator, use of background measurements and ROI delineation. The phantom study demonstrated higher counts for the water-dissolved formulation than capsules using both automatic and square box ROI. Also, higher counts were found using a square box ROI than an automatic ROI. The retrospective study showed feasibility of RAIU calculations using camera-specific reference standards and good correlation with the original RAIU measurements. CONCLUSIONS This study demonstrated considerable technical variation in RAIU measurement in clinical practice. The phantom study demonstrated that these differences could result in differences in count measurements, potentially resulting in different dose calculations for radioactive iodine therapy. Retrospective data suggest that camera-specific reference standards may be used instead of individual reference measurements using separate activity sources, which may thus eliminate some sources of variation.
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Affiliation(s)
- Jurgen E M Mourik
- Department of Nuclear Medicine, Franciscus Gasthuis & Vlietland Hospital, Kleiweg 500, 3045 PM, Rotterdam, The Netherlands.
| | - Mark Derks
- Department of Nuclear Medicine, IJsselland Hospital, Capelle aan den IJssel, The Netherlands
| | - Erik T Te Beek
- Department of Nuclear Medicine, Reinier de Graaf Hospital, Delft, The Netherlands
| | - Marc R J Ten Broek
- Department of Nuclear Medicine, IJsselland Hospital, Capelle aan den IJssel, The Netherlands
- Department of Nuclear Medicine, Reinier de Graaf Hospital, Delft, The Netherlands
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Wang Y, Sun Y, Yang B, Wang Q, Kuang H. The management and metabolic characterization: hyperthyroidism and hypothyroidism. Neuropeptides 2023; 97:102308. [PMID: 36455479 DOI: 10.1016/j.npep.2022.102308] [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: 08/19/2022] [Revised: 10/21/2022] [Accepted: 11/08/2022] [Indexed: 11/13/2022]
Abstract
Hyperthyroidism and hypothyroidism are common diseases resulting from thyroid dysfunction, and are simple to diagnose and treat. The traditional treatment for hypothyroidism is thyroid hormone replacement therapy. The traditional treatments for hyperthyroidism include antithyroid drug, iodine radiotherapy, and surgery. Thyroid disease can be fatal in severe cases if untreated. Current statistical reference ranges used for diagnosis based on relevant biochemical parameters have been debated, and insufficient treatment can result in long-term thyroid hormone deficiency, which is associated with increased risk of cardiovascular disease and persistent symptoms. In contrast, overtreatment can result in heart disease and osteoporosis, particularly in older people and pregnant women. Therefore, under- or over-treatment should be avoided and treatment regimens should be monitored closely. A significant proportion of patients who achieve biochemical treatment goals still complain of significant symptoms. Systematic literature review was performed through the Embase (Elsevier), PubMed and Web of Science databases, and studies summarized evidence regarding treatment and management of hypothyroidism and hyperthyroidism, and reviewed clinical practice guidelines. We also reviewed the latest research on the metabolic mechanisms of hyperthyroidism and hypothyroidism, which contributed to understanding of thyroid diseases in the clinic. A reliable algorithm is needed to management, assessment, and treatment patients with hyperthyroidism and hypothyroidism, which can not only improve management efficiency, but also providing a broad application. In addition, the thyroid disorder showed a lipid metabolism tissue specificity in the Ventromedial Hypothalamus, and effect oxidative stress and energy metabolism of whole body. This review summarizes an algorithm for thyroid disease and the latest pathogenesis that would be useful to generalist and subspecialty physicians and others providing care for patients with this condition.
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Affiliation(s)
- Yangyang Wang
- Key Laboratory of Basic and Application Research of Beiyao (Heilongjiang University of Chinese Medicine), Ministry of Education, Harbin, China
| | - YanPing Sun
- Key Laboratory of Basic and Application Research of Beiyao (Heilongjiang University of Chinese Medicine), Ministry of Education, Harbin, China
| | - Bingyou Yang
- Key Laboratory of Basic and Application Research of Beiyao (Heilongjiang University of Chinese Medicine), Ministry of Education, Harbin, China
| | - Qiuhong Wang
- School of Traditional Chinese Medicine, Guangdong Pharmaceutical University, Guangzhou, China.
| | - Haixue Kuang
- Key Laboratory of Basic and Application Research of Beiyao (Heilongjiang University of Chinese Medicine), Ministry of Education, Harbin, China.
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Perros P, Basu A, Boelaert K, Dayan C, Vaidya B, Williams GR, Lazarus JH, Hickey J, Drake WM, Crown A, Orme SM, Johnson A, Ray DW, Leese GP, Jones TH, Abraham P, Grossman A, Rees A, Razvi S, Gibb FW, Moran C, Madathil A, Žarković MP, Plummer Z, Jarvis S, Falinska A, Velusamy A, Sanderson V, Pariani N, Atkin SL, Syed AA, Sathyapalan T, Nag S, Gilbert J, Gleeson H, Levy MJ, Johnston C, Sturrock N, Bennett S, Mishra B, Malik I, Karavitaki N. Postradioiodine Graves' management: The PRAGMA study. Clin Endocrinol (Oxf) 2022; 97:664-675. [PMID: 35274331 DOI: 10.1111/cen.14719] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/01/2021] [Revised: 01/04/2022] [Accepted: 01/05/2022] [Indexed: 11/29/2022]
Abstract
OBJECTIVE Thyroid status in the months following radioiodine (RI) treatment for Graves' disease can be unstable. Our objective was to quantify frequency of abnormal thyroid function post-RI and compare effectiveness of common management strategies. DESIGN Retrospective, multicentre and observational study. PATIENTS Adult patients with Graves' disease treated with RI with 12 months' follow-up. MEASUREMENTS Euthyroidism was defined as both serum thyrotropin (thyroid-stimulating hormone [TSH]) and free thyroxine (FT4) within their reference ranges or, when only one was available, it was within its reference range; hypothyroidism as TSH ≥ 10 mU/L, or subnormal FT4 regardless of TSH; hyperthyroidism as TSH below and FT4 above their reference ranges; dysthyroidism as the sum of hypo- and hyperthyroidism; subclinical hypothyroidism as normal FT4 and TSH between the upper limit of normal and <10 mU/L; and subclinical hyperthyroidism as low TSH and normal FT4. RESULTS Of 812 patients studied post-RI, hypothyroidism occurred in 80.7% and hyperthyroidism in 48.6% of patients. Three principal post-RI management strategies were employed: (a) antithyroid drugs alone, (b) levothyroxine alone, and (c) combination of the two. Differences among these were small. Adherence to national guidelines regarding monitoring thyroid function in the first 6 months was low (21.4%-28.7%). No negative outcomes (new-onset/exacerbation of Graves' orbitopathy, weight gain, and cardiovascular events) were associated with dysthyroidism. There were significant differences in demographics, clinical practice, and thyroid status postradioiodine between centres. CONCLUSIONS Dysthyroidism in the 12 months post-RI was common. Differences between post-RI strategies were small, suggesting these interventions alone are unlikely to address the high frequency of dysthyroidism.
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Affiliation(s)
- Petros Perros
- Department of Endocrinology, Royal Victoria Infirmary, Newcastle upon Tyne, UK
| | - Ansu Basu
- Department of Endocrinology and Diabetes, Sandwell and West Birmingham Hospitals, Birmingham, UK
| | - Kristien Boelaert
- Institute of Applied Health Research, College of Medical and Dental Sciences, University of Birmingham, Birmingham, UK
| | - Colin Dayan
- Thyroid Research Group, Institute of Molecular Medicine, Cardiff University School of Medicine, Cardiff, UK
| | - Bijay Vaidya
- Department of Endocrinology, Royal Devon and Exeter Hospital NHS Foundation Trust, Exeter, UK
| | - Graham R Williams
- Molecular Endocrinology Laboratory, Imperial College London, London, UK
| | - John H Lazarus
- Thyroid Research Group, Institute of Molecular Medicine, Cardiff University School of Medicine, Cardiff, UK
| | | | - William M Drake
- Department of Endocrinology, St Bartholomews Hospital, London, UK
| | - Anna Crown
- Department of Endocrinology, Royal Sussex County Hospital, University Hospitals Sussex NHS Foundation Trust, Brighton, UK
| | - Stephen M Orme
- Department of Endocrinology, St. James's University Hospital, Leeds, UK
| | - Andrew Johnson
- Department of Endocrinology and Diabetes, North Bristol NHS Trust, Bristol, UK
| | - David W Ray
- Manchester Centre for Endocrinology and Diabetes, Institute of Human Development, The University of Manchester, Manchester, UK
| | - Graham P Leese
- Department of Endocrinology and Diabetes, Ninewells Hospital and Medical School, Dundee, UK
| | - Thomas Hugh Jones
- Centre for Diabetes and Endocrinology, Barnsley Hospital NHS Foundation Trust, Barnsley, UK
| | - Prakash Abraham
- Department of Diabetes and Endocrinology, Aberdeen Royal Infirmary, Aberdeen, UK
| | - Ashley Grossman
- Department of Endocrinology, Oxford Centre for Diabetes, Endocrinology and Metabolism, University of Oxford, Oxford, UK
| | - Aled Rees
- School of Medicine, Neuroscience and Mental Health Research Institute, Cardiff University, Cardiff, UK
| | - Salman Razvi
- Department of Endocrinology, Gateshead Health NHS Foundation Trust, Gateshead, UK
| | - Fraser W Gibb
- Edinburgh Centre for Endocrinology and Diabetes, Edinburgh, UK
| | - Carla Moran
- Addenbrooke's Hospital, Wellcome Trust-MRC Institute of Metabolic Science, University of Cambridge Metabolic Research Laboratories, Cambridge, UK
| | - Asgar Madathil
- Department of Endocrinology and Metabolic Medicine, Northumbria Healthcare NHS Foundation Trust, Northumberland, UK
| | - Miloš P Žarković
- Serbia Faculty of Medicine, University of Belgrade, Belgrade, Serbia
| | | | - Sheba Jarvis
- Molecular Endocrinology Laboratory, Imperial College London, London, UK
| | | | - Anand Velusamy
- Department of Endocrinology, Royal Sussex County Hospital, University Hospitals Sussex NHS Foundation Trust, Brighton, UK
| | - Violet Sanderson
- Department of Endocrinology, Oxford Centre for Diabetes, Endocrinology and Metabolism, University of Oxford, Oxford, UK
| | - Nadia Pariani
- Addenbrooke's Hospital, Wellcome Trust-MRC Institute of Metabolic Science, University of Cambridge Metabolic Research Laboratories, Cambridge, UK
| | - Stephen L Atkin
- Academic Endocrinology, Diabetes and Metabolism, Hull York Medical School, Hull, UK
| | - Akheel A Syed
- Department of Endocrinology, Salford Royal NHS Foundation Trust, Salford, UK
| | | | - Sath Nag
- Department of Endocrinology, The James Cook University Hospital, South Tees Hospitals NHS Foundation Trust, Middlesbrough, UK
| | - Jackie Gilbert
- Department of Endocrinology, King's College Hospital, London, UK
| | - Helena Gleeson
- Department of Endocrinology, University Hospitals of Leicester, Leicester, UK
| | - Miles J Levy
- Department of Endocrinology, University Hospitals of Leicester, Leicester, UK
| | - Colin Johnston
- Department of Endocrinology and Diabetes, West Hertfordshire Hospitals NHS Trust, Hertfordshire, UK
| | - Nigel Sturrock
- Department of Endocrinology and Metabolic Medicine, Nottingham City Hospitals NHS Trust, Nottingham, UK
| | - Stuart Bennett
- Department of Endocrinology and Metabolic Medicine, Northumbria Healthcare NHS Foundation Trust, Northumberland, UK
| | - Biswa Mishra
- Department of Endocrinology and Metabolic Medicine, Pennine Acute Hospitals NHS Trust, Royal Oldham Hospital, Oldham, UK
| | - Isha Malik
- Department of Endocrinology and Metabolic Medicine, Pennine Acute Hospitals NHS Trust, Royal Oldham Hospital, Oldham, UK
| | - Niki Karavitaki
- Department of Endocrinology, Oxford Centre for Diabetes, Endocrinology and Metabolism, University of Oxford, Oxford, UK
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Pamnani H, Jindal R, Khare J, Sharma M, Siddiqui A, Wangnoo SK. Observational Study on Outcomes after Radioiodine Ablation in Hyperthyroid Patients. Indian J Endocrinol Metab 2022; 26:149-153. [PMID: 35873945 PMCID: PMC9302425 DOI: 10.4103/ijem.ijem_29_22] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/13/2022] [Revised: 02/12/2022] [Accepted: 03/30/2022] [Indexed: 11/21/2022] Open
Abstract
INTRODUCTION Radio-active Iodine (RAI) is a safe, definitive, and cost-effective modality of treatment that is used as the first line of treatment for Graves' hyperthyroidism by most endocrinologists. Very few reports are available from India, observational follow-up data is needed to determine the meaningful prognostic outcomes of RAI ablation in the Indian population. AIMS To study the outcomes in hyperthyroid patients undergoing RAI ablation. MATERIALS AND METHODS This observational cohort study was conducted at Department of Endocrinology at Indraprastha Apollo Hospital, New Delhi. A total of 82 hyperthyroid patients who underwent RAI ablation between June 2014 to June 2018 were enrolled. RAI dose was calculated arbitrarily in most cases; often by an empirical fixed dose based on the goiter size and RAIU. The patients were reviewed at 1, 3 and 6 months post-RAI ablation. During follow-up, along with a detailed clinical examination, free T4, free T3 and TSH were checked. RESULTS The dose of I-131 varied from 6 mCi to 14 mCi. Most of the patients were given RAI in the dose of 7.1-10 mci. About 63.4% of patients achieved hypothyroidism in 6 months, 6.1% in 1 month, 37.8% in 3 months, and 19.5% in 6 months. Gender, age, etiology of hyperthyroidism, baseline thyroid function, goiter, and ophthalmopathy did not affect outcomes after RAI ablation. Those who were not treated with antithyroid drugs prior to RAI therapy were found to have higher rates of conversion to a hypothyroid state. CONCLUSION RAI can be given safely as the first line of treatment in Graves' disease and antithyroid drug naïve patients respond better to therapy.
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Affiliation(s)
- Harsha Pamnani
- Department of Endocrinology, Peoples College of Medical Sciences and Research Centre, Bhopal, Madhya Pradesh, India
| | - Radhika Jindal
- Department of Endocrinology, Safdarjung Hospital, New Delhi, India
| | - Jaideep Khare
- Department of Endocrinology, Peoples College of Medical Sciences and Research Centre, Bhopal, Madhya Pradesh, India
| | - Monika Sharma
- Consultant Endocrinologist, Venkateshwar Hospital, New Delhi, India
| | - Asim Siddiqui
- Senior Consultant Endocrinologist, Indraprastha Apollo Hospital, New Delhi, India
| | - Subhash K. Wangnoo
- Senior Consultant Endocrinologist, Indraprastha Apollo Hospital, New Delhi, India
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Tran T, Maringe C, Benitez Majano S, Rachet B, Boutron‐Ruault M, Journy N. Thyroid dysfunction and breast cancer risk among women in the UK Biobank cohort. Cancer Med 2021; 10:4604-4614. [PMID: 34041857 PMCID: PMC8267139 DOI: 10.1002/cam4.3978] [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: 01/20/2021] [Revised: 04/05/2021] [Accepted: 04/29/2021] [Indexed: 12/24/2022] Open
Abstract
This study aimed to evaluate the association between thyroid dysfunction and breast cancer risk. We included 239,436 females of the UK Biobank cohort. Information on thyroid dysfunction, personal and family medical history, medications, reproductive factors, lifestyle, and socioeconomic characteristics was retrieved from baseline self-reported data and hospital inpatient databases. Breast cancer diagnoses were identified through population-based registries. We computed Cox models to estimate hazard ratios (HRs) of breast cancer incidence for thyroid dysfunction diagnosis and treatments, and examined potential confounding and effect modification by comorbidities and breast cancer risk factors. In our study, 3,227 (1.3%) and 20,762 (8.7%) women had hyper- and hypothyroidism prior to the baseline. During a median follow-up of 7.1 years, 5,326 (2.2%) women developed breast cancer. Compared to no thyroid dysfunction, there was no association between hypothyroidism and breast cancer risk overall (HR = 0.93, 95% confidence interval (CI): 0.84-1.02, 442 cases), but we found a decreased risk more than 10 years after hypothyroidism diagnosis (HR=0.85, 95%CI 0.74-0.97, 226 cases). There was no association with hyperthyroidism overall (HR=1.08, 95%CI 0.86-1.35, 79 cases) but breast cancer risk was elevated among women with treated hyperthyroidism (HR=1.38, 95%CI: 1.03-1.86, 44 cases) or aged 60 years or more at hyperthyroidism diagnosis (HR=1.74, 95%CI: 1.01-3.00, 113 cases), and 5-10 years after hyperthyroidism diagnosis (HR=1.58, 95%CI: 1.06-2.33, 25 cases). In conclusion, breast cancer risk was reduced long after hypothyroidism diagnosis, but increased among women with treated hyperthyroidism. Future studies are needed to determine whether the higher breast cancer risk observed among treated hyperthyroidism could be explained by hyperthyroidism severity, type of treatment or aetiology.
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Affiliation(s)
- Thi‐Van‐Trinh Tran
- Epidemiology of radiation GroupCenter for Research in Epidemiology and Population HealthINSERM U1018Paris Sud‐Paris Saclay UniversityVillejuifFrance
| | - Camille Maringe
- Inequalities in Cancer Outcomes NetworkDepartment of Non‐Communicable Disease EpidemiologyLondon School of Hygiene and Tropical MedicineLondonUK
| | - Sara Benitez Majano
- Inequalities in Cancer Outcomes NetworkDepartment of Non‐Communicable Disease EpidemiologyLondon School of Hygiene and Tropical MedicineLondonUK
| | - Bernard Rachet
- Inequalities in Cancer Outcomes NetworkDepartment of Non‐Communicable Disease EpidemiologyLondon School of Hygiene and Tropical MedicineLondonUK
| | - Marie‐Christine Boutron‐Ruault
- Health across Generations TeamCenter for Research in Epidemiology and Population HealthINSERM U1018Paris Sud‐Paris Saclay UniversityVillejuifFrance
| | - Neige Journy
- Epidemiology of radiation GroupCenter for Research in Epidemiology and Population HealthINSERM U1018Paris Sud‐Paris Saclay UniversityVillejuifFrance
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7
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Sjölin G, Byström K, Holmberg M, Törring O, Khamisi S, Calissendorff J, Lantz M, Hallengren B, Filipsson Nyström H, Planck T, Wallin G. Treatment of patients with Graves' disease in Sweden compared to international surveys of an 'index patient'. ENDOCRINOLOGY DIABETES & METABOLISM 2021; 4:e00244. [PMID: 34277969 PMCID: PMC8279596 DOI: 10.1002/edm2.244] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 12/30/2020] [Revised: 01/11/2021] [Accepted: 02/06/2021] [Indexed: 01/21/2023]
Abstract
Introduction The treatment strategies for a 42‐year‐old female index patient with moderate Graves’ disease (GD) vary according to several international surveys. The important question whether surveys of treatment preferences in theoretical patient cases also match how real patients are treated has not yet been addressed. Materials and Methods From a Swedish cohort of 1186 GD patients (TT‐12 cohort), 27 women were identified using the same criteria as from the index patient surveys from the European and American Thyroid Associations. This ‘index patient cohort’ was age 40–45, otherwise healthy female, with two children and uncomplicated GD. The applied first‐line treatment of the patients in the index cohort, together with its variations, was compared with the treatment preferences according to international surveys. A comparison with the TT‐12 cohort was also performed. Results In the ‘Index cohort’, 77.8% were treated with antithyroid drugs (ATD), and 22.2% were treated with radioiodine (131I). This preference for ATD is in line with most countries/regions, with the exception of USA and the Middle East/North Africa, where 131I was preferred. The distribution of treatment in the TT‐12 cohort did not significantly differ from the index cohort. ATD was the preferred treatment in male and young (age 19–22) patients, as was RAI in old (age 69–73) patients. The age‐related, but not the gender‐related, cases differed significantly from the entire TT‐12 cohort. Conclusion The treatment choice in an index patient in Sweden seems in line with European practice, where ATD is the preferred first choice. This differs compared to US and North African survey intentions, where 131I is more often used. Age more than gender influences the treatment choice of GD patients. This is, to our best knowledge, the first time an index patient from ‘real life’ has been presented and compared to treatment preferences of international thyroid association surveys.
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Affiliation(s)
- Gabriel Sjölin
- Faculty of Medicine and Health Örebro University Hospital Örebro Sweden
| | - Kristina Byström
- Department of Medicine Örebro University and University Hospital Örebro Sweden
| | - Mats Holmberg
- Institute of Medicine Sahlgrenska Academy University of Gothenburg Göteborg Sweden.,ANOVA, Karolinska University Hospital Stockholm Sweden
| | - Ove Törring
- Institution for Clinical Science and Education Karolinska Institutet Stockholm Sweden
| | - Selwan Khamisi
- Department of Endocrinology Uppsala University Hospital Uppsala Sweden.,Department of Medical Sciences Uppsala University Uppsala Sweden
| | - Jan Calissendorff
- Department of Molecular Medicine and Surgery Karolinska Institutet Stockholm Sweden.,Department of Endocrinology, Metabolism and Diabetes Karolinska University Hospital Stockholm Sweden
| | - Mikael Lantz
- Department of Endocrinology Skåne University Hospital Malmö Sweden.,Department of Clinical Sciences Lund University Lund Sweden
| | - Bengt Hallengren
- Department of Endocrinology Skåne University Hospital Malmö Sweden.,Department of Clinical Sciences Lund University Lund Sweden
| | - Helena Filipsson Nyström
- Institute of Medicine Sahlgrenska Academy University of Gothenburg Göteborg Sweden.,Department of Endocrinology Sahlgrenska University Hospital Göteborg Sweden.,Wallenberg Center for Molecular and Translational Medicine Göteborg Sweden
| | - Tereza Planck
- Department of Endocrinology Skåne University Hospital Malmö Sweden.,Department of Clinical Sciences Lund University Lund Sweden
| | - Göran Wallin
- Faculty of Medicine and Health Örebro University Hospital Örebro Sweden.,Department of Molecular Medicine and Surgery Karolinska Institutet Stockholm Sweden
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8
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Žarković M, Wiersinga W, Perros P, Bartalena L, Donati S, Okosieme O, Morris D, Fichter N, Lareida J, Daumerie C, Burlacu MC, Kahaly GJ, Pitz S, Beleslin B, Ćirić J, Ayvaz G, Konuk O, Törüner FB, Salvi M, Covelli D, Curro N, Hegedüs L, Brix T. Antithyroid drugs in Graves' hyperthyroidism: differences between "block and replace" and "titration" regimes in frequency of euthyroidism and Graves' orbitopathy during treatment. J Endocrinol Invest 2021; 44:371-378. [PMID: 32524368 DOI: 10.1007/s40618-020-01320-7] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/12/2020] [Accepted: 05/30/2020] [Indexed: 02/08/2023]
Abstract
PURPOSE Whereas antithyroid drugs (ATD) are the preferred treatment modality for Graves' hyperthyroidism (GH), there is still controversy about the optimal regimen for delivering ATD. To evaluate whether 'Block and Replace' (B + R) and 'Titration' (T) regimes are equivalent in terms of frequency of euthyroidism and Graves' Orbitopathy (GO) during ATD therapy. METHODS A prospective multicentre observational cohort study of 344 patients with GH but no GO at baseline. Patients were treated with ATD for 18 months according to B + R or T regimen in line with their institution's policy. RESULTS Baseline characteristics were similar in both groups. In the treatment period between 6 and 18 months thyrotropin (TSH) slightly increased in both groups, but TSH was on average 0.59 mU/L (95% CI 0.27-0.85) lower in the B + R group at all time points (p = 0.026). Serum free thyroxine (FT4) remained stable during the same interval, with a tendency to higher values in the B + R group. The point-prevalence of euthyroidism (TSH and FT4 within their reference ranges) increased with longer duration of ATD in both groups; it was always higher in the T group than in the B + R group: 48 and 24%, respectively, at 6 months, 81 and 58% at 12 months, and 87 and 63% at 18 months (p < 0.002). There were no significant differences between the B + R and T regimens with respect to the fall in thyrotropin binding inhibiting immunoglobulins (TBII) or thyroid peroxidase antibodies (TPO-Ab). GO developed in 15.9% of all patients: 9.1 and 17.8% in B + R group and T group, respectively, (p = 0.096). GO was mild in 13% and moderate-to-severe in 2%. CONCLUSION The prevalence of biochemical euthyroidism during treatment with antithyroid drugs is higher during T compared to B + R regimen. De novo development of GO did not differ significantly between the two regimens, although it tended to be higher in the T group. Whether one regimen is clinically more advantageous than the other remains unclear.
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Affiliation(s)
- M Žarković
- School of Medicine, University of Belgrade, Belgrade, Serbia.
- Clinic of Endocrinology Clinical Centre of Serbia, Belgrade, Serbia.
| | - W Wiersinga
- Department of Endocrinology and Metabolism, Academic Medical Center, University of Amsterdam, Amsterdam, Netherlands
| | - P Perros
- Department of Endocrinology, Royal Victoria Infirmary, Newcastle upon Tyne, UK
| | - L Bartalena
- School of Medicine, University of Insubria, Varese, Italy
| | - S Donati
- School of Medicine, University of Insubria, Varese, Italy
| | - O Okosieme
- Department of Endocrinology, Institute of Molecular and Experimental Medicine, Cardiff University School of Medicine, Cardiff, UK
| | - D Morris
- Cardiff Eye Unit, University Hospital of Wales, Cardiff, UK
| | - N Fichter
- Interdisciplinary Centre for Graves' Orbitopathy, Olten and University Eye Hospital, Basel, Switzerland
| | - J Lareida
- Interdisciplinary Centre for Graves' Orbitopathy, Olten and University Eye Hospital, Basel, Switzerland
| | - C Daumerie
- Department of Endocrinology, Université Catholique de Louvain, Cliniques Universitaires Saint-Luc, Brussels, Belgium
| | - M-C Burlacu
- Department of Endocrinology, Université Catholique de Louvain, Cliniques Universitaires Saint-Luc, Brussels, Belgium
| | - G J Kahaly
- Department of Medicine I, Johannes Gutenberg University Medical Center, Mainz, Germany
| | - S Pitz
- Orbital Center, Ophthalmic Clinic, Buergerhospital, Frankfurt, Germany
| | - B Beleslin
- School of Medicine, University of Belgrade, Belgrade, Serbia
- Clinic of Endocrinology Clinical Centre of Serbia, Belgrade, Serbia
| | - J Ćirić
- School of Medicine, University of Belgrade, Belgrade, Serbia
- Clinic of Endocrinology Clinical Centre of Serbia, Belgrade, Serbia
| | - G Ayvaz
- Department of Endocrinology and Metabolism, Faculty of Medicine, Gazi University, Ankara, Turkey
| | - O Konuk
- Department of Ophthalmology, Faculty of Medicine, Gazi University, Ankara, Turkey
| | - F B Törüner
- Department of Endocrinology and Metabolism, Faculty of Medicine, Gazi University, Ankara, Turkey
| | - M Salvi
- Graves' Orbitopathy Unit, Department of Clinical Science and Community Health, Fondazione Ca'Granda IRCCS, University of Milan, Milan, Italy
| | - D Covelli
- Graves' Orbitopathy Unit, Department of Clinical Science and Community Health, Fondazione Ca'Granda IRCCS, University of Milan, Milan, Italy
| | - N Curro
- Department of Ophthalmology, Fondazione IRCCS Ca'Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - L Hegedüs
- Department of Endocrinology and Metabolism, Odense University Hospital, University of Southern Denmark, Odense, Denmark
| | - T Brix
- Department of Endocrinology and Metabolism, Odense University Hospital, University of Southern Denmark, Odense, Denmark
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9
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Effect of Different 131I Dose Strategies for Treatment of Hyperthyroidism on Graves' Ophthalmopathy. Clin Nucl Med 2020; 45:514-518. [PMID: 32433165 DOI: 10.1097/rlu.0000000000003086] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
PURPOSE The study aims to define the effect of different dose strategies on ophthalmic complications in patients with Graves' disease (GD). METHODS All the patients with GD and no or inactive ophthalmopathy (clinical activity score; CAS < 3) underwent Snellen chart examination, measurement of proptosis, thyroid volume, and radioactive iodine uptake, and randomized into 1 of 3 groups. In group 1, all the patients received fixed low dose (FLD) of 259 MBq of I, whereas in group 2, all the patients received fixed high dose (FHD) of 555 MBq, and in group 3, calculated dose (CD) was administered to deliver 5.55 MBq/g (thyroid weight) of I. All examinations were repeated 6 months after treatment. The measurement of thyroid function tests and clinical examination were repeated after 12 months. RESULTS We studied 92 patients (58 female and 34 male) with mean age of 38.2 ± 12.0 years. Overall, 29, 32, and 31 patients were studied in FLD, FHD, and CD groups, respectively. The patients in CD received a mean activity of 240.5 MBq. The 3 groups were not significantly different regarding age, sex ratio, radioactive iodine uptake, smoking, visual acuity, and proptosis. The response rate 12 months after radioactive iodine therapy was 66.7%, 94.4%, and 92.9% in FLD, FHD, and CD groups, respectively (P = 0.05). Overall, CAS was increased significantly after treatment. Delta proptosis and delta CAS were increased significantly in FHD group compared with other groups (P < 0.05). The highest increment in proptosis was seen in FHD group. CONCLUSIONS The administration of 5.55 MBq/g of I has fewer ophthalmic complications compared with high fixed dose model and is more effective than low fixed dose strategy.
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Francis N, Francis T, Lazarus JH, Okosieme OE. Current controversies in the management of Graves' hyperthyroidism. Expert Rev Endocrinol Metab 2020; 15:159-169. [PMID: 32315207 DOI: 10.1080/17446651.2020.1754192] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/01/2020] [Accepted: 04/07/2020] [Indexed: 12/12/2022]
Abstract
Introduction: The management of Graves' disease centers on the use of effective and well-established therapies, namely thionamide antithyroid drugs, radioactive iodine, and thyroidectomy. Optimal treatment strategies are however controversial and vary significantly across centers.Areas covered: This review addresses specific controversies in Graves' disease management including the choice of primary therapy, the approach to women planning pregnancy, and optimal strategies for antithyroid drug and radioiodine therapy.Expert opinion: Important considerations in choosing therapy include treatment efficacy, adverse effects, patient convenience, and resource settings. Recent data suggest that early and effective control of hyperthyroidism is key to improving cardiovascular morbidity and mortality. Studies addressing cancer risk in radioiodine-treated patients face methodological challenges and require clarification in appropriately designed studies. Remission rates with antithyroid drugs are comparable when thionamides are used alone (titration-regimen) or in combination with levothyroxine (block and replace) and can be optimized by extending treatment for at least 12-18 months. Fixed and calculated radioiodine activity regimens are both effective but entail a trade-off between convenience and precision in the administered activity. Optimal preconception strategies are still evolving but ablative treatment in advance of pregnancy offers the most pragmatic means of reducing adverse effects of hyperthyroidism in subsequent pregnancy.
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Affiliation(s)
- Niroshan Francis
- Endocrinology and Diabetes Department, Prince Charles Hospital, Cwm Taf University Health Board, Merthyr Tydfil, UK
| | - Thanuya 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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11
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Plazinska MT, Sawicka-Gutaj N, Czarnywojtek A, Wolinski K, Kobylecka M, Karlińska M, Prasek K, Zgorzalewicz-Stachowiak M, Borowska M, Gut P, Ruchala M, Krolicki L. Radioiodine therapy and Graves' disease - Myths and reality. PLoS One 2020; 15:e0226495. [PMID: 31929534 PMCID: PMC6957158 DOI: 10.1371/journal.pone.0226495] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/28/2019] [Accepted: 11/07/2019] [Indexed: 12/04/2022] Open
Abstract
Introduction Autoimmune reactions in Graves’ disease (GD) occur not only in the thyroid gland, but also in the orbital connective tissue, eyelids, extraocular muscles. The occurrence of orbitopathy in the course of GD is influenced by environmental factors, e.g. cigarette smoking. Objectives The aim of the study was to analyze the effect of cigarette smoking on the efficacy of activity of radioiodine(131I) therapy in patients with GD. We also studied the influence of cigarette smoking and the efficacy of prednisone prophylaxis on the risk of thyroid-associated ophthalmopathy (TAO) development after radioiodine therapy (RIT) during two years of follow-up. Patients and methods Medical records of hyperthyroid patients treated with radioiodine had been included. Patients were scheduled to visit outpatient clinics at baseline and 1, 3, 6, 9, 12, 18, and 24 months after RIT. Results The studied group consisted of 336 patients (274 women, 62 men) diagnosed with GD and treated with RIT; 130 patients received second therapeutic dose of 131I due to recurrent hyperthyroidism. Among all studied patients, 220 (65.5%) were smokers and 116 (34.5%) non-smokers. In the group of smokers 115 (52.2%) of patients received single RIT, 105 (47.8%) received second dose of RAI due to recurrent hyperthyroidism. In non-smokers 91 (78.6%) received single activity of RAI, while 25 (21.4%) patients required second RIT due to recurrent hyperthyroidism. The ophthalmic symptoms in the group of smokers after RIT were less frequent, if the patient received preventative treatment in the form of oral prednisone (P = 0.0088). Conclusions The results of our study suggest that cigarette smoking reduces the efficacy of treatment with 131I in patients with GD. The study also confirmed the effectiveness of steroid prophylaxis against TAO development or exacerbation after RIT.
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Affiliation(s)
| | - Nadia Sawicka-Gutaj
- Department of Endocrinology, Metabolism and Internal Medicine, Poznan University of Medical Sciences, Poznan, Poland
| | - Agata Czarnywojtek
- Department of Endocrinology, Metabolism and Internal Medicine, Poznan University of Medical Sciences, Poznan, Poland
- Department of Pharmacology, Poznan University of Medical Sciences, Poznan, Poland
| | - Kosma Wolinski
- Department of Endocrinology, Metabolism and Internal Medicine, Poznan University of Medical Sciences, Poznan, Poland
- * E-mail:
| | | | - Maria Karlińska
- Department of Medical Informatics and Telemedicine, Warsaw Medical University, Warsaw, Poland
| | - Karolina Prasek
- Department of Nuclear Medicine, Warsaw Medical University, Warsaw, Poland
| | | | - Magdalena Borowska
- Department of Pharmacology, Poznan University of Medical Sciences, Poznan, Poland
| | - Paweł Gut
- Department of Endocrinology, Metabolism and Internal Medicine, Poznan University of Medical Sciences, Poznan, Poland
| | - Marek Ruchala
- Department of Endocrinology, Metabolism and Internal Medicine, Poznan University of Medical Sciences, Poznan, Poland
| | - Leszek Krolicki
- Department of Nuclear Medicine, Warsaw Medical University, Warsaw, Poland
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12
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The success rate of radioactive iodine therapy for Graves' disease in iodine-replete area and affecting factors: a single-center study. Nucl Med Commun 2020; 41:212-218. [PMID: 31895759 DOI: 10.1097/mnm.0000000000001138] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVE Initial treatment options for Graves' disease include antithyroid drugs, radioactive iodine (RAI), and surgery. Because of similar effects of three modalities, initial treatment preferences differ by country to country. In Korea, iodine-replete area, RAI was used as a second-line option. For these reasons, the RAI success rate in Korea might differ from other countries. METHODS A total of 247 patients were enrolled. The primary outcome was cumulative success rate in the first year, and the secondary outcome was factors that affected the success. Delayed response, which included patients who attained successful RAI during the follow-up, after the first year without further RAI, and factors that affected the delayed response were reviewed. RESULTS The cumulative success rate in the first year was 62.8%. Higher RAI activity [odds ratio (OR) 2.56, P = 0.02], longer disease duration (OR 0.43, P = 0.01), larger goiter (OR 0.31, P = 0.01), and higher post-RAI fT4 (fT4 between upper normal limit (UNL) to 1.5 × UNL; OR 0.24; P < 0.01, 1.5 × UNL<; OR 0.08; P < 0.01) were associated with RAI success. Twenty-seven patients showed delayed response, and goiter size (P < 0.05), pre-RAI TSH receptor Ab (TRAb) level (P < 0.01) and post-RAI fT4 (P < 0.01) were associated. CONCLUSION The success rate of the first RAI in Korea was lower than that in other countries. Delayed response was observed in patients with smaller goiter, low pre-RAI TRAb, and low post-RAI fT4. In these patients, clinical follow-up with monitoring could be an option, and decision of optimal timing of first RAI is crucial.
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13
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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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14
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Lawrence N, Cheetham T, Elder C. How do paediatricians use and monitor antithyroid drugs in the UK? A clinician survey. Clin Endocrinol (Oxf) 2019; 91:417-423. [PMID: 31179554 DOI: 10.1111/cen.14046] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/06/2019] [Revised: 05/17/2019] [Accepted: 06/06/2019] [Indexed: 12/14/2022]
Abstract
OBJECTIVE We aimed to document current practice in the medical management of paediatric hyperthyroidism in the UK and compare to international recommendations. DESIGN A 27-question online survey distributed via an electronic newsletter in August 2018. PARTICIPANTS Responses from 48 members (11%) of the British Society for Paediatric Endocrinology and Diabetes. MEASUREMENTS Information about antithyroid drug (ATD) preference, treatment duration, monitoring of full blood count (FBC), management of neutropaenia, agranulocytosis screening and patient education. RESULTS Carbimazole is favoured by 98% of respondents and a "dose titration" regimen preferred over "block and replace" (65% vs 29%). TRAbs (thyroid-stimulating hormone receptor antibodies) are used for diagnostic purposes by 85% and by 33% to look for evidence of disease remission. The majority (81%) treat for a minimum of 2 years before considering a trial off ATD. All respondents reported that they "always/usually" warn their patients about the risk of agranulocytosis before starting ATD, but written information is "rarely/never" provided by 63%. Sore throat (98%) and fever (92%) are the most commonly cited symptoms used to alert a patient to possible agranulocytosis. FBC is measured prior to treatment by 65% and measured periodically during treatment by 70%. CONCLUSIONS The management of paediatric hyperthyroidism with ATDs in the UK is not consistent with all international recommendations because a block and replace ATD regimen remains widely used. TRAbs are utilized at presentation, but underused for detecting disease remission. National consensus guidelines and written patient information may refine the management of paediatric patients on ATDs.
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Affiliation(s)
- Neil Lawrence
- Sheffield Children's Hospital NHS Foundation Trust, Western Bank, Sheffield, UK
| | - Tim Cheetham
- Department of Paediatric Endocrinology, Royal Victoria Infirmary, Newcastle University, Newcastle upon Tyne, UK
| | - Charlotte Elder
- Sheffield Children's Hospital NHS Foundation Trust, Western Bank, Sheffield, UK
- Western Bank, The University of Sheffield, Sheffield, UK
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15
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Investigation of factors influencing radioiodine (131I) biokinetics in patients with benign thyroid disease using nonlinear mixed effects approach. Eur J Clin Pharmacol 2018; 74:1037-1045. [DOI: 10.1007/s00228-018-2459-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/27/2017] [Accepted: 04/04/2018] [Indexed: 10/16/2022]
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16
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Affiliation(s)
- Obin Kwon
- Department of Psychiatry, Harvard Medical School and Molecular Neurobiology Laboratory, McLean Hospital, Belmont, MA, USA.
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17
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Conaglen HM, Tamatea JAU, Conaglen JV, Elston MS. Treatment choice, satisfaction and quality of life in patients with Graves' disease. Clin Endocrinol (Oxf) 2018; 88:977-984. [PMID: 29633307 DOI: 10.1111/cen.13611] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/31/2017] [Revised: 03/14/2018] [Accepted: 03/31/2018] [Indexed: 11/28/2022]
Abstract
BACKGROUND Thyrotoxicosis, most often caused by Graves' disease (GD), when treated inadequately may result in premature mortality. There is little consensus as to which of the 3 treatment options available - antithyroid drugs (ATD), radioactive iodine (RAI) and surgery, is better. AIMS (i) To assess factors involved in treatment choice and treatment satisfaction in patients treated for Graves' disease; (ii) To assess quality of life (QoL) following treatment of Graves' disease. METHOD Participants were selected from a prospective study cohort assessing thyrotoxicosis incidence and severity. Of the 172 eligible patients with Graves' disease, 123 treated patients participated (64% had received ATD only, 11% RAI and 25% total thyroidectomy, the latter 2 usually after a period of ATD), along with 18 untreated patients with newly diagnosed Graves' disease (overall participation rate, 73%). Consented patients completed a questionnaire detailing factors involved in treatment choice, QoL and satisfaction with treatment. RESULTS Participants reported that the most important factors in choosing a treatment were the following: the effects on activities of daily living, concern about use of radioiodine, possibility of depression or anxiety, and doctor's recommendations. Satisfaction levels were high across all 3 treatment types. QoL 1-year following treatment was higher than in untreated patients, and comparable with other international studies. CONCLUSIONS Patient satisfaction with therapy and QoL does not differ by treatment type. Therefore, clinical and social factors, in combination with patient choice and resource availability, should determine which treatment modality patients with Graves' disease should receive.
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Affiliation(s)
- Helen M Conaglen
- Department of Medicine, Faculty of Medical & Health Sciences, University of Auckland, Waikato Clinical Campus, Hamilton, New Zealand
| | - Jade A U Tamatea
- Department of Medicine, Faculty of Medical & Health Sciences, University of Auckland, Waikato Clinical Campus, Hamilton, New Zealand
- Department of Endocrinology, Waikato Hospital, Hamilton, New Zealand
| | - John V Conaglen
- Department of Medicine, Faculty of Medical & Health Sciences, University of Auckland, Waikato Clinical Campus, Hamilton, New Zealand
- Department of Endocrinology, Waikato Hospital, Hamilton, New Zealand
| | - Marianne S Elston
- Department of Medicine, Faculty of Medical & Health Sciences, University of Auckland, Waikato Clinical Campus, Hamilton, New Zealand
- Department of Endocrinology, Waikato Hospital, Hamilton, New Zealand
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18
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Taylor PN, Albrecht D, Scholz A, Gutierrez-Buey G, Lazarus JH, Dayan CM, Okosieme OE. Global epidemiology of hyperthyroidism and hypothyroidism. Nat Rev Endocrinol 2018; 14:301-316. [PMID: 29569622 DOI: 10.1038/nrendo.2018.18] [Citation(s) in RCA: 640] [Impact Index Per Article: 106.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
Thyroid hormones are essential for growth, neuronal development, reproduction and regulation of energy metabolism. Hypothyroidism and hyperthyroidism are common conditions with potentially devastating health consequences that affect all populations worldwide. Iodine nutrition is a key determinant of thyroid disease risk; however, other factors, such as ageing, smoking status, genetic susceptibility, ethnicity, endocrine disruptors and the advent of novel therapeutics, including immune checkpoint inhibitors, also influence thyroid disease epidemiology. In the developed world, the prevalence of undiagnosed thyroid disease is likely falling owing to widespread thyroid function testing and relatively low thresholds for treatment initiation. However, continued vigilance against iodine deficiency remains essential in developed countries, particularly in Europe. In this report, we review the global incidence and prevalence of hyperthyroidism and hypothyroidism, highlighting geographical differences and the effect of environmental factors, such as iodine supplementation, on these data. We also highlight the pressing need for detailed epidemiological surveys of thyroid dysfunction and iodine status in developing countries.
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Affiliation(s)
- Peter N Taylor
- Thyroid Research Group, Systems Immunity Research Institute, Cardiff University School of Medicine, Cardiff, UK
| | - Diana Albrecht
- University Medicine Greifswald, Institute for Community Medicine, Greifswald, Germany
| | - Anna Scholz
- Thyroid Research Group, Systems Immunity Research Institute, Cardiff University School of Medicine, Cardiff, UK
| | - Gala Gutierrez-Buey
- Clinica Universidad de Navarra, Department of Endocrinology and Nutrition, Pamplona, Spain
| | - John H Lazarus
- Thyroid Research Group, Systems Immunity Research Institute, Cardiff University School of Medicine, Cardiff, UK
| | - Colin M Dayan
- Thyroid Research Group, Systems Immunity Research Institute, Cardiff University School of Medicine, Cardiff, UK
| | - Onyebuchi E Okosieme
- Thyroid Research Group, Systems Immunity Research Institute, Cardiff University School of Medicine, Cardiff, UK
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Abstract
BACKGROUND Several studies have reported inconsistent findings on the advantages and disadvantages of long-term treatment with antithyroid drugs (ATD). A systematic review and meta-analysis was undertaken to clarify the numerous aspects of long-term treatment with ATD. METHODS Medline and the Cochrane Library for trials published between 1950 and May 2016 were systematically searched. Studies containing data for long-term (>24 months) ATD treatment were included. Summary estimates of pooled prevalence, odds ratio, and weighted mean difference were calculated with a random effects model. RESULTS Of 587 related articles found, six fulfilled the inclusion criteria. Long-term ATD treatment induced a remission rate of 57% [confidence interval (CI) 45-68%], a rate that was higher in adults than in non-adults (61% vs. 53%). The rate of complications was 19.1% [CI 9.6-30.9%], of which only 1.5% were major complications. The annual remission rate for each year of treatment was 16% [CI 10-27%], which was higher in adults than non-adults (19% vs. 14%). However, it should be noted that this is not a true linear correlation, but a positive relationship can be suggested between time and remission rate. Meta-regression revealed that smoking had a significant lowering effect on remission rate. CONCLUSIONS Long-term ATD treatment is effective and safe, especially in adults, indicating that it should be considered as an alternative treatment for Graves' disease.
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Affiliation(s)
- Fereidoun Azizi
- Endocrine Research Center of Research Institute for Endocrine Sciences, Shahid Beheshti University of Medical Sciences , Tehran, I.R. Iran
| | - Ramin Malboosbaf
- Endocrine Research Center of Research Institute for Endocrine Sciences, Shahid Beheshti University of Medical Sciences , Tehran, I.R. Iran
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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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Okosieme OE, Lazarus JH. Current trends in antithyroid drug treatment of Graves' disease. Expert Opin Pharmacother 2016; 17:2005-17. [PMID: 27615550 DOI: 10.1080/14656566.2016.1232388] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/23/2023]
Abstract
INTRODUCTION Graves' hyperthyroidism is associated with significant morbidity and mortality risk. The thionamides, methimazole, its pro-drug derivative carbimazole, and propylthiouracil, remain a cornerstone of management. Yet despite decades of use, optimal strategies for maximising treatment response and curtailing adverse effect risk remains uncertain. AREAS COVERED We reviewed the current literature on the evidence based medical management of Graves' disease. Specifically, we evaluated current approaches to the use of thionamides, adjunctive therapies, and potential novel agents for controlling Graves' hyperthyroidism. EXPERT OPINION Primary medical therapy is successful in less than 50% of cases and so careful selection of patients for medical treatment based on a combination of pathological and pragmatic considerations is essential. Carbimazole or methimazole is the treatment of choice in the non-pregnant population driven by its more favourable pharmacokinetic and adverse effect profile over propylthiouracil. In pregnancy the choice of treatment is less straightforward and an approach that minimises undue fetal exposure to all thionamides should be adopted. Additional data is needed on the value of adjunctive therapies including potassium perchlorate, iodides, glucocorticoids, lithium, and cholestyramine. Novel agents directed against pathogenetic targets including TSH receptor blocking monoclonal antibodies and small molecule antagonists may hold promise for the future.
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Affiliation(s)
- Onyebuchi E Okosieme
- a Thyroid Research Group, Institute of Molecular and Experimental Medicine , School of Medicine, Cardiff University , Cardiff , UK.,b Endocrine and Diabetes Department , Prince Charles Hospital, Cwm Taf University Health Board , Merthyr Tydfil , UK
| | - John H Lazarus
- a Thyroid Research Group, Institute of Molecular and Experimental Medicine , School of Medicine, Cardiff University , Cardiff , UK
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Hookham J, Collins EE, Allahabadia A, Balasubramanian SP. Variation in the use of definitive treatment options in the management of Graves' disease: a UK clinician survey. Postgrad Med J 2016; 93:198-204. [DOI: 10.1136/postgradmedj-2016-134187] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/26/2016] [Revised: 07/18/2016] [Accepted: 07/25/2016] [Indexed: 11/04/2022]
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Zaman MU, Fatima N, Zaman U, Sajjad Z, Zaman A, Tahseen R. Predictive value of pyramidal lobe, percentage thyroid uptake and age for ablation outcome after 15 mCi fixed dose of radioiodine-131 in Graves' disease. Indian J Nucl Med 2015; 30:309-13. [PMID: 26430313 PMCID: PMC4579614 DOI: 10.4103/0972-3919.164062] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
PURPOSE The purpose was to find out the efficacy of fixed 15 mCi radioactive iodine-131 (RAI) dose and predictive values of various factors for inducing hypothyroidism in Graves' disease (GD). MATERIALS AND METHODS Retrospective study conducted from January 2012 till August 2014. Patients with GD who had a technetium-99m thyroid scan, thyroid antibodies, received fixed 15 mCi RAI and did follow endocrine clinics for at least 6 months were selected. RAI was considered successful if within 6 months of RAI therapy patients developed hypothyroidism. RESULTS Of the 370 patients with GD who had RAI during study period, 210 (57%) qualified study criteria. Mean age of patients was 48 ± 15 years with female: male ratio of 69:31, positive thyroid antibodies in 61%, means thyroid uptake of 15.09 ± 11.23%, and presence of pyramidal lobe in 40% of total population. Hypothyroidism was achieved in 161 (77%) patients while 49 (23%) patients failed to achieve it (remained either hyperthyroid or euthyroid on antithyroid medication). Patients who became hypothyroid were significantly younger with higher proportion of presence of thyroid antibodies and pyramidal lobe and lower percentage thyroid uptake than those who failed. Multiple logistic regression analysis revealed that age (odds ratio; OR = 2.074), pyramidal lobe (OR = 3.317), thyroid antibodies (OR = 8.198), and percentage thyroid uptake (OR = 3.043) were found to be significant prognostic risk factors for post-RAI hypothyroidism. Gender was found to have nonsignificant association with the development of hypothyroidism. Receiver operating characteristic analysis revealed age <42 years and thyroid uptake <15% as threshold values for the development of post-RAI hypothyroidism. CONCLUSION We conclude that fixed (15 mCi) RAI dose is highly effective in rendering hypothyroidism in patients with GD. Age (≤42 years), thyroid uptake (≤15%) and presence of pyramidal lobe are strong predictors of hypothyroidism and must be considered for selecting optimal RAI dose.
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Affiliation(s)
- Maseeh Uz Zaman
- Department of Radiology, Section of Nuclear Medicine, Aga Khan University Hospital, Karachi, Pakistan
| | - Nosheen Fatima
- Department of Nuclear Medicine, Dr. Ziauddin Hospital, Karachi, Pakistan
| | - Unaiza Zaman
- Dow Medical College, Dow University of Health Sciences, Karachi, Pakistan
| | - Zafar Sajjad
- Department of Radiology, Section of Nuclear Medicine, Aga Khan University Hospital, Karachi, Pakistan
| | - Areeba Zaman
- Dow Medical College, Dow University of Health Sciences, Karachi, Pakistan
| | - Rabia Tahseen
- Dow Medical College, Dow University of Health Sciences, Karachi, Pakistan
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Guo K, Gao R, Yu Y, Zhang W, Yang Y, Yang A. Quantitative mRNA expression analysis of selected genes in patients with early-stage hypothyroidism induced by treatment with iodine-131. Mol Med Rep 2015; 12:7673-80. [PMID: 26398137 DOI: 10.3892/mmr.2015.4350] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/03/2014] [Accepted: 08/20/2015] [Indexed: 11/05/2022] Open
Abstract
The present study aimed to investigate the molecular markers indicative of early-stage hypothyroidism induced by treatment with iodine-131, in order to assist in further investigations of radio iodine‑induced hypothyroidism. A total of 59 patients diagnosed with hyperthyroidism (male/female, 16/43; median age, 46.4 years) and 27 healthy subjects (male/female, 7/21; median age, 44.6 years) were included in the present study. All patients were treated with appropriate doses of iodine‑131 and, three months following treatment, the patients were subdivided into two groups: A group with early‑stage hypothyroidism symptoms, and a group with non‑early‑stage hypothyroidism, including euthyroid patients and patients remaining with hyperthyroidism. Tissue samples from the patients and healthy subjects were collected by fine needle biopsies, and the mRNA expression levels of B-cell lymphoma 2 (Bcl‑2), nuclear factor (NF)‑κB, Ku70, epidermal growth factor receptor (EGFR), early growth response 1 (Egr‑1), TP53 and ataxia telangiectasia mutated were analyzed using reverse transcription‑quantitative polymerase chain reaction prior to iodine‑131 treatment. The association of the variation of target genes with susceptibility to early‑stage hypothyroidism was analyzed. Compared with normal subjects, the mRNA expression levels of Ku70 (0.768, vs. 3.304, respectively; P<0.001) and EGFR (0.859, vs. 1.752, respectively; P<0.05) were significantly higher, whereas those of NF‑κB (0.884, vs. 0.578, respectively; P<0.05) and Bcl‑2 (1.235, vs. 0.834, respectively; P<0.05) were lower in the hyperthyroid patients. Following treatment with iodine‑131, 30 of the 59 (50.8%) patients with hyperthyroidism were diagnosed with early‑stage hypothyroidism, and in the early‑stage hypothyroidism group, the mRNA expression levels of Bcl‑2 were significantly decreased (P<0.05), whereas those of Egr‑1 (P<0.05) were significantly increased, compared with the non‑early‑stage hypothyroidism group. The association between the changes in the expression levles of Bcl‑2 and Egr‑1 and susceptibility to early‑stage hypothyroidism was supported by multivariate regression analysis. No significant changes in the expression levels of the other target genes were detected. The opposing changes in the mRNA expression levels of Bcl‑2 and Egr‑1 in patients with early‑stage hypothyroidism indicates their potential as prognostic markers of early-stage hypothyroidism induced by iodine-131 treatment.
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Affiliation(s)
- Kun Guo
- Department of Nuclear Medicine, The First Affiliated Hospital of Xi'an Jiaotong University College of Medicine, Xi'an, Shaanxi 710061, P.R. China
| | - Rui Gao
- Department of Nuclear Medicine, The First Affiliated Hospital of Xi'an Jiaotong University College of Medicine, Xi'an, Shaanxi 710061, P.R. China
| | - Yan Yu
- Department of Public Health, Medical College of Xi'an Jiaotong University, Xi'an, Shaanxi 710061, P.R. China
| | - Weixiao Zhang
- Department of Nuclear Medicine, The First Affiliated Hospital of Xi'an Jiaotong University College of Medicine, Xi'an, Shaanxi 710061, P.R. China
| | - Yuxuan Yang
- Department of Public Health, Medical College of Xi'an Jiaotong University, Xi'an, Shaanxi 710061, P.R. China
| | - Aimin Yang
- Department of Nuclear Medicine, The First Affiliated Hospital of Xi'an Jiaotong University College of Medicine, Xi'an, Shaanxi 710061, P.R. China
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Vaidya B, Wright A, Shuttleworth J, Donohoe M, Warren R, Brooke A, Gericke CA, Ukoumunne OC. Block & replace regime versus titration regime of antithyroid drugs for the treatment of Graves' disease: a retrospective observational study. Clin Endocrinol (Oxf) 2014; 81:610-3. [PMID: 24801484 DOI: 10.1111/cen.12478] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/13/2014] [Revised: 03/19/2014] [Accepted: 04/16/2014] [Indexed: 11/29/2022]
Abstract
CONTEXT Two widely used antithyroid drug (ATD) regimes for Graves' disease (GD) include the 'block & replace' (B&R) regime (a fixed high-dose of ATD combined with levothyroxine) and the 'titration' regime (a titrating dose of ATD). Anecdotally, it is believed that B&R is less prone to fluctuating thyroid function. OBJECTIVE To study whether, in routine clinical practice, the B&R regime, compared with the titration regime, is associated with more stable thyroid function. METHODS We retrospectively analysed case-records for 450 patients treated with ATDs for GD at a secondary care hospital. Exclusion criteria included treatment with ATDs for <6 months, thyrotoxicosis due to other causes, treatment with radioiodine or thyroidectomy and pregnancy. RESULTS Two hundred and twenty three patients were treated with the B&R regime ('B&R group'), 149 with the titration regime ('titration group') and 78 with both regimes. The number of thyroid function tests (TFTs) performed per year (mean(SD): 3·2(1·2) vs 3·4(1·5); adjusted mean difference = -0·4; 95% CI: -0·7 to -0·1; and P = 0·008) and the number of hospital clinic visits per year (mean (SD): 2·9 (1·0) vs 3·2 (1·3); adjusted mean difference = -0·4; 95% CI: -0·7 to -0·2; and P = 0·002) were lower in the B&R group than the titration group. The number of abnormal TFT results per year was similar in the two groups (mean(SD): 1·8(1·3) vs 1·8(1·4); adjusted mean difference = 0·05; 95%CI: -0·3 to 0·4; and P = 0·74). CONCLUSIONS In this retrospective study, there was little evidence that patients under B&R have more stable thyroid function. Further data from prospective studies, however, are needed to confirm this finding.
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Affiliation(s)
- Bijay Vaidya
- Department of Endocrinology, Royal Devon & Exeter Hospital, Exeter, UK; NIHR CLAHRC South West Peninsula (PenCLAHRC), University of Exeter Medical School, Exeter, UK
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Rokni H, Sadeghi R, Moossavi Z, Treglia G, Zakavi SR. Efficacy of different protocols of radioiodine therapy for treatment of toxic nodular goiter: systematic review and meta-analysis of the literature. Int J Endocrinol Metab 2014; 12:e14424. [PMID: 24803943 PMCID: PMC4005974 DOI: 10.5812/ijem.14424] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/09/2013] [Revised: 12/02/2013] [Accepted: 12/25/2013] [Indexed: 11/28/2022] Open
Abstract
CONTEXT To evaluate treatment success and hypothyroidism following main methods of radioiodine therapy of toxic nodular goiter (TNG); calculated versus fixed dose and high versus low dose of radioiodine. EVIDENCE ACQUISITIONS We searched MEDLINE and SCOPUS databases from inception till July 2013, for clinical trials that compared two different methods of radioiodine administration in TNG. The trials were classified into two groups, those that compared fixed versus calculated dosimetry method and those that assessed high fixed dose versus low fixed dose method. Treatment response was defined as euthyroidism or hypothyroidism, one year after radioiodine administration. We calculated the risk ratio and risk difference of treatment response as well as permanent hypothyroidism as outcome variables. Random effects model was used for data pooling. RESULTS The literature search yielded 2538 articles. Two randomized and five non-randomized clinical trials with 669 patients met the eligibility criteria for the meta-analysis. Patients with TNG who were treated according to the calculated method had 9.6% higher cure rate (risk ratio=1.17) and only 0.3% more permanent hypothyroidism compared to patients treated with the fixed dose method. There was no significant difference in the amount of administered radio-iodine in the two groups. Patients treated with fixed high dose had 18.1% more cure rate (risk ratio = 1.2) and 23.9% more permanent hypothyroidism (risk ratio = 2.40) compared to patients treated by fixed low dose protocols. CONCLUSIONS Calculated radioiodine therapy may be preferred to fixed dose method in patients with TNG. High dose methods are associated with more response and more hypothyroidism.
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Affiliation(s)
- Haleh Rokni
- Endocrinology Research Center, Mashhad University of Medical Sciences, Mashhad, IR Iran
| | - Ramin Sadeghi
- Nuclear Medicine Research Center, Mashhad University of Medical Sciences, Mashhad, IR Iran
| | - Zohreh Moossavi
- Endocrinology Research Center, Mashhad University of Medical Sciences, Mashhad, IR Iran
| | - Giorgio Treglia
- Department of Nuclear Medicine and PET/CT Centre, Oncology Institute of Southern Switzerland, Bellinzona, Switzerland
| | - Seyed Rasoul Zakavi
- Nuclear Medicine Research Center, Mashhad University of Medical Sciences, Mashhad, IR Iran
- Corresponding author: Seyed Rasoul Zakavi, Nuclear Medicine Research Center, Ghaem Hospital, Ahmadabad St, Mashhad, IR Iran. Tel: +98-5118012799, Fax: +98-5118419521, E-mail:
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Oh SR, Priel A, Granet DB, Levi L, Korn BS, Kikkawa DO. Thyroid-related orbitopathy: a multidisciplinary perspective. EXPERT REVIEW OF OPHTHALMOLOGY 2014. [DOI: 10.1586/eop.10.81] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
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Abstract
Graves disease is an autoimmune disorder characterized by goitre, hyperthyroidism and, in 25% of patients, Graves ophthalmopathy. The hyperthyroidism is caused by thyroid hypertrophy and stimulation of function, resulting from interaction of anti-TSH-receptor antibodies (TRAb) with the TSH receptor on thyroid follicular cells. Measurements of serum levels of TRAb and thyroid ultrasonography represent the most important diagnostic tests for Graves disease. Management of the condition currently relies on antithyroid drugs, which mainly inhibit thyroid hormone synthesis, or ablative treatments ((131)I-radiotherapy or thyroidectomy) that remove or decrease thyroid tissue. None of these treatments targets the disease process, and patients with treated Graves disease consequently experience either a high rate of recurrence, if receiving antithyroid drugs, or lifelong hypothyroidism, after ablative therapy. Geographical differences in the use of these therapies exist, partially owing to the availability of skilled thyroid surgeons and suitable nuclear medicine units. Novel agents that might act on the disease process are currently under evaluation in preclinical or clinical studies, but evidence of their efficacy and safety is lacking.
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Affiliation(s)
- Luigi Bartalena
- Department of Clinical and Experimental Medicine, University of Insubria, Endocrine Unit, Ospedale di Circolo, Viale Borri, 57, 21100 Varese, Italy
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Total thyroidectomy for safe and definitive management of Graves' disease. The Journal of Laryngology & Otology 2013; 127:681-4. [DOI: 10.1017/s0022215113001254] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
AbstractBackground:The role of total thyroidectomy in the management of patients with Graves' disease remains controversial. However, there is increasing evidence to support the role of the procedure as a safe and definitive treatment for Graves' disease.Method:Patients were identified from a prospective thyroid database of the multidisciplinary thyroid clinic at Hull Royal Infirmary. All case notes were independently reviewed to confirm the data held on the database.Results:Over a 7-year period, the senior author has performed 206 total thyroidectomies for Graves' disease. The incidence of temporary recurrent laryngeal nerve palsy and hypoparathyroidism was 3.4 per cent and 24 per cent respectively. There was one case of permanent unilateral recurrent laryngeal nerve palsy, and 3.9 per cent of patients developed permanent hypoparathyroidism. There has been no relapse of thyrotoxicosis.Conclusion:In the context of a multidisciplinary thyroid clinic, total thyroidectomy should be offered as a safe and effective first-line treatment option for Graves' disease.
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Boelaert K, Maisonneuve P, Torlinska B, Franklyn JA. Comparison of mortality in hyperthyroidism during periods of treatment with thionamides and after radioiodine. J Clin Endocrinol Metab 2013; 98:1869-82. [PMID: 23543662 DOI: 10.1210/jc.2012-3459] [Citation(s) in RCA: 46] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
CONTEXT Hyperthyroidism is common, but opinions regarding optimal therapy with antithyroid drugs or radioiodine (131-I) differ. There are no randomized trials comparing these options in terms of mortality. OBJECTIVE The aim of the study was to determine whether mortality associated with hyperthyroidism varies with treatment administered or other factors. DESIGN, SETTING, AND PATIENTS We conducted a prospective observational population-based study of 1036 subjects aged ≥ 40 years presenting to a single specialist clinic from 1989-2003 with a first episode of hyperthyroidism who were followed until June 2012. INTERVENTIONS Antithyroid drugs or radioiodine (131-I) were administered. MAIN OUTCOME MEASURES We compared causes of death with age-, sex-, and period-specific mortality in England and Wales and used within-cohort analysis of influence of treatment modality, outcome, disease etiology, severity and control, and comorbidities. RESULTS In 12 868 person-years of follow-up, 334 died vs 290.6 expected (standardized mortality ratio [SMR], 1.15 [95% confidence interval (CI),1.03-1.28]; P = .01). Increased all-cause mortality largely reflected increased circulatory deaths (SMR, 1.20 [95% CI, 1.01-1.43]; P = .04). All-cause mortality was increased for the person-years accumulated during thionamide treatment (SMR, 1.30 [95% CI, 1.05-1.61]; P = .02) and after 131-I not associated with hypothyroidism (SMR, 1.24 [95% CI, 1.04-1.46]; P = .01) but not during T₄ replacement for 131-I-induced hypothyroidism (SMR, 0.98 [95% CI, 0.82-1.18]; P = .85). Within-cohort analysis comparing mortality during thionamide treatment showed a similar hazard ratio (HR) for all-cause mortality when 131-I did not result in hypothyroidism (HR, 0.95 [95% CI, 0.70-1.29]), but reduced mortality with 131-I-induced hypothyroidism (HR, 0.70 [95% CI, 0.51-0.96]). Reduced mortality associated with hypothyroidism was seen only in those without significant comorbidities and not in those with other serious diseases. Atrial fibrillation at presentation (P = .02) and an increment of 10 pmol/L in serial free T₄ concentration during follow-up (P = .009) were independently associated with mortality. CONCLUSIONS Among hyperthyroid subjects aged 40 years or older, mortality was increased during periods of thionamide treatment and after radioiodine not resulting in hypothyroidism, but not during follow-up after radioiodine-induced hypothyroidism. Independent associations of mortality with atrial fibrillation and incomplete biochemical control during treatment indicate potential causative links with poor outcome.
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Affiliation(s)
- Kristien Boelaert
- Centre for Endocrinology, Diabetes, and Metabolism, School of Clinical and Experimental Medicine, College of Medical and Dental Sciences, University of Birmingham, Birmingham B15 2TT, United Kingdom.
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Bonnema SJ, Hegedüs L. Radioiodine therapy in benign thyroid diseases: effects, side effects, and factors affecting therapeutic outcome. Endocr Rev 2012; 33:920-80. [PMID: 22961916 DOI: 10.1210/er.2012-1030] [Citation(s) in RCA: 160] [Impact Index Per Article: 13.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/18/2023]
Abstract
Radioiodine ((131)I) therapy of benign thyroid diseases was introduced 70 yr ago, and the patients treated since then are probably numbered in the millions. Fifty to 90% of hyperthyroid patients are cured within 1 yr after (131)I therapy. With longer follow-up, permanent hypothyroidism seems inevitable in Graves' disease, whereas this risk is much lower when treating toxic nodular goiter. The side effect causing most concern is the potential induction of ophthalmopathy in predisposed individuals. The response to (131)I therapy is to some extent related to the radiation dose. However, calculation of an exact thyroid dose is error-prone due to imprecise measurement of the (131)I biokinetics, and the importance of internal dosimetric factors, such as the thyroid follicle size, is probably underestimated. Besides these obstacles, several potential confounders interfere with the efficacy of (131)I therapy, and they may even interact mutually and counteract each other. Numerous studies have evaluated the effect of (131)I therapy, but results have been conflicting due to differences in design, sample size, patient selection, and dose calculation. It seems clear that no single factor reliably predicts the outcome from (131)I therapy. The individual radiosensitivity, still poorly defined and impossible to quantify, may be a major determinant of the outcome from (131)I therapy. Above all, the impact of (131)I therapy relies on the iodine-concentrating ability of the thyroid gland. The thyroid (131)I uptake (or retention) can be stimulated in several ways, including dietary iodine restriction and use of lithium. In particular, recombinant human thyrotropin has gained interest because this compound significantly amplifies the effect of (131)I therapy in patients with nontoxic nodular goiter.
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Affiliation(s)
- Steen Joop Bonnema
- Department of Endocrinology, Odense University Hospital, DK-5000 Odense C, Denmark.
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Turner N, Driver I, Salotti JA, Pearce MS, Cheetham T. Increasing use of radioiodine in young people with thyrotoxicosis in Great Britain. Eur J Endocrinol 2012; 167:715-8. [PMID: 22956555 DOI: 10.1530/eje-12-0542] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
OBJECTIVE Radioiodine (RI) is an important therapeutic option in young patients with thyrotoxicosis. We wanted to determine whether RI is being used more frequently in this age group. DESIGN National survey of Great Britain (England, Wales and Scotland). METHODS Sixty-one medical physics departments were asked to provide the age and number of patients with thyrotoxicosis <21 years treated with RI (1990-2008). Information on the total number of RI treatments for thyrotoxicosis was also collected. RESULTS Forty-three departments (70%), with representation from 21 of the 25 most populous areas of Great Britain, provided data on 69,258 treatments. The number of treatments recorded on patients <21 years during this period was 560 (0.9%). The frequency of treatments in young people as a percentage of the total increased from 0.2% in 1990 to 1.5% in 2008 (P<0.001). When the 18 centres submitting at least 17 years of data were analysed, a similar pattern was observed. The maximum number of young people treated was greatest in 2008 (62) with a fall in the youngest age at which RI was administered from 18 years (1990) to 11 years (2008). CONCLUSIONS A rising proportion of patients with thyrotoxicosis receiving RI are in those <21 years. This is largely due to an increase in the number of young people treated with a reduction in the minimum age at RI administration. We suspect that European clinicians are becoming more comfortable with RI treatment in young people with thyrotoxicosis, although a changing incidence is a potential contributing factor.
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Affiliation(s)
- Neil Turner
- Nuclear Medicine, Regional Medical Physics Department, Freeman Hospital, Newcastle-upon-Tyne, UK
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The role of thyrotrophin receptor antibody assays in graves' disease. J Thyroid Res 2012; 2012:525936. [PMID: 22577596 PMCID: PMC3345237 DOI: 10.1155/2012/525936] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/31/2011] [Accepted: 01/27/2012] [Indexed: 11/17/2022] Open
Abstract
Thyrotrophin receptor antibodies (TRAb) exist as stimulating or blocking antibodies in the serum (neutral TRAb have been identified recently). The clinical features of GD occur when stimulating TRAb predominate. But the relationship of TRAb to clinical phenotype and outcome is not clear when current assay methods are used. Therefore no consensus exists about its utility in diagnosing and predicting outcome in GD. The most commonly used TRAb assays, measure thyroid binding inhibiting immunoglobulins (TBII or “receptor assays”) and don't differentiate between stimulating and blocking antibodies. However, the more expensive, technically demanding and less freely available “biological assays” differentiate between them by their ability to stimulate cyclic AMP or failure to do so. Failure to differentiate between TRAb types and its heterogeneous molecular and functional properties has limited TBII use to GD diagnosis and differentiating from other forms of thyrotoxicosis. The current 2nd-3rd generation receptor assays are highly sensitive and specific when used for this purpose. TRAb assays should also be done in appropriate pregnant women. Current data do not support its use in outcome prediction as there is a significant variability of assay methodology, population characteristics and study design in published data, resulting in a lack of consensus.
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Abstract
All forms of thyroid diseases are much more frequently observed in women than men, although the reasons are still not completely elucidated.Hyperthyroidism is defined by elevated circulating free thyroid hormones. The prevalence is about 2 % in women and 0.2 % in men. The most frequent causes are various forms of thyroid autonomy in elderly women and Graves' disease, which occurs mostly in younger women.Hypothyroidism is defined by a lack of thyroid hormones. It is a common endocrine disorder caused by autoimmune thyroiditis (Hashimoto thyroiditis), iodine deficiency or following surgery or radioiodine therapy. Thyroxine requirements depend on fat-free mass and are, therefore, somewhat higher in males who are more often undersubstituted. In pregnancy lower TSH-reference ranges have to be considered and thyroid function should be monitored throughout pregnancy to avoid harm to the foetus caused by maternal thyroid dysfunctions. If overtreated women more often feature fractures, whereas males more often develop atrial fibrillation.
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Affiliation(s)
- Alois Gessl
- Department of Internal Medicine III, Medical University Of Vienna, Vienna, Austria
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Abstract
Subclinical hyperthyroidism is defined as serum thyroid hormone levels within their respective reference ranges in the presence of low-undetectable serum thyrotropin-stimulating hormone levels. Subclinical hyperthyroidism is associated with important cardiovascular risk factors and negative effects on bone metabolism and structure. However, there are conflicting results on cardiovascular mortality and the risk of bone fractures. Treatment and management of subclinical hyperthyroidism is controversial. This article will address the necessity to treat this disorder in relation to the cause of hyperthyroidism, the patient's age, the degree of thyroid-stimulating hormone suppression and the presence of comorbidities.
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Affiliation(s)
- Bernadette Biondi
- a Department of Clinical and Molecular Endocrinology and Oncology, University of Naples Federico II, Via S. Pansini 5, 80131 Naples, Italy.
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Kahaly GJ, Bartalena L, Hegedüs L. The American Thyroid Association/American Association of Clinical Endocrinologists guidelines for hyperthyroidism and other causes of thyrotoxicosis: a European perspective. Thyroid 2011; 21:585-91. [PMID: 21663420 DOI: 10.1089/thy.2011.2106.ed3] [Citation(s) in RCA: 46] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
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Greenlee C, Burmeister LA, Butler RS, Edinboro CH, Morrison SM, Milas M. Current safety practices relating to I-131 administration for diseases of the thyroid: a survey of physicians and allied practitioners. Thyroid 2011; 21:151-60. [PMID: 21275765 DOI: 10.1089/thy.2010.0090] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
BACKGROUND There is little information about the individual safety instructions provided by healthcare professionals to patients receiving radioactive iodine (I-131) therapy for the treatment of benign and malignant thyroid disorders or about whether these instructions are consistent across medical specialties. Currently, no national guidelines exist to standardize safety instructions related to I-131 administration. Here, we examine the spectrum of I-131 safety practices in contemporary use. METHODS Members of major societies of physicians and allied specialists who treat patients with thyroid disorders were invited to complete a 27-question online survey about safety practices related to I-131 administration. Data from questionnaires were analyzed by type of safety recommendation and grouped according to provider specialty and geographic location. RESULTS A total of 311 endocrinologists, surgeons, nuclear medicine radiologists, and allied health professionals completed questionnaires. They indicated that patients often receive instruction from more than one treating specialist. The decision to hospitalize a patient for treatment and the length of stay were determined by the patient's social situation and the dose of I-131 administered. Starting at I-131 doses between 259 and 1073 MBq (7 and 29 mCi), over 60% of respondents advised avoiding contact with children, sexual activity, and breastfeeding, with the latter recommendation continuing beyond 48 hours after treatment. Personal hygiene, laundry, and meal preparation precautions varied across respondents. Over 90% of respondents used serum or urine testing to screen for pregnancy status. Precautions to delay parenthood were given more often to female than male patients (90% vs. 60%), with a minimum recommended delay of 6 months. About 20% of respondents considered insurance coverage as a factor in selecting outpatient versus inpatient I-131 therapy, and this consideration varied geographically. CONCLUSION A wide variety of safety recommendations are given to patients who receive I-131. To our knowledge, this survey represents the first organized inquiry into safety practices related to I-131 administration. The diversity of responses suggests an opportunity for multispecialty collaboration in defining more uniform recommendations for patient safety instructions during and after I-131 treatment.
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Zhou ZH, Ma LL, Wang LX. Risk factors for persistent atrial fibrillation following successful hyperthyroidism treatment with radioiodine therapy. Intern Med 2011; 50:2947-51. [PMID: 22185984 DOI: 10.2169/internalmedicine.50.6135] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022] Open
Abstract
OBJECTIVE To investigate the predicting factors for persistent atrial fibrillation (AF) following radioiodine therapy for hyperthyroidism. METHODS Standard 12-lead ECG and 24-h Holter monitoring were performed in 94 patients (38 males, mean age 46.1±8.2 years) with persistent AF following radioiodine therapy for hyperthyroidism. Left ventricular (LV) function was assessed with two-dimensional echocardiography. RESULTS Euthyroidism or hypothyroidism was achieved in 81% and 19% of the patients, respectively, after radioiodine therapy. At the end of follow-up (1.6±1.3 years), LV ejection fraction in the 52 patients with LV dysfunction was increased from 39.3±3.3% to 59.0±5.5% (p<0.01). In the 38 patients with pre-treatment paroxysmal AF, no AF was documented during the follow-up. In the 45 patients with pre-treatment persistent AF, AF was found in 27 (60%) during the follow-up. Multivariate logistic regression analysis showed that more than 55 years old in age (RR 2.76, 95% CI: 1.16-8.79, p<0.01), duration of hyperthyroidism (RR 3.08, 95% CI: 1.22-11.41, p<0.01) and duration of pre-treatment atrial fibrillation (RR 2.96, 95% CI: 1.31-7.68, p<0.01) were independent predictors for persistent AF following radioiodine therapy. CONCLUSION Older age, duration of hyperthyroidism and pre-treatment duration of AF are risk factors for persistent AF following radioiodine therapy.
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Affiliation(s)
- Zhen-Hu Zhou
- Department of Nuclear Medicine, Liaocheng People's Hospital and Liaocheng Clinical School of Taishan Medical University, China
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Razvi S, Weaver JU, Pearce SHS. Subclinical thyroid disorders: significance and clinical impact. J Clin Pathol 2010; 63:379-86. [PMID: 20418229 DOI: 10.1136/jcp.2008.057414] [Citation(s) in RCA: 33] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Abstract
Subclinical thyroid diseases are defined by abnormal serum thyroid stimulating hormone (TSH) levels associated with normal thyroid hormone concentrations. The diagnosis of these conditions depends on defining the 'normal' euthyroid TSH range; in this review, arguments for and against lowering the upper limit of TSH are summarised. Although, subclinical hypothyroidism and subclinical hyperthyroidism are frequently encountered, their long-term consequences are debated due to conflicting results from many observational studies. The causes, effects and outcomes of treatment of both subclinical diseases are described, and the direction of future research in these conditions is outlined.
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Affiliation(s)
- Salman Razvi
- Department of Endocrinology, Gateshead Health NHS Foundation Trust, Gateshead, UK.
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Abstract
BACKGROUND Autoimmunity against the thyrotropin receptor (TSH-R) is a key pathogenic element in Graves' disease (GD) and the autoimmune aberration may be modified by antithyroid treatment. An association between radioactive iodine (RAI) therapy for GD and the development or worsening of Graves' orbitopathy (GO) is widely quoted. RAI-associated leakage of thyroid antigen(s) leads to an increased production of TSH-R antibodies that may initiate the eye injury. SUMMARY RAI therapy leads to prolonged worsening of autoimmunity against the TSH-R, and the number of patients entering remission of TSH-R autoimmunity is considerably lower than with other antithyroid therapies. Scientific evidence has indicated that RAI treatment for GD is associated with increased risk of occurrence or progression of GO compared with antithyroid drugs (ATD) and thyroid surgery. The risks of developing new GO or worsening of preexisting GO is around 20% after RAI and around 5% after ATD. The risk of developing severe GO after RAI is around 7%. Smoking, high levels of pretreatment serum triiodothyronine, and post-RAI hypothyroidism are associated with increased risk of GO, whereas a high TSH-R autoantibody titer is an independent risk factor for the progression of GO. In patients with mild preexisting GO, steroid prophylaxis is effective in preventing deterioration of GO. Also, routine use of prophylactic oral steroids with RAI therapy should be considered in GD patients without overt GO, but even more so in those at higher risks of eye complications such as smokers, old men, and those with severe hyperthyroidism or high TSH-R antibody titers. CONCLUSION In contrast to ATD, remission of TSH-R autoimmunity after RAI therapy is less common, and RAI for GD is associated with definite increased risk of GO. Oral steroids are beneficial for patients with preexisting GO, particularly smokers.
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Affiliation(s)
- Katharina A Ponto
- Department of Ophthalmology, Gutenberg University Medical Center, Mainz, Germany
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Lazarus JH, Bartalena L, Marcocci C, Kahaly GJ, Krassas G, Wiersinga WM. Glucocorticoid administration for Graves' hyperthyroidism treated by radioiodine. A questionnaire survey among members of the European Thyroid Association. J Endocrinol Invest 2010; 33:409-13. [PMID: 20101098 DOI: 10.1007/bf03346613] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND Glucocorticoid prophylaxis is required in some instances after radioiodine (RAI) treatment for Graves' hyperthyroidism to prevent progression of Graves' orbitopathy (GO). However, no randomized clinical trial has been performed to ascertain the optimum glucocorticoid therapy. AIM AND METHODS Aim of this study was to perform a questionnaire-based survey of glucocorticoid prophylaxis among European thyroidologist members of the European Thyroid Association. RESULTS Eighty-two responses from 25 European Countries were received. Two respondents did not prescribe steroids in any clinical scenario, while 8 gave the drug to all patients receiving RAI therapy. The majority of respondents only gave glucocorticoids to patients showing some degree of ocular involvement or if risk factors for the progression of GO after RAI were present (e.g., cigarette smoking); 24% of responses indicated that clinicians would not give glucocorticoids if patients were thought to have no GO or inactive GO. Ninety-one percent of clinicians used prednisone (53%) or prednisolone (38%). The mean starting dose [given for 16 days (range 2-60 days)] was 37.6 mg prednisone or prednisone-equivalent (range 15-80 mg). Overall, the results of this survey showed a wide diversity in the regimens used, in terms of timing of initiation of treatment, duration of treatment, cumulative doses of administered glucocorticoids and monitoring of side-effects of glucocorticoid treatment. CONCLUSIONS The results of this study underscore the need for randomized clinical trials to ascertain the optimum regimen of prophylactic glucocorticoid therapy.
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Affiliation(s)
- J H Lazarus
- Centre for Endocrine and Diabetes Sciences, Cardiff University School of Medicine, Cardiff, UK.
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Boelaert K, Torlinska B, Holder RL, Franklyn JA. Older subjects with hyperthyroidism present with a paucity of symptoms and signs: a large cross-sectional study. J Clin Endocrinol Metab 2010; 95:2715-26. [PMID: 20392869 DOI: 10.1210/jc.2009-2495] [Citation(s) in RCA: 103] [Impact Index Per Article: 7.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
CONTEXT The absence of classical symptoms and signs of hyperthyroidism often results in delayed diagnosis and treatment. OBJECTIVES The objective of the study was to determine the prevalence of symptoms and signs of hyperthyroidism according to patients' age and gender as well as severity and type of hyperthyroidism. DESIGN, PARTICIPANTS AND SETTING This was a cross-sectional study of 3049 consecutive patients with hyperthyroidism presenting to a single secondary/tertiary care clinic. MAIN OUTCOME MEASURES Calculation of adjusted odds ratios for presence/absence of symptoms/signs of hyperthyroidism simultaneously analyzing the influence of patients' age/gender, disease etiology/severity, symptom duration, and smoking. RESULTS The majority of patients older than 61 yr had two or more symptoms. The lowest proportion of subjects reporting five or more symptoms was found in those older than 61 yr. Increasing age was associated with reduced adjusted odds ratio for the presence of most classical symptoms except for weight loss and shortness of breath, independent of disease severity. Those with more severe hyperthyroidism and smokers had increased odds ratios for most symptoms. Older age, higher serum free T(4) concentrations at diagnosis, male gender, and toxic nodular hyperthyroidism were independently associated with risk of atrial fibrillation. Signs of ophthalmopathy were associated with increasing age, smoking, longer symptom duration, and female gender. CONCLUSIONS Classical symptoms and signs of hyperthyroidism are significantly less prevalent in older patients and more prevalent in smokers and subjects with higher free T(4) concentrations. We propose a lower threshold for performing thyroid function tests in patients older than 60 yr, especially in those presenting with atrial fibrillation, weight loss, or shortness of breath.
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Affiliation(s)
- K Boelaert
- School of Clinical and Experimental Medicine, College of Medical and Dental Sciences, University of Birmingham, Birmingham B15 2TT, United Kingdom
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Lai A, Sassi L, Compri E, Marino F, Sivelli P, Piantanida E, Tanda ML, Bartalena L. Lower dose prednisone prevents radioiodine-associated exacerbation of initially mild or absent graves' orbitopathy: a retrospective cohort study. J Clin Endocrinol Metab 2010; 95:1333-7. [PMID: 20061414 DOI: 10.1210/jc.2009-2130] [Citation(s) in RCA: 69] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
CONTEXT Radioiodine (RAI) therapy may cause progression of mild or absent Graves' orbitopathy (GO), preventable by oral prednisone. Optimal doses of prednisone are undefined. OBJECTIVE The aim of this study was to compare the effectiveness of reported doses [starting dose, >0.3 mg/kg body weight (bw)], and lower (<0.3 mg/kg bw)] doses of prednisone. DESIGN AND SETTING We conducted a retrospective matched cohort study at a University Center. PATIENTS Of 111 RAI-treated Graves' patients with mild or no GO, 35 received no steroid prophylaxis (absence of GO and/or risk factors for RAI-associated GO progression); 28 received low-dose prednisone (starting dose, 0.16-0.27 mg/kg bw; mean +/- sd, 0.22 +/- 0.03 mg/kg bw; group 1); and 48 received higher doses (group 2). Among the latter, 28 (starting dose, 0.32-0.56 mg/kg bw; mean +/- sd, 0.36 +/- 0.05 mg/kg bw) were matched with group 1 according to several relevant variables. Prednisone was started 1 d after RAI and withdrawn after 6 wk. MAIN OUTCOME MEASURES We assessed ocular changes (1, 3, and 6 months after RAI) and side effects of prednisone. RESULTS Two of 35 patients not receiving steroid prophylaxis (6%) developed mild-to-moderate GO (clinical activity score, 2/7 and 3/7) after RAI. No patients in group 1 or group 2 had GO progression. Side effects were very mild and inconstant, although more frequent in group 2. Both groups showed an increase in bw, an increase that was significantly higher in group 2. CONCLUSION Lower doses of oral prednisone (about 0.2 mg/kg bw) are as effective as previously reported doses (0.3-0.5 mg/kg bw). A shorter treatment period (6 wk) is probably sufficient. The increase in bw is less using lower doses of prednisone.
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Affiliation(s)
- Adriana Lai
- Department of Clinical Medicine, University of Insubria, Division of Endocrinology, Ospedale di Circolo, Viale Borri, 57, 21100 Varese, Italy
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Abraham P, Acharya S. Current and emerging treatment options for Graves' hyperthyroidism. Ther Clin Risk Manag 2010; 6:29-40. [PMID: 20169034 PMCID: PMC2817786 DOI: 10.2147/tcrm.s5229] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/18/2009] [Indexed: 11/23/2022] Open
Abstract
Radioiodine, antithyroid drugs and surgery have been well established therapies for Graves' hyperthyroidism for several decades. However there remain large variations in practice among physicians in the preferred modality and the method of administration. Patient choice and perceptions also play a big role in the choice of treatment. Radioiodine may be given using fixed high doses or by calculated doses following uptake studies. The risks of radioiodine including eye disease and the role of prophylactic steroid therapy are discussed. The commonly used antithyroid drugs include carbimazole, methimazole and propylthiouracil; however a number of other agents have been tried in special situations or in combination with these drugs. The antithyroid drugs may be given in high (using additional levothyroxine in a block-replace regimen) or low doses (in a titration regimen). This review examines the current evidence and relative benefits for these options as well as looking at emerging therapies including immunomodulatory treatments such as rituximab which have come into early clinical trials. The use of antithyroid therapies in special situations is also discussed as well as clinical practice issues which may influence the choices.
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Affiliation(s)
- Prakash Abraham
- Department of Endocrinology, Aberdeen Royal Infirmary, Aberdeen, UK
| | - Shamasunder Acharya
- Department of Endocrinology, John Hunter Hospital, New Lambton NSW, Australia
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Franklyn JA. What is the role of radioiodine uptake measurement and thyroid scintigraphy in the diagnosis and management of hyperthyroidism? Clin Endocrinol (Oxf) 2010; 72:11-2. [PMID: 19473173 DOI: 10.1111/j.1365-2265.2009.03633.x] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Affiliation(s)
- Jayne A Franklyn
- School of Clinical and Experimental Medicine, College of Medical and Dental Sciences, University of Birmingham, Birmingham, UK.
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Estcourt S, Hickey J, Perros P, Dayan C, Vaidya B. The patient experience of services for thyroid eye disease in the United Kingdom: results of a nationwide survey. Eur J Endocrinol 2009; 161:483-7. [PMID: 19542244 DOI: 10.1530/eje-09-0383] [Citation(s) in RCA: 34] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
BACKGROUND A recent consensus statement from the European Group on Graves' Orbitopathy recommends referring all patients with thyroid eye disease (TED), except the mildest cases, to a specialist multidisciplinary clinic. OBJECTIVE To study the patients' experiences of accessing services for the treatment of TED in the UK. METHODS A postal questionnaire survey of 395 members of two patients support organisations for TED in the UK, the TED Charitable Trust and the British Thyroid Foundation. RESULTS The response rate was 67%. The majority of responders were females (91%) and aged above 45 (74%). There were delays in the diagnosis and referral. In 26% of responders, the time lapsed from the first symptoms to the diagnosis of TED for over 12 months. There was a wide variation in the type of clinic and healthcare professionals involved in the treatment of TED. Only 25% of the responders attended a specialist TED clinic. Out of these, 33% waited over 6 months from the first consultation with a doctor to being seen at a specialist TED clinic. Only 56% of responders were satisfied with the treatment they received for TED. More responders who had attended a specialist TED clinic were satisfied with the treatment than those who had not attended a specialist clinic (67 vs 52%, P<0.05). CONCLUSION Only a minority of patients with TED are treated at a specialist TED clinic in the UK. Those patients who are treated at a specialist TED clinic are more likely to be satisfied with the treatment.
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Affiliation(s)
- Stephanie Estcourt
- Department of Endocrinology, Royal Devon and Exeter Hospital and Peninsula Medical School, Exeter EX2 5DW, UK
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Boelaert K, Syed AA, Manji N, Sheppard MC, Holder RL, Gough SC, Franklyn JA. Prediction of cure and risk of hypothyroidism in patients receiving 131I for hyperthyroidism. Clin Endocrinol (Oxf) 2009; 70:129-38. [PMID: 18462261 DOI: 10.1111/j.1365-2265.2008.03291.x] [Citation(s) in RCA: 56] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
CONTEXT There is little consensus regarding the most appropriate dose of radioiodine ((131)I) to be administered to patients with hyperthyroidism. OBJECTIVE To compare the efficacy of fixed dose regimens of (131)I in curing hyperthyroidism and to define simple clinical and biochemical factors that predict outcome in individual patients. DESIGN Consecutive series of hyperthyroid subjects treated with (131)I. SETTING Single Secondary/Tertiary Care Hospital Clinic. PARTICIPANTS A total of 1278 patients (1013 females and 262 males, mean age 49.7 years) presenting with hyperthyroidism between 1984 and 2006. INTERVENTION Treatment with (131)I using a fixed dose regimen. MAIN OUTCOME MEASURES Probability of cure and risk of development of hypothyroidism following a single dose of (131)I. RESULTS Patients given a single dose of (131)I of 600 MBq (n = 485) had a higher cure rate (84.1%) compared with those receiving either 370 MBq (74.9%, P < 0.001) or those given 185 Bq (63%, P < 0.001). An increased incidence of hypothyroidism by 1 year was evident with higher doses (600 MBq: 60.4%; 370 MBq: 49.2%, P = 0.001; 185 Bq: 38.1%, P < 0.001). Binary logistic regression analysis identified a 600 Bq dose of (131)I [adjusted odds ratio, AOR 3.33 (2.28-4.85), P < 0.001], female gender [AOR 1.75 (1.23-2.47), P = 0.002], lower presenting serum free T4 concentration [AOR 1.01 (1.01-1.02), P < 0.001] and absence of a palpable goitre [AOR 3.33 (2.00-5.56), P < 0.001] to be independent predictors of cure. Similarly, a 600 MBq dose [AOR 3.79 (2.66-5.38), P < 0.001], female gender [AOR 1.46 (1.05-2.02), P = 0.02], younger age [AOR 1.03 (1.02-1.04), P < 0.001], absence of a palpable goitre [AOR 3.85 (2.38-5.88), P < 0.001] and presence of ophthalmopathy [AOR 1.57 (1.06-2.31), P = 0.02] were identified as independent factors predicting the probability of development of hypothyroidism at one year. Based on these findings, formulae to indicate probability of cure and risk of hypothyroidism for application to individual patients were derived. CONCLUSIONS Simple clinical/biochemical criteria can be used to predict outcome after (131)I treatment. These factors determine that males, those with severe biochemical hyperthyroidism, and those with a palpable goitre require larger doses (600 MBq) in order to achieve cure.
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Affiliation(s)
- K Boelaert
- Division of Medical Sciences, University Hospital Birmingham, NHS Foundation Trust, Edgbaston, Birmingham, UK.
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Tanda ML, Lai A, Bartalena L. Relation between Graves' orbitopathy and radioiodine therapy for hyperthyroidism: facts and unsolved questions. Clin Endocrinol (Oxf) 2008; 69:845-7. [PMID: 18785990 DOI: 10.1111/j.1365-2265.2008.03417.x] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Affiliation(s)
- Maria Laura Tanda
- Department of Clinical Medicine, University of Insubria, Varese, Italy
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Affiliation(s)
- Gregory A Brent
- Veterans Affairs Greater Los Angeles Healthcare System, and the Department of Medicine, David Geffen School of Medicine at UCLA, Los Angeles, CA 90073, USA.
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