Frequency of Adverse Events of Antithyroid Drugs Administered during Pregnancy

Evaluation of the therapeutic effect of Descurainia sophia (L.) Webb ex Prantl seed extract on hyperthyroidism: A double-blind placebo-controlled pilot clinical trial

The seeds of Descurainia sophia (L.) Webb ex Prantl contain goitrogenic glucosinolates, such as gluconapin (3-butenyl glucosinolate). Because of the important role of iodine in the synthesis of thyroid hormones and the inhibitory activity of D. sophia on iodine uptake by the thyroid gland, this study aimed to determine the effects of D. sophia syrup on clinical and biochemical variables of thyrotoxicosis in hyperthyroid patients. In this randomized, double-blind trial, 10 newly diagnosed hyperthyroid female patients were randomly assigned to treatment with (1) methimazole (MMI) plus D. sophia capsules (350 mg/d) or (2) MMI plus placebo capsules. The primary outcomes were clinical and biochemical manifestations of hyperthyroidism after 60 days. Serum levels of FT3 and FT4 significantly decreased (5.9 ± 2.5 vs. 9.4 ± 5.9 and 29.1 ± 3.1 vs. 31.77 ± 3.7, respectively) and the serum thyroid-stimulating hormone (TSH) concentration significantly increased in the D. sophia group contrasted to the placebo group (4.7 ± 0.1 vs. 0.05 ± 0.02). Significant improvement in the thyrotoxicosis clinical symptoms was reported in the D. sophia group contrasted to the placebo group (p < .05). D. sophia can suppress plasma levels of FT3 and FT4 and may be useful as adjunctive therapy for hyperthyroidism.

Antithyroid drugs and birth defects

Antithyroid drugs (ATDs) are preferred for the treatment of hyperthyroidism caused by Graves’ disease in pregnant women. The drugs have been a recognized treatment for decades, and a general risk of side effects is known. For the use of ATDs in pregnancy, a concern about teratogenic side effects has been brought forward since the 1970s. In more recent years, a number of large observational studies have added new evidence and quantified the risk of birth defects associated with different types of ATDs. The findings that both Methimazole (MMI) and Propylthiouracil (PTU) are associated with birth defects have challenged the clinical recommendations on the treatment of hyperthyroidism in pregnancy, and certain aspects remain unclarified. In this review, the current evidence on the risk of birth defects associated with the use of ATDs in early pregnancy is described, and determinants of causality are discussed. This includes the current evidence of a biological gradient and the role of maternal thyroid function per se. Finally, clinical aspects of the timing and type of treatment is discussed, and future perspectives are addressed. Current evidence corroborates a risk of birth defects associated with MMI while more evidence is needed to determine the teratogenic potential of PTU. Detailed assessment of type and timing of exposure in large cohorts are needed. Moreover, studies investigating alternative or new treatments are warranted.

Drug-induced liver injury in pregnancy

Drug intake in pregnant women is common, including prescribed and over-the-counter medications, and herbal medicine and supplements. Drug-induced liver injury (DILI) has become the leading cause of acute liver failure in Western countries, and pregnancy is thought to be a risk factor, but only few anecdotal reports concerning pregnant women are found. These involved antihypertensive, antithyroid, antiretroviral, and antituberculosis medications, and antibiotics. Presentation was usually in the first 20 weeks of gestation following a latency of several weeks, because these drugs were usually prescribed before or in early pregnancy due to their fetal safety. The hepatotoxicity is usually of the idiosyncratic form, and most would resolve spontaneously although occasional liver transplantation and maternal death were reported. The scanty reports could have been related to under-reporting and missed diagnosis due to spontaneous resolution in most cases. DILI should remain one of the differential diagnoses in pregnant women with hepatitis.

Clinical efficacy of Yingliu mixture combined with metimazole for treating diffuse goitre with hyperthyroidism and its impact on related cytokines

CONTEXT

Yingliu mixture was developed in 1990s by Affiliated Longhua Hospital of Shanghai University of Traditional Chinese Medicine, for treating diffuse goitre with hyperthyroidism (Graves' disease, GD). Former studies have shown Yingliu mixture combined with methimazole (Y-M) can effectively improve thyroid function and decrease thyrotropin-receptor antibody level. Furthermore, we researched its impact on related cytokines to prove that Y-M improve patients' immunity status.

OBJECTIVE

To observe the clinical efficacy of Y-M for treating GD.

METHODS

A total of 120 GD patients were randomly divided into two groups, the treatment and the control groups (n = 60). The treatment group's patients were treated with Y-M. The control group's patients were treated with methimazole alone. Yingliu mixture was orally administered, 25 mL three times daily. Methimazole was administered at 5-25 mg/day. After 12 weeks of the treatment, the cytokines, antibodies related to thyroid function, and Chinese medical syndromes were evaluated.

RESULTS

After the treatment, the free triiodothyronine and thyroxine levels in both groups decreased. The thyroid-stimulating hormone level increased in the treatment group. The thyrotropin-receptor antibody levels and TNF-α levels decreased in both groups. In the control group, IL-6 and IFN-γ levels were lower than that before the treatment. In the treatment group, CD4⁺ and CD25⁺ levels were higher than pretreatment levels, but IL-10 levels were reduced.

CLINICAL SYMPTOMS

the total CMS scores for both groups decreased.

CONCLUSIONS

The Y-M combination can improve thyroid function, and decrease autoantibodies, cytokines, and clinical symptoms, so its efficacy may surpass that of methimazole alone.

Risk of embryopathies with use of antithyroidal medications

PURPOSE OF REVIEW

Hyperthyroidism in pregnant women should be adequately treated to prevent maternal and fetal complications. The treatment of choice in pregnancy is antithyroidal medications (ATDs). The risk of embryopathies associated with the use of Methimazole (MMI) and Propylthiouracil (PTU) in early pregnancy is a matter of clinical attention and concern. This review describes current evidence and how scientific findings are reflected in current clinical guidelines.

RECENT FINDINGS

Embryopathies after the use of ATDs were previously mainly described in case reports and considered rare. Recent large observational studies, including nonexposed control groups, have quantified an increased risk of embryopathies associated with use of ATDs during pregnancy. Findings suggest a risk of embryopathies with the use of both MMI and PTU, but the pattern of embryopathies differs, and embryopathies with the use of PTU appear less severe.

SUMMARY

Current guidelines highlight the need for clinical attention on the use of ATDs in early pregnancy. Patients managed on ATDs for the treatment of hyperthyroidism should be counseled to report a pregnancy as early as possible. PTU is the recommended treatment in early pregnancy, but if the risk of relapse or worsening of hyperthyroidism is considered low, it is suggested that ATD treatment can be withdrawn followed by frequent monitoring of thyroid function.

Gestational thyrotoxicosis, antithyroid drug use and neonatal outcomes within an integrated healthcare delivery system

BACKGROUND

Increasing attention has focused on the prevalence and outcomes of hyperthyroidism in pregnancy, given concerns for hepatotoxicity and embryopathy associated with antithyroid drugs (ATDs).

METHODS

In an integrated health care delivery system, we examined the prevalence of thyrotoxicosis and gestational ATD use (propylthiouracil [PTU] or methimazole [MMI]) in women with delivered pregnancies from 1996 to 2010. Birth outcomes were compared among all infants and those born to mothers with diagnosed thyrotoxicosis or ATD therapy during gestation, with examination of ATD-associated hepatotoxicity and congenital malformations in the latter subgroups.

RESULTS

Among 453,586 mother-infant pairs (maternal age 29.7±6.0 years, 57.1% nonwhite), 3.77 per 1000 women had diagnosed thyrotoxicosis and 1.29 per 1000 had gestational ATD exposure (86.5% PTU, 5.1% MMI, 8.4% both). Maternal PTU-associated hepatotoxicity occurred with a frequency of 1.80 per 1000 pregnancies. Infants of mothers with diagnosed thyrotoxicosis (odds ratio [OR] 1.28, 95% confidence interval [CI 1.05-1.55]) or gestational ATD use (OR 1.31 [1.00-1.72]) had an increased risk of preterm birth compared to those born to mothers without thyrotoxicosis or ATD. The risk of neonatal intensive care unit (NICU) admission was also higher with maternal thyrotoxicosis (OR 1.30 [1.07-1.59]) and ATD exposure (OR 1.64 [CI 1.26-2.13]), adjusting for prematurity. Congenital malformation rates were low and similar among infants born to mothers with thyrotoxicosis or ATD exposure (30-44 per 1000 infants).

CONCLUSIONS

Gestational ATD exposure occurred in 1.29 per 1000 mother-infant pairs while a much larger number had maternal diagnosed thyrotoxicosis but no drug exposure during pregnancy. Infants of mothers with gestational ATD use or diagnosed thyrotoxicosis were more likely to be preterm and admitted to the NICU. The rates of congenital malformation were low for mothers diagnosed with thyrotoxicosis and did not differ by ATD use. Among women with gestational PTU therapy, the frequency of PTU-associated hepatotoxicity was 1.8 per 1000 delivered pregnancies. These findings from a large, population-based cohort provide generalizable estimates of maternal and infant risks associated with maternal thyrotoxicosis and related pharmacotherapy.

Thyrotoxicosis of Pregnancy

Thyrotoxicosis presenting during pregnancy is a common clinical problem and can be challenging to differentiate between physiologic patterns of thyroid dysfunction during gestation and intrinsic hyperthyroidism. This review provides a summary of the differential diagnosis, clinical presentation, diagnostic options, potential adverse effects of maternal thyrotoxicosis to the fetus, and treatment recommendations for thyrotoxicosis arising in pregnancy.