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Vadini V, Vasistha P, Shalit A, Maraka S. Thyroid storm in pregnancy: a review. Thyroid Res 2024; 17:2. [PMID: 38229163 DOI: 10.1186/s13044-024-00190-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/22/2023] [Accepted: 01/02/2024] [Indexed: 01/18/2024] Open
Abstract
BACKGROUND Thyroid storm is a state of circulating thyroid hormone excess leading to multiorgan dysfunction and systemic decompensation. It typically occurs in the setting of poorly controlled hyperthyroidism and a precipitating illness or event. Management of thyroid storm in pregnancy poses unique diagnostic and therapeutic challenges. MAIN BODY Thyroid storm is a clinical diagnosis characterized by hyperpyrexia, tachyarrhythmias, congestive heart failure, gastrointestinal and neuropsychiatric disturbances. However, diagnostic scoring systems have not been validated in pregnancy. Treatment involves specialist consultation, supportive care, and pharmacological options such as anti-thyroid medications, beta blockers, iodine solutions, glucocorticoids, and cholestyramine. These must be adapted and modified in pregnancy to prevent fetal and maternal complications. CONCLUSION There is a critical need to recognize thyroid storm during pregnancy and initiate proper medical interventions promptly.
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Affiliation(s)
- Vidhu Vadini
- Department of Internal Medicine, University of Arkansas for Medical Sciences, 4301 W. Markham St, Little Rock, AR, 72205, USA
| | - Prabhav Vasistha
- Department of Internal Medicine, University of Arkansas for Medical Sciences, 4301 W. Markham St, Little Rock, AR, 72205, USA
| | - Almog Shalit
- Endocrine Unit and Diabetes Center, Department of Clinical Therapeutics, School of Medicine, Alexandra Hospital, National and Kapodistrian University of Athens, Athens, Greece
| | - Spyridoula Maraka
- Division of Endocrinology and Metabolism, University of Arkansas for Medical Sciences, 4301 W. Markham St, Little Rock, AR, 72205, USA.
- Section of Endocrinology, Central Arkansas Veterans Healthcare System, 4300 W. 7Th St, Little Rock, AR, 72205, USA.
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Khan AA, Ata F, Aziz A, Elamin H, Shahzad A, Yousaf Z, Donato A. Clinical Characteristics and Outcomes of Patients With Antithyroid Drug-Related Liver Injury. J Endocr Soc 2023; 8:bvad133. [PMID: 38178906 PMCID: PMC10765380 DOI: 10.1210/jendso/bvad133] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/18/2023] [Indexed: 01/06/2024] Open
Abstract
Context Antithyroid drugs (ATDs) are the cornerstone of hyperthyroidism management. Hepatotoxicity due to ATDs can range from mild transaminase elevation to liver transplantation requirement and mortality. Objective The primary objective of the systematic review was to assess the clinical characteristics and outcomes of patients with drug induced liver injury (DILI) due to ATDs. Methods We conducted a systematic review of PUBMED, SCOPUS, and EMBASE on characteristics and outcomes of adults (>18 years) with DILI due to ATDs. We defined DILI as bilirubin ≥2.5 mg/dL or international normalized ratio >1.5 with any rise in alanine aminotransferase (ALT), aminotransferase (AST), or alkaline phosphatase (ALP), or an elevation of ALT or AST >5 times or ALP >2 times the upper limit of normal without jaundice/coagulopathy. Results The review included 100 articles describing 271 patients; 148 (70.8%) were female (N = 209). Mean age was 42.9 ± 17.2 years. Graves' disease was the most common indication for ATDs. Carbimazole/methimazole (CBM/MMI) was the most common offending agent (55.7%). DILI pattern was hepatocellular in 41.8%, cholestatic in 41.3%, and mixed in 16.9%. Outcomes included death in 11.8%, liver transplantation in 6.4%, partial improvement in 2.2%, and complete resolution in 79.6% with a median time (IQR) to resolution of 45 (20-90) days. Patients in the propylthiouracil (PTU) group had higher initial bilirubin, initial AST, initial ALT, peak ALT, peak AST, severe and fatal DILI, liver transplantation, and mortality than CBM/MMI. Rechallenge of antithyroid medication was infrequently reported (n = 16) but was successful in 75%. Conclusion DILI due to ATDs can present with different patterns and should prompt immediate drug discontinuation. Referral to a hepatologist should be considered if severe as transplantation is sometimes required. PTU-induced DILI may have worse outcomes than CBM/MMI.
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Affiliation(s)
- Adeel Ahmad Khan
- Department of Endocrinology, Hamad Medical Corporation, 3050, Doha, Qatar
| | - Fateen Ata
- Department of Endocrinology, Hamad Medical Corporation, 3050, Doha, Qatar
| | - Afia Aziz
- Department of Internal Medicine, Hamad Medical Corporation, 3050, Doha, Qatar
| | - Hana Elamin
- National University-Sudan, Khartoum 11115, Sudan
| | - Aamir Shahzad
- Department of Medicine, Tower Health, West Reading, PA 19611, USA
| | - Zohaib Yousaf
- Department of Medicine, Tower Health, West Reading, PA 19611, USA
| | - Anthony Donato
- Department of Medicine, Tower Health, West Reading, PA 19611, USA
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Shale WT, Umer KM, Tola GG, Guluju FA. Asymptomatic Propylthiouracil Induced Agranulocytosis in a Patient with Toxic Nodular Goiter: A Rare Case Report. Int Med Case Rep J 2023; 16:503-512. [PMID: 37701536 PMCID: PMC10493100 DOI: 10.2147/imcrj.s424053] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/01/2023] [Accepted: 08/31/2023] [Indexed: 09/14/2023] Open
Abstract
Background Agranulocytosis is a rare but fatal side effect of antithyroid drugs (ATDs) with incidence reported at 0.1%-1%. Agranulocytosis is defined as a granulocyte count <500 cells/μL following the use of ATDs and is an absolute contraindication to the use of these drugs; in this case, radioactive iodine (RAI) or surgery are therapeutic options. Case Presentation A 28-year-old female patient was on follow-up at our clinic after she presented with anterior neck swelling of 4 years. The patient was started on propylthiouracil (PTU) and propranolol based on clinical symptoms of hyperthyroidism and low thyroid stimulating hormone (TSH) levels. After taking the ATDs for 7 months, she came to the clinic for her regular follow-up. At this point, she was declared euthyroid and booked for surgery. Investigations were sent and the complete blood count (CBC) result showed leucopenia with agranulocytosis, even though she was completely asymptomatic. The offending ATD was immediately discontinued. The patient was kept inpatient for monitoring, and lugol's iodine and propranolol were initiated. Eight days after discontinuing the ATD, the CBC profile was determined once again, showing normalized total leukocyte, as well as, absolute neutrophil count. Eventually, the multinodular goiter (MNG) was managed with subtotal thyroidectomy. Conclusion Despite the fact that agranulocytosis is an extremely rare side effect of ATDs, most often PTU; it is a potentially fatal complication when it occurs. Patient education at the time of prescription should not be overlooked, and systematic programs should be put in place. The baseline granulocyte count should be determined and monitored on a regular basis.
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Affiliation(s)
- Wongel Tena Shale
- Jimma University, College of Public Health and Medical Sciences, Department of Surgery, Jimma, Oromia, Ethiopia
| | - Keno Mohammed Umer
- Department of General Surgery, Dire Dawa University, Dire Dawa, Ethiopia
| | - Gutu Ganati Tola
- Jimma University, College of Public Health and Medical Sciences, Department of Surgery, Jimma, Oromia, Ethiopia
| | - Fayera Abetu Guluju
- Jimma University, College of Public Health and Medical Sciences, Department of Surgery, Jimma, Oromia, Ethiopia
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Azizi F, Abdi H, Mehran L, Amouzegar A. Appropriate duration of antithyroid drug treatment as a predictor for relapse of Graves' disease: a systematic scoping review. J Endocrinol Invest 2022; 45:1139-1150. [PMID: 35088381 DOI: 10.1007/s40618-021-01730-1] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/25/2021] [Accepted: 12/18/2021] [Indexed: 11/25/2022]
Abstract
BACKGROUND Following the conventional 12-18 month antithyroid drug (ATD) treatment in Graves' disease (GD), 50% of patients experience relapse of hyperthyroidism. OBJECTIVE The aim of this systematic scoping review was critical appraisal of duration of ATD therapy in the last 80 years. METHODS Articles were identified through the search of PubMed from January 1, 1941 to April 30, 2021. All study types were included. Articles were eligible if they reported data on the length of ATD treatment, particularly thyroid hormones and TSH receptor antibodies (TRAb) concentrations and specifically those with data on the remission and/or relapse rates. RESULTS We described major progress regarding the duration of ATD therapy and related outcomes at every 20 years. Articles of 1941-1960 were mainly concerned with determination of favorable treatment, minimal effective dose, side effects and rate of remission after < 12-month ATD therapy. Studies with larger number of patients and longer follow-ups appeared in 1961-1980; higher remission rate after 18-24 months versus 6 months of ATD therapy was reported. Articles of 1981-2000 focused on identification of factors associated with high relapse rates after discontinuation of ATD. In 2001-2021, ATD became the first choice of treatment in many countries. However, 12-18 months of ATD therapy was arbitrarily chosen as the appropriate option. According to recent studies, persistent normalization of TRAb occurs after 5 years of methimazole therapy and ATD treatment of > 60 months could offer a 4-year remission rate of 85%. CONCLUSION Long-term ATD treatment for more than 60 months is safe and effective, has the highest remission rate and cures most patients with GD; hence, it should be considered as the most appropriate duration for ATD therapy in these patients.
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Affiliation(s)
- F Azizi
- Endocrine Research Center, Research Institute for Endocrine Sciences, Shahid Beheshti University of Medical Sciences, No. 24, Aerabi St, Daneshjoo Blv, Velenjak, P.O. Box 19395-4763, Tehran, Iran
| | - H Abdi
- Endocrine Research Center, Research Institute for Endocrine Sciences, Shahid Beheshti University of Medical Sciences, No. 24, Aerabi St, Daneshjoo Blv, Velenjak, P.O. Box 19395-4763, Tehran, Iran
| | - L Mehran
- Endocrine Research Center, Research Institute for Endocrine Sciences, Shahid Beheshti University of Medical Sciences, No. 24, Aerabi St, Daneshjoo Blv, Velenjak, P.O. Box 19395-4763, Tehran, Iran
| | - A Amouzegar
- Endocrine Research Center, Research Institute for Endocrine Sciences, Shahid Beheshti University of Medical Sciences, No. 24, Aerabi St, Daneshjoo Blv, Velenjak, P.O. Box 19395-4763, Tehran, Iran.
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Han Z, Cen C, Ou Q, Pan Y, Zhang J, Huo D, Chen K. The Potential Prebiotic Berberine Combined With Methimazole Improved the Therapeutic Effect of Graves' Disease Patients Through Regulating the Intestinal Microbiome. Front Immunol 2022; 12:826067. [PMID: 35082799 PMCID: PMC8785824 DOI: 10.3389/fimmu.2021.826067] [Citation(s) in RCA: 11] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2021] [Accepted: 12/20/2021] [Indexed: 12/12/2022] Open
Abstract
Graves’ disease, a typical metabolism disorder, causes diffuse goiter accompanied by ocular abnormalities and ocular dysfunction. Although methimazole (MI) is a commonly used drug for the treatment of GD, the efficacy of methimazole is only limited to the control of clinical indicators, and the side effects of MI should be seriously considered. Here, we designed a 6-month clinical trial that divided the patients into two groups: a methimazole group (n=8) and a methimazole combined with potential prebiotic berberine group (n=10). The effects of both treatments on thyroid function and treatment outcomes in patients with GD were assessed by thyroid index measurements and gut microbiota metagenomic sequencing. The results showed that the addition of berberine restored the patients’ TSH and FT3 indices to normal levels, whereas MI alone restored only FT3. In addition, TRAb was closer to the healthy threshold at the end of treatment with the drug combination. MI alone failed to modulate the gut microbiota of the patients. However, the combination of berberine with methimazole significantly altered the microbiota structure of the patients, increasing the abundance of the beneficial bacteria Lactococcus lactis while decreasing the abundance of the pathogenic bacteria Enterobacter hormaechei and Chryseobacterium indologenes. Furthermore, further mechanistic exploration showed that the addition of berberine resulted in a significant upregulation of the synthesis of enterobactin, which may have increased iron functioning and thus restored thyroid function. In conclusion, methimazole combined with berberine has better efficacy in patients with GD, suggesting the potential benefit of berberine combined with methimazole in modulating the composition of intestinal microbes in the treatment of GD, providing new strong evidence for the effectiveness of combining Chinese and Western drugs from the perspective of modulating the intestinal microbiota.
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Affiliation(s)
- Zhe Han
- School of Food Science and Engineering, Hainan University, Department of Endocrinology, Hainan General Hospital, Hainan Affiliated Hospital of Hainan Medical University, Haikou, China
| | - Chaoping Cen
- School of Food Science and Engineering, Hainan University, Department of Endocrinology, Hainan General Hospital, Hainan Affiliated Hospital of Hainan Medical University, Haikou, China
| | - Qianying Ou
- School of Food Science and Engineering, Hainan University, Department of Endocrinology, Hainan General Hospital, Hainan Affiliated Hospital of Hainan Medical University, Haikou, China
| | - Yonggui Pan
- Key Laboratory of Food Nutrition and Functional Food of Hainan Province, Hainan University, Haikou, China
| | - Jiachao Zhang
- School of Food Science and Engineering, Hainan University, Department of Endocrinology, Hainan General Hospital, Hainan Affiliated Hospital of Hainan Medical University, Haikou, China.,Key Laboratory of Food Nutrition and Functional Food of Hainan Province, Hainan University, Haikou, China
| | - Dongxue Huo
- School of Food Science and Engineering, Hainan University, Department of Endocrinology, Hainan General Hospital, Hainan Affiliated Hospital of Hainan Medical University, Haikou, China.,Key Laboratory of Food Nutrition and Functional Food of Hainan Province, Hainan University, Haikou, China
| | - Kaining Chen
- School of Food Science and Engineering, Hainan University, Department of Endocrinology, Hainan General Hospital, Hainan Affiliated Hospital of Hainan Medical University, Haikou, China
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Theiler-Schwetz V, Benninger T, Trummer C, Pilz S, Reichhartinger M. Mathematical Modeling of Free Thyroxine Concentrations During Methimazole Treatment for Graves' Disease: Development and Validation of a Computer-Aided Thyroid Treatment Method. Front Endocrinol (Lausanne) 2022; 13:841888. [PMID: 35721705 PMCID: PMC9205409 DOI: 10.3389/fendo.2022.841888] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/22/2021] [Accepted: 04/05/2022] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND Methimazole (MMI) is the first-line treatment for patients with Graves' disease (GD). While there are empirical recommendations for initial MMI doses, there is no clear guidance for subsequent MMI dose titrations. We aimed to (a) develop a mathematical model capturing the dynamics of free thyroxine (FT4) during MMI treatment (b), validate this model by use of numerical simulation in comparison with real-life patient data (c), develop the software application Digital Thyroid (DigiThy) serving either as a practice tool for treating virtual patients or as a decision support system with dosing recommendations for MMI, and (d) validate this software framework by comparing the efficacy of its MMI dosing recommendations with that from clinical endocrinologists. METHODS Based on concepts of automatic control and by use of optimization techniques, we developed two first order ordinary differential equations for modeling FT4 dynamics during MMI treatment. Clinical data from patients with GD derived from the outpatient clinic of Endocrinology at the Medical University of Graz, Austria, were used to develop and validate this model. It was subsequently used to create the web-based software application DigiThy as a simulation environment for treating virtual patients and an autonomous computer-aided thyroid treatment (CATT) method providing MMI dosing recommendations. RESULTS Based on MMI doses, concentrations of FT4, thyroid-stimulating hormone (TSH), and TSH-receptor antibodies (TRAb), a mathematical model with 8 patient-specific constants was developed. Predicted FT4 concentrations were not significantly different compared to the available consecutively measured FT4 concentrations in 9 patients with GD (52 data pairs, p=0.607). Treatment success of MMI dosing recommendations in 41 virtually generated patients defined by achieved target FT4 concentrations preferably with low required MMI doses was similar between CATT and usual care. Statistically, CATT was significantly superior (p<0.001). CONCLUSIONS Our mathematical model produced valid FT4 predictions during MMI treatment in GD and provided the basis for the DigiThy application already serving as a training tool for treating virtual patients. Clinical trial data are required to evaluate whether DigiThy can be approved as a decision support system with automatically generated MMI dosing recommendations.
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Affiliation(s)
- Verena Theiler-Schwetz
- Division of Endocrinology and Diabetology, Department of Internal Medicine, Medical University of Graz, Graz, Austria
| | - Thomas Benninger
- Institute of Automation and Control, Graz University of Technology, Graz, Austria
| | - Christian Trummer
- Division of Endocrinology and Diabetology, Department of Internal Medicine, Medical University of Graz, Graz, Austria
| | - Stefan Pilz
- Division of Endocrinology and Diabetology, Department of Internal Medicine, Medical University of Graz, Graz, Austria
- *Correspondence: Stefan Pilz,
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Nuclear medicine therapy of thyroid goiter. Nucl Med Mol Imaging 2022. [DOI: 10.1016/b978-0-12-822960-6.00204-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
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Li J, Hussain Z, Zhu J, Lei S, Lu J, Ma X. Role of CYP2A6 in Methimazole Bioactivation and Hepatotoxicity. Chem Res Toxicol 2021; 34:2534-2539. [PMID: 34788025 DOI: 10.1021/acs.chemrestox.1c00300] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
Methimazole (MMI) is a widely used antithyroid drug, but it can cause hepatotoxicity by unknown mechanisms. Previous studies showed that the hepatic metabolism of MMI produces N-methylthiourea, leading to liver damage. However, the specific enzyme responsible for the production of the toxic metabolite N-methylthiourea is still unclear. In this study, we screened cytochromes P450 (CYPs) in N-methylthiourea production from MMI. CYP2A6 was identified as the key enzyme in catalyzing MMI metabolism to produce N-methylthiourea. When mice were pretreated with a CYP2A6 inhibitor, formation of N-methylthiourea from MMI was remarkably reduced. Consistently, the CYP2A6 inhibitor prevented MMI-induced hepatotoxicity. These results demonstrated that CYP2A6 is essential in MMI bioactivation and hepatotoxicity.
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Affiliation(s)
- Jianhua Li
- Center for Pharmacogenetics, Department of Pharmaceutical Sciences, School of Pharmacy, University of Pittsburgh, Pittsburgh, Pennsylvania 15261, United States
| | - Zahir Hussain
- Center for Pharmacogenetics, Department of Pharmaceutical Sciences, School of Pharmacy, University of Pittsburgh, Pittsburgh, Pennsylvania 15261, United States
| | - Junjie Zhu
- Center for Pharmacogenetics, Department of Pharmaceutical Sciences, School of Pharmacy, University of Pittsburgh, Pittsburgh, Pennsylvania 15261, United States
| | - Saifei Lei
- Center for Pharmacogenetics, Department of Pharmaceutical Sciences, School of Pharmacy, University of Pittsburgh, Pittsburgh, Pennsylvania 15261, United States
| | - Jie Lu
- Center for Pharmacogenetics, Department of Pharmaceutical Sciences, School of Pharmacy, University of Pittsburgh, Pittsburgh, Pennsylvania 15261, United States
| | - Xiaochao Ma
- Center for Pharmacogenetics, Department of Pharmaceutical Sciences, School of Pharmacy, University of Pittsburgh, Pittsburgh, Pennsylvania 15261, United States
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Tan S, Chen L, Jin L, Fu X. The efficiency and safety of methimazole and propylthiouracil in hyperthyroidism: A meta-analysis of randomized controlled trials. Medicine (Baltimore) 2021; 100:e26707. [PMID: 34397700 PMCID: PMC8322508 DOI: 10.1097/md.0000000000026707] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/01/2020] [Accepted: 06/22/2021] [Indexed: 01/04/2023] Open
Abstract
PURPOSE The aim of this study was to evaluate the efficiency and safety of methimazole (MMI) and propylthiouracil (PTU) in the treatment of hyperthyroidism. METHODS Articles were searched through the PubMed, EMBASE, Cochrane Library, Web of Science, CNKI, Wanfang, and QVIP. The primary outcomes were clinical efficacy and thyroid hormone levels in MMI and PTU groups. The secondary outcomes were liver function indexes and adverse reactions in MMI and PTU groups. Results were expressed as weighted mean difference (WMD) or odds ratio (OR) with 95% confidence intervals (CIs). The Begg test was applied to assess the publication bias. RESULTS Totally, 16 randomized controlled trials were retained in this meta-analysis with 973 patients receiving MMI and 933 receiving PTU. The levels of triiodothyronine (T3) (WMD = -1.321, 95% CI: -2.271 to -0.372, P = .006), thyroxine (T4) (WMD = -37.311, 95% CI: -61.012 to -13.610, P = .002), Free T3 (FT3) (WMD = -1.388, 95% CI: -2.543 to -0.233, P = .019), Free T4 (FT4) (WMD = -3.613, 95% CI: -5.972 to -1.255, P = .003), and the risk of liver function damage (OR = 0.208, 95% CI: 0.146-0.296, P < .001) in the MMI group were lower than those in the PTU group. The thyroid-stimulating hormone level (WMD = 0.787, 95% CI: 0.380-1.194, P < .001) and the risk of hypothyroidism (OR = 2.738, 95% CI: 1.444-5.193, P = .002) were higher in the MMI group than those in the PTU group. CONCLUSIONS Although MMI might have higher risk of hypothyroidism than PTU, the efficacy of MMI may be better than PTU in patients with hyperthyroidism regarding reducing T3, T4, FT3, and FT4 levels, decreasing the risk of liver function damage and increasing the level of thyroid-stimulating hormone. REGISTER NUMBER osf.io/ds637 (https://osf.io/search/).
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Affiliation(s)
- Shuang Tan
- Department of Acupuncture and Moxibustion, Huguo Temple Hospital of Traditional Chinese medicine affiliated to Beijing University of Chinese Medicine, Beijing
| | - Long Chen
- Department of Chinese medicine, Inner Mongolia Qingshuihe Hospital of Chinese and Mongolian medicine, Inner Mongolia
| | - Likun Jin
- Department of Orthopaedics, Beijing Fengsheng Special Hospital of Traditional Medical Traumatology and Orthopaedics, Beijing, China
| | - Xiaomin Fu
- Department of Acupuncture and Moxibustion, Huguo Temple Hospital of Traditional Chinese medicine affiliated to Beijing University of Chinese Medicine, Beijing
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Abera BT, Abera MA, Berhe G, Abreha GF, Gebru HT, Abraha HE, Ebrahim MM. Thyrotoxicosis and dilated cardiomyopathy in developing countries. BMC Endocr Disord 2021; 21:132. [PMID: 34182968 PMCID: PMC8240202 DOI: 10.1186/s12902-021-00796-5] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/24/2021] [Accepted: 06/15/2021] [Indexed: 11/29/2022] Open
Abstract
BACKGROUND Thyrotoxicosis is the state of thyroid hormone excess. But, in sub-Saharan Africa (SSA), specifically Northern Ethiopia, scientific evidence about thyrotoxicosis and its cardiac complications like dilated cardiomyopathy is limited. Therefore, this study aimed to explore the thyrotoxicosis presentation and management and identify factors associated with dilated cardiomyopathy in a tertiary hospital in Northern Ethiopia. METHODS An institution-based cross-sectional study was conducted in Ayder Comprehensive Specialized Hospital from 2017 to 2018. Data from 200 thyrotoxicosis cases were collected using a structured questionnaire. After describing variables, logistic regression was conducted to identify independent predictors of dilated cardiomyopathy. Statistical significance was declared at p < 0.05. RESULTS Mean age at presentation of thyrotoxicosis was 45 years and females accounted for 89 % of the cases. The most frequent etiology was multinodular toxic goiter (51.5 %). As well, the most common symptoms and signs were palpitation and goiter respectively. Thyroid storm occurred in 6 % of the cases. Out of 89 patients subjected to echocardiography, 35 (39.3 %) of them had dilated cardiomyopathy. And, the odds of dilated cardiomyopathy were higher in patients who had atrial fibrillation (AOR = 15.95, 95 % CI:5.89-38.16, p = 0.001) and tachycardia (AOR = 2.73, 95 % CI:1.04-7.15, p = 0.040). All patients took propylthiouracil and 13.0 % of them experienced its side effects. Concerning β-blockers, propranolol was the most commonly (78.5 % of the cases) used drug followed by atenolol (15.0 %). Six patients underwent surgery. CONCLUSIONS In developing countries like Ethiopia, patients with thyrotoxicosis have no access to methimazole which is the first-line anti-thyroid drug. Besides, they greatly suffer from dilated cardiomyopathy (due to late presentation) and side effects of propylthiouracil. Therefore, we recommend that patients should get adequate health information about thyrotoxicosis and anti-thyroid drugs including their side effects. Additionally, hospitals and other concerned bodies should also avail of TSH tests and methimazole at an affordable cost. Furthermore, community awareness about iodized salt and iodine-rich foods should be enhanced.
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Xiao Y, Yang W, Zhou L, Hao H, Bao Y, Yin Q, Xie C. Growth mechanism of the spherulitic propylthiouracil–kaempferol cocrystal: new perspectives into surface nucleation. CrystEngComm 2021. [DOI: 10.1039/d1ce00022e] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
A growth mechanism of spherulitic cocrystals shows three stages of single crystal growth, non-crystallographic branching and surface nucleation. Low supersaturation forms loose spherulites, and high temperature causes “spherulites on spherulites”.
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Affiliation(s)
- Yuntian Xiao
- Equation Chapter 1 Section 1 School of Chemical Engineering and Technology
- Tianjin University
- Tianjin 300072
- PR China
| | - Wenchao Yang
- Equation Chapter 1 Section 1 School of Chemical Engineering and Technology
- Tianjin University
- Tianjin 300072
- PR China
| | - Ling Zhou
- Equation Chapter 1 Section 1 School of Chemical Engineering and Technology
- Tianjin University
- Tianjin 300072
- PR China
- National Collaborative Innovation Centre of Chemical Science and Engineering (Tianjin)
| | - Hongxun Hao
- Equation Chapter 1 Section 1 School of Chemical Engineering and Technology
- Tianjin University
- Tianjin 300072
- PR China
- National Collaborative Innovation Centre of Chemical Science and Engineering (Tianjin)
| | - Ying Bao
- Equation Chapter 1 Section 1 School of Chemical Engineering and Technology
- Tianjin University
- Tianjin 300072
- PR China
- National Collaborative Innovation Centre of Chemical Science and Engineering (Tianjin)
| | - Qiuxiang Yin
- Equation Chapter 1 Section 1 School of Chemical Engineering and Technology
- Tianjin University
- Tianjin 300072
- PR China
- National Collaborative Innovation Centre of Chemical Science and Engineering (Tianjin)
| | - Chuang Xie
- Equation Chapter 1 Section 1 School of Chemical Engineering and Technology
- Tianjin University
- Tianjin 300072
- PR China
- National Collaborative Innovation Centre of Chemical Science and Engineering (Tianjin)
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Ghosh R, Raveendranath R, Kishore N. Unraveling diverse action of triton X-100 and methimazole on lysozyme fibrillation/aggregation: Physicochemical insights. Int J Biol Macromol 2020; 167:736-745. [PMID: 33278448 DOI: 10.1016/j.ijbiomac.2020.11.210] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/09/2020] [Revised: 11/19/2020] [Accepted: 11/30/2020] [Indexed: 01/18/2023]
Abstract
Identification of functionalities responsible for prevention of fibrillation in proteins is important to design effective drugs in addressing neurodegenerative diseases. We have used nonionic surfactant triton X-100 (TX-100) and antithyroid drug methimazole (MMI) to understand mechanistic aspects of action of these molecules having different functionalities on hen egg-white lysozyme at different stages of fibrillation. After establishing the nucleation, elongation and maturation stages of fibrillation of protein at 57 °C, energetics of interactions with these molecules have been determined by using isothermal titration calorimetry. Differential scanning calorimetry has permitted assessment of thermal stability of the protein at these stages, with or without these molecular entities. The enthalpies of interaction of TX-100 and MMI with protein fibrils suggest importance of hydrogen bonding and polar interactions in their effectiveness towards prevention of fibrils. TX-100, in spite of several polar centres, is unable to prevent fibrillation, rather it promotes. MMI is able to establish polar interactions with interacting strands of the protein and disintegrate fibrils. A rigorous comparison with inhibitors reported in literature highlights importance -OH and >CO functionalities in fibrillation prevention. Even though MMI has hydrogen bonding centres, its efficiency as inhibitor falls after the inhibited lysozyme fibrils further interact and form amorphous aggregates.
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Affiliation(s)
- Ritutama Ghosh
- Department of Chemistry, Indian Institute of Technology Bombay, Powai, Mumbai 400 076, India
| | - Revathy Raveendranath
- Department of Chemistry, Indian Institute of Technology Bombay, Powai, Mumbai 400 076, India
| | - Nand Kishore
- Department of Chemistry, Indian Institute of Technology Bombay, Powai, Mumbai 400 076, India.
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13
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Deisenroth C, Soldatow VY, Ford J, Stewart W, Brinkman C, LeCluyse EL, MacMillan DK, Thomas RS. Development of an In Vitro Human Thyroid Microtissue Model for Chemical Screening. Toxicol Sci 2020; 174:63-78. [PMID: 31808822 PMCID: PMC8061085 DOI: 10.1093/toxsci/kfz238] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022] Open
Abstract
Thyroid hormones (TH) are essential for regulating a number of diverse physiological processes required for normal growth, development, and metabolism. The US EPA Endocrine Disruptor Screening Program (EDSP) has identified several molecular thyroid targets relevant to hormone synthesis dynamics that have been adapted to high-throughput screening (HTS) assays to rapidly evaluate the ToxCast/Tox21 chemical inventories for potential thyroid disrupting chemicals (TDCs). The uncertainty surrounding the specificity of active chemicals identified in these screens and the relevance to phenotypic effects on in vivo human TH synthesis are notable data gaps for hazard identification of TDCs. The objective of this study was to develop a medium-throughput organotypic screening assay comprised of reconstructed human thyroid microtissues to quantitatively evaluate the disruptive effects of chemicals on TH production and secretion. Primary human thyroid cells procured from qualified euthyroid donors were analyzed for retention of NK2 homeobox 1 (NKX2-1), Keratin 7 (KRT7), and Thyroglobulin (TG) protein expression by high-content image analysis to verify enrichment of follicular epithelial cells. A direct comparison of 2-dimensional (2D) and 3-dimensional (3D) 96-well culture formats was employed to characterize the morphology, differential gene expression, TG production, and TH synthesis over the course of 20 days. The results indicate that modeling human thyroid cells in the 3D format was sufficient to restore TH synthesis not observed in the 2D culture format. Inhibition of TH synthesis in an optimized 3D culture format was demonstrated with reference chemicals for key molecular targets within the thyroid gland. Implementation of the assay may prove useful for interpreting phenotypic effects of candidate TDCs identified by HTS efforts currently underway in the EDSP.
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Affiliation(s)
- Chad Deisenroth
- National Center for Computational Toxicology, Office of Research and Development, U.S. Environmental Protection Agency, Research Triangle Park, North Carolina 27711
| | | | - Jermaine Ford
- Research Cores Unit, Office of Research and Development, National Health and Environmental Effects Research Laboratory, Research Triangle Park, North Carolina 27711
| | - Wendy Stewart
- National Center for Computational Toxicology, Office of Research and Development, U.S. Environmental Protection Agency, Research Triangle Park, North Carolina 27711
| | - Cassandra Brinkman
- National Center for Computational Toxicology, Office of Research and Development, U.S. Environmental Protection Agency, Research Triangle Park, North Carolina 27711
| | | | - Denise K. MacMillan
- Research Cores Unit, Office of Research and Development, National Health and Environmental Effects Research Laboratory, Research Triangle Park, North Carolina 27711
| | - Russell S. Thomas
- National Center for Computational Toxicology, Office of Research and Development, U.S. Environmental Protection Agency, Research Triangle Park, North Carolina 27711
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14
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Mechanistic examination of methimazole-induced hepatotoxicity in patients with Grave’s disease: a metabolomic approach. Arch Toxicol 2019; 94:231-244. [DOI: 10.1007/s00204-019-02618-z] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/17/2019] [Accepted: 11/06/2019] [Indexed: 12/11/2022]
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15
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Abstract
The two most common autoimmune conditions of the thyroid include chronic lymphocytic (Hashimoto's) thyroiditis and Graves' disease. Both conditions can be treated medically, but surgery plays an important role. Hashimoto's thyroiditis and Graves' disease are mediated by autoantibodies that interact directly with the thyroid, creating inflammation and impacting thyroid function. Patients may develop large goiters with compressive symptoms or malignancy requiring surgical intervention. In addition, there are several surgical indications specific to Hashimoto's and Graves' Disease.
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Affiliation(s)
- Tong Gan
- Department of Surgery, University of Kentucky, 800 Rose Street, MN275, Lexington, KY 40536, USA
| | - Reese W Randle
- Department of Surgery, University of Kentucky, 125 East Maxwell Street, Suite 302, Lexington, KY 40508, USA.
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16
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Kahaly GJ, Bartalena L, Hegedüs L, Leenhardt L, Poppe K, Pearce SH. 2018 European Thyroid Association Guideline for the Management of Graves' Hyperthyroidism. Eur Thyroid J 2018; 7:167-186. [PMID: 30283735 PMCID: PMC6140607 DOI: 10.1159/000490384] [Citation(s) in RCA: 435] [Impact Index Per Article: 72.5] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/26/2018] [Revised: 05/24/2018] [Indexed: 12/12/2022] Open
Abstract
Graves' disease (GD) is a systemic autoimmune disorder characterized by the infiltration of thyroid antigen-specific T cells into thyroid-stimulating hormone receptor (TSH-R)-expressing tissues. Stimulatory autoantibodies (Ab) in GD activate the TSH-R leading to thyroid hyperplasia and unregulated thyroid hormone production and secretion. Diagnosis of GD is straightforward in a patient with biochemically confirmed thyrotoxicosis, positive TSH-R-Ab, a hypervascular and hypoechoic thyroid gland (ultrasound), and associated orbitopathy. In GD, measurement of TSH-R-Ab is recommended for an accurate diagnosis/differential diagnosis, prior to stopping antithyroid drug (ATD) treatment and during pregnancy. Graves' hyperthyroidism is treated by decreasing thyroid hormone synthesis with the use of ATD, or by reducing the amount of thyroid tissue with radioactive iodine (RAI) treatment or total thyroidectomy. Patients with newly diagnosed Graves' hyperthyroidism are usually medically treated for 12-18 months with methimazole (MMI) as the preferred drug. In children with GD, a 24- to 36-month course of MMI is recommended. Patients with persistently high TSH-R-Ab at 12-18 months can continue MMI treatment, repeating the TSH-R-Ab measurement after an additional 12 months, or opt for therapy with RAI or thyroidectomy. Women treated with MMI should be switched to propylthiouracil when planning pregnancy and during the first trimester of pregnancy. If a patient relapses after completing a course of ATD, definitive treatment is recommended; however, continued long-term low-dose MMI can be considered. Thyroidectomy should be performed by an experienced high-volume thyroid surgeon. RAI is contraindicated in Graves' patients with active/severe orbitopathy, and steroid prophylaxis is warranted in Graves' patients with mild/active orbitopathy receiving RAI.
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Affiliation(s)
- George J. Kahaly
- Department of Medicine I, Johannes Gutenberg University (JGU) Medical Center, Mainz, Germany
- *Prof. George J. Kahaly, JGU Medical Center, DE-55101 Mainz (Germany), E-Mail
| | - Luigi Bartalena
- Department of Medicine and Surgery, University of Insubria, Varese, Italy
| | - Lazlo Hegedüs
- Department of Endocrinology and Metabolism, Odense University Hospital, Odense, Denmark
| | - Laurence Leenhardt
- Thyroid and Endocrine Tumors Unit, Pitié Salpêtrière Hospital, Sorbonne University, Paris, France
| | - Kris Poppe
- Endocrine Unit, CHU Saint-Pierre, Université Libre de Bruxelles (ULB), Brussels, Belgium
| | - Simon H. Pearce
- Department of Endocrinology, Institute of Genetic Medicine, Newcastle University, Newcastle upon Tyne, United Kingdom
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17
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Kauff DW, Staubitz JI, Musholt TJ, Lang H. Synchronous Antithyroid Drug-Induced Agranulocytosis and Fournier Gangrene. AACE Clin Case Rep 2018. [DOI: 10.4158/ep171801.cr] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
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18
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Jamshidzadeh A, Niknahad H, Heidari R, Azadbakht M, Khodaei F, Arabnezhad MR, Farshad O. Propylthiouracil-induced mitochondrial dysfunction in liver and its relevance to drug-induced hepatotoxicity. PHARMACEUTICAL SCIENCES 2017. [DOI: 10.15171/ps.2017.15] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022] Open
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19
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Minamitani K, Sato H, Ohye H, Harada S, Arisaka O. Guidelines for the treatment of childhood-onset Graves' disease in Japan, 2016. Clin Pediatr Endocrinol 2017; 26:29-62. [PMID: 28458457 PMCID: PMC5402306 DOI: 10.1297/cpe.26.29] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/03/2016] [Accepted: 12/02/2016] [Indexed: 12/12/2022] Open
Abstract
Purpose behind developing these guidelines: Over one decade ago, the “Guidelines for the
Treatment of Graves’ Disease with Antithyroid Drug, 2006” (Japan Thyroid Association
(JTA)) were published as the standard drug therapy protocol for Graves’ disease. The
“Guidelines for the Treatment of Childhood-Onset Graves’ Disease with Antithyroid Drug in
Japan, 2008” were published to provide guidance on the treatment of pediatric patients.
Based on new evidence, a revised version of the “Guidelines for the Treatment of Graves’
Disease with Antithyroid Drug, 2006” (JTA) was published in 2011, combined with the
“Handbook of Radioiodine Therapy for Graves’ Disease 2007” (JTA). Subsequently, newer
findings on pediatric Graves’ disease have been reported. Propylthiouracil (PTU)-induced
serious hepatopathy is an important problem in pediatric patients. The American Thyroid
Association’s guidelines suggest that, in principle, physicians must not administer PTU to
children. On the other hand, the “Guidelines for the Treatment of Graves’ Disease with
Antithyroid Drug, 2011” (JTA) state that radioiodine therapy is no longer considered a
“fundamental contraindication” in children. Therefore, the “Guidelines for the Treatment
of Childhood-Onset Graves’ Disease with Antithyroid Drug in Japan, 2008” required
revision.
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Affiliation(s)
| | - Kanshi Minamitani
- Department of Pediatrics, Teikyo University Chiba Medical Center, Chiba, Japan
| | | | - Hidemi Ohye
- Department of Internal Medicine, Ito Hospital, Tokyo, Japan
| | - Shohei Harada
- Division of Neonatal Screening, National Center for Child Health and Development, Tokyo, Japan
| | - Osamu Arisaka
- Department of Pediatrics, Dokkyo Medical University, Tochigi, Japan
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20
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Niknahad H, Jamshidzadeh A, Heidari R, Abdoli N, Ommati MM, Jafari F, Zarei M, Asadi B. The Postulated Hepatotoxic Metabolite of Methimazole Causes Mitochondrial Dysfunction and Energy Metabolism Disturbances in Liver. PHARMACEUTICAL SCIENCES 2016. [DOI: 10.15171/ps.2016.35] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022] Open
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21
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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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22
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Paradoxical effect of methimazole on liver mitochondria: In vitro and in vivo. Toxicol Lett 2016; 259:108-115. [DOI: 10.1016/j.toxlet.2016.08.003] [Citation(s) in RCA: 36] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/15/2016] [Revised: 06/14/2016] [Accepted: 08/05/2016] [Indexed: 11/22/2022]
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23
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Negro R, Attanasio R, Grimaldi F, Guglielmi R, Papini E. A 2015 Italian Survey of Clinical Practice Patterns in the Management of Graves' Disease: Comparison with European and North American Surveys. Eur Thyroid J 2016; 5:112-9. [PMID: 27493885 PMCID: PMC4949368 DOI: 10.1159/000444482] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/30/2015] [Revised: 02/05/2016] [Indexed: 12/12/2022] Open
Abstract
BACKGROUND Patients suffering from Graves' disease (GD) are quite frequent in endocrine clinical practice. In particular, overt hyperthyroidism may be complicated by serious adverse events and requires careful treatment, but its management has changed over the years in both the USA and European Union (EU). OBJECTIVES To evaluate the current diagnosis and management of patient's with GD in Italy, and compare results with those obtained in previous similar surveys in the USA and EU. METHODS Members of the Italian Association of Clinical Endocrinologists (AME) were asked to participate in a Web-based survey on management of GD. RESULTS In total, 947 responses were obtained. The preferred diagnostic modality in Italy is TSH receptor antibody determination in conjunction with ultrasound, while radioactive iodine uptake/scan is preferred in the USA. Methimazole (MMI) 20-30 mg/day with a β-blocker is the initial treatment of choice in Italy and the EU, whereas the USA opts more frequently for radioactive therapy. If Graves' orbitopathy occurs, orbit CT/MRI scans are more often obtained in Italy and the EU than in the USA. In case of planned pregnancy in 6-12 months, surgery is more frequently suggested in Italy than in the EU and USA. Propylthiouracil is generally preferred to MMI in the first trimester. CONCLUSIONS Italian endocrinologists have shown significantly different patterns in diagnosis and management of GD compared to both the USA and EU.
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Affiliation(s)
- Roberto Negro
- Division of Endocrinology, ‘V. Fazzi’ Hospital, Lecce, Italy
| | - Roberto Attanasio
- Endocrinology Service, Galeazzi Institute IRCCS, Milan, Italy
- *Roberto Negro, MD, Division of Endocrinology, ‘V. Fazzi’ Hospital, Piazza Muratore 1, IT–73100 Lecce (Italy), E-Mail
| | - Franco Grimaldi
- Endocrinology and Metabolic Disease Unit, Azienda Ospedaliero-Universitaria ‘S. Maria della Misericordia’, Udine, Italy
| | - Rinaldo Guglielmi
- Department of Endocrinology, Regina Apostolorum Hospital, Albano Laziale, Italy
| | - Enrico Papini
- Department of Endocrinology, Regina Apostolorum Hospital, Albano Laziale, Italy
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24
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Arrigo T, Cutroneo PM, Vaccaro M, Impollonia D, Squadrito V, Mecchio A, Salpietro C, Altavilla D. Lateralized exanthem mimicking figurate inflammatory dermatosis of infancy after methimazole therapy. Int J Immunopathol Pharmacol 2016; 29:707-711. [PMID: 27272160 DOI: 10.1177/0394632016652412] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/05/2016] [Accepted: 05/09/2016] [Indexed: 11/15/2022] Open
Abstract
We reported a case of an 11-year-old girl admitted to our hospital for goiter, tachycardia, sweating, and visible and palpable thyroid. Thyroid function tests revealed a low thyrotropin level (<0.004 mIU/L) and elevated free thyroxine level (3.4 ng/ dL) diagnosed with Graves' disease and treated with methimazole. This anti-thyroid drug is recommended as first-line treatment in children with Graves' disease because it produces minor adverse effects with respect to propylthiouracil. She developed a lateralized exanthem mimicking figurate inflammatory dermatosis of infancy after methimazole therapy. The symptoms resolved after discontinuation of methimazole and treatment with an antihistamine and a corticosteroid. Furthermore, the treatment was changed to propylthiouracil without any adverse effects. According to current literature this is the first case of cutaneous figurate erythema related to methimazole, different from other well-known reactions such as skin eruption or urticaria.
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Affiliation(s)
- T Arrigo
- Department of Human Pathology of Adult and Developmental Evolutive Age, University of Messina, Messina, Italy
| | - P M Cutroneo
- Department of Biomedical and Dental Sciences and Morphofunctional Imaging, University of Messina, Messina, Italy
| | - M Vaccaro
- Department of Clinical and Experimental Medicine, University of Messina, Messina, Italy
| | - D Impollonia
- Department of Human Pathology of Adult and Developmental Evolutive Age, University of Messina, Messina, Italy
| | - V Squadrito
- Department of Human Pathology of Adult and Developmental Evolutive Age, University of Messina, Messina, Italy
| | - A Mecchio
- Department of Biomedical and Dental Sciences and Morphofunctional Imaging, University of Messina, Messina, Italy
| | - C Salpietro
- Department of Human Pathology of Adult and Developmental Evolutive Age, University of Messina, Messina, Italy
| | - D Altavilla
- Department of Biomedical and Dental Sciences and Morphofunctional Imaging, University of Messina, Messina, Italy
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25
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Sheehan MT, Doi SAR. Transient Hypothyroidism after Radioiodine for Graves' Disease: Challenges in Interpreting Thyroid Function Tests. Clin Med Res 2016; 14:40-5. [PMID: 26864507 PMCID: PMC4851449 DOI: 10.3121/cmr.2015.1297] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/18/2015] [Accepted: 10/28/2015] [Indexed: 01/20/2023]
Abstract
Graves' disease is the most common cause of hyperthyroidism and is often managed with radioactive iodine (RAI) therapy. With current dosing schemes, the vast majority of patients develop permanent post-RAI hypothyroidism and are placed on life-long levothyroxine therapy. This hypothyroidism typically occurs within the first 3 to 6 months after RAI therapy is administered. Indeed, patients are typically told to expect life-long thyroid hormone replacement therapy to be required within this timeframe and many providers expect this post-RAI hypothyroidism to be complete and permanent. There is, however, a small subset of patients in whom a transient post-RAI hypothyroidism develops which, initially, presents exactly as the typical permanent hypothyroidism. In some cases the transient hypothyroidism leads to a period of euthyroidism of variable duration eventually progressing to permanent hypothyroidism. In others, persistent hyperthyroidism requires a second dose of RAI. Failure to appreciate and recognize the possibility of transient post-RAI hypothyroidism can delay optimal and appropriate treatment of the patient. We herein describe five cases of transient post-RAI hypothyroidism which highlight this unusual sequence of events. Increased awareness of this possible outcome after RAI for Graves' disease will help in the timely management of patients.
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Affiliation(s)
| | - Suhail A R Doi
- Research School of Population Health, Australian National University, Acton, Canberra, Australia
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26
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Paul Friedman K, Watt ED, Hornung MW, Hedge JM, Judson RS, Crofton KM, Houck KA, Simmons SO. Tiered High-Throughput Screening Approach to Identify Thyroperoxidase Inhibitors Within the ToxCast Phase I and II Chemical Libraries. Toxicol Sci 2016; 151:160-80. [PMID: 26884060 DOI: 10.1093/toxsci/kfw034] [Citation(s) in RCA: 84] [Impact Index Per Article: 10.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/01/2023] Open
Abstract
High-throughput screening for potential thyroid-disrupting chemicals requires a system of assays to capture multiple molecular-initiating events (MIEs) that converge on perturbed thyroid hormone (TH) homeostasis. Screening for MIEs specific to TH-disrupting pathways is limited in the U.S. Environmental Protection Agency ToxCast screening assay portfolio. To fill 1 critical screening gap, the Amplex UltraRed-thyroperoxidase (AUR-TPO) assay was developed to identify chemicals that inhibit TPO, as decreased TPO activity reduces TH synthesis. The ToxCast phase I and II chemical libraries, comprised of 1074 unique chemicals, were initially screened using a single, high concentration to identify potential TPO inhibitors. Chemicals positive in the single-concentration screen were retested in concentration-response. Due to high false-positive rates typically observed with loss-of-signal assays such as AUR-TPO, we also employed 2 additional assays in parallel to identify possible sources of nonspecific assay signal loss, enabling stratification of roughly 300 putative TPO inhibitors based upon selective AUR-TPO activity. A cell-free luciferase inhibition assay was used to identify nonspecific enzyme inhibition among the putative TPO inhibitors, and a cytotoxicity assay using a human cell line was used to estimate the cellular tolerance limit. Additionally, the TPO inhibition activities of 150 chemicals were compared between the AUR-TPO and an orthogonal peroxidase oxidation assay using guaiacol as a substrate to confirm the activity profiles of putative TPO inhibitors. This effort represents the most extensive TPO inhibition screening campaign to date and illustrates a tiered screening approach that focuses resources, maximizes assay throughput, and reduces animal use.
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Affiliation(s)
- Katie Paul Friedman
- *Oak Ridge Institute for Science Education Postdoctoral Fellow, Oak Ridge, TN, 37831 Integrated Systems Toxicology Division, National Health and Environmental Effects Research Laboratory, Office of Research and Development, U.S. Environmental Protection Agency, Research Triangle Park, NC, 27711
| | - Eric D Watt
- *Oak Ridge Institute for Science Education Postdoctoral Fellow, Oak Ridge, TN, 37831 National Center for Computational Toxicology, Office of Research and Development, U.S. Environmental Protection Agency, Research Triangle Park, NC, 27711
| | - Michael W Hornung
- Mid-Continent Ecology Division, National Health and Environmental Effects Research Laboratory, Office of Research and Development, U.S. Environmental Protection Agency, Duluth, MN, 55804
| | - Joan M Hedge
- Integrated Systems Toxicology Division, National Health and Environmental Effects Research Laboratory, Office of Research and Development, U.S. Environmental Protection Agency, Research Triangle Park, NC, 27711
| | - Richard S Judson
- National Center for Computational Toxicology, Office of Research and Development, U.S. Environmental Protection Agency, Research Triangle Park, NC, 27711
| | - Kevin M Crofton
- National Center for Computational Toxicology, Office of Research and Development, U.S. Environmental Protection Agency, Research Triangle Park, NC, 27711
| | - Keith A Houck
- National Center for Computational Toxicology, Office of Research and Development, U.S. Environmental Protection Agency, Research Triangle Park, NC, 27711
| | - Steven O Simmons
- National Center for Computational Toxicology, Office of Research and Development, U.S. Environmental Protection Agency, Research Triangle Park, NC, 27711,
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27
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Cheung CL, Sing CW, Tang CSM, Cheng VKF, Pirmohamed M, Choi CH, Hung CS, Lau EYF, Lee KF, Mak MWH, Leung JYY, Wong TW, Ho AYY, Chan KW, Hung VHF, Tam V, Siu SC, Pang HK, Wat WZM, Lee HHY, Chung CT, Hue RSM, Sham PC, Cheung BMY, Wong ICK, Tan KCB, Kung AWC. HLA-B*38:02:01predicts carbimazole/methimazole-induced agranulocytosis. Clin Pharmacol Ther 2016; 99:555-61. [PMID: 26599303 DOI: 10.1002/cpt.309] [Citation(s) in RCA: 44] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/09/2015] [Accepted: 11/17/2015] [Indexed: 12/30/2022]
Affiliation(s)
- C-L Cheung
- Pharmacogenomics and Precision Therapeutics Laboratory, Department of Pharmacology and Pharmacy, Li Ka Shing Faculty of Medicine; The University of Hong Kong; Pokfulam Hong Kong China
- The State Key Laboratory of Pharmaceutical Biotechnology, Li Ka Shing Faculty of Medicine; The University of Hong Kong; Pokfulam Hong Kong China
- Department of Medicine, Li Ka Shing Faculty of Medicine; The University of Hong Kong; Pokfulam Hong Kong China
- Centre for Genomic Sciences, Li Ka Shing Faculty of Medicine; The University of Hong Kong; Pokfulam Hong Kong China
| | - C-W Sing
- Pharmacogenomics and Precision Therapeutics Laboratory, Department of Pharmacology and Pharmacy, Li Ka Shing Faculty of Medicine; The University of Hong Kong; Pokfulam Hong Kong China
| | - CSM Tang
- Centre for Genomic Sciences, Li Ka Shing Faculty of Medicine; The University of Hong Kong; Pokfulam Hong Kong China
- Department of Psychiatry, Li Ka Shing Faculty of Medicine; The University of Hong Kong; Pokfulam Hong Kong China
| | - VKF Cheng
- Pharmacogenomics and Precision Therapeutics Laboratory, Department of Pharmacology and Pharmacy, Li Ka Shing Faculty of Medicine; The University of Hong Kong; Pokfulam Hong Kong China
| | - M Pirmohamed
- Department of Molecular and Clinical Pharmacology; The University of Liverpool; United Kingdom
- Royal Liverpool and Broadgreen University Hospital NHS Trust; Liverpool United Kingdom
| | - C-H Choi
- Department of Medicine; Queen Elizabeth Hospital; Hong Kong China
| | - C-S Hung
- Department of Medicine and Geriatrics; United Christian Hospital; Hong Kong China
| | - EY-F Lau
- Department of Medicine; Pamela Youde Nethersole Eastern Hospital; Hong Kong China
| | - KF Lee
- Department of Medicine and Geriatrics; Kwong Wah Hospital; Hong Kong China
| | - MW-H Mak
- Department of Medicine and Geriatrics; Kwong Wah Hospital; Hong Kong China
| | - JYY Leung
- Department of Medicine and Geriatrics; Ruttonjee & Tang Shiu Kin Hospitals; Hong Kong China
| | - T-W Wong
- Department of Medicine and Geriatrics; Ruttonjee & Tang Shiu Kin Hospitals; Hong Kong China
| | - AYY Ho
- Department of Medicine and Geriatrics; Tuen Mun Hospital; Hong Kong China
| | - K-W Chan
- Department of Medicine and Geriatrics; Princess Margaret Hospital; Hong Kong China
| | - VHF Hung
- Department of Medicine and Geriatrics; Princess Margaret Hospital; Hong Kong China
| | - V Tam
- F.H.K.A.M, Department of Medicine; Caritas Medical Centre; Hong Kong China
| | - S-C Siu
- Department of Medicine; Tung Wah Eastern Hospital; Hong Kong China
| | - H-K Pang
- Department of Medicine; Pamela Youde Nethersole Eastern Hospital; Hong Kong China
| | - WZ-M Wat
- Department of Medicine; Pamela Youde Nethersole Eastern Hospital; Hong Kong China
| | - HH-Y Lee
- Department of Medicine; Pamela Youde Nethersole Eastern Hospital; Hong Kong China
| | - C-T Chung
- Department of Medicine; Pamela Youde Nethersole Eastern Hospital; Hong Kong China
| | - RS-M Hue
- Department of Medicine; Pamela Youde Nethersole Eastern Hospital; Hong Kong China
| | - P-C Sham
- Centre for Genomic Sciences, Li Ka Shing Faculty of Medicine; The University of Hong Kong; Pokfulam Hong Kong China
- Department of Psychiatry, Li Ka Shing Faculty of Medicine; The University of Hong Kong; Pokfulam Hong Kong China
| | - BMY Cheung
- The State Key Laboratory of Pharmaceutical Biotechnology, Li Ka Shing Faculty of Medicine; The University of Hong Kong; Pokfulam Hong Kong China
- Department of Medicine, Li Ka Shing Faculty of Medicine; The University of Hong Kong; Pokfulam Hong Kong China
- Centre for Genomic Sciences, Li Ka Shing Faculty of Medicine; The University of Hong Kong; Pokfulam Hong Kong China
| | - ICK Wong
- Pharmacogenomics and Precision Therapeutics Laboratory, Department of Pharmacology and Pharmacy, Li Ka Shing Faculty of Medicine; The University of Hong Kong; Pokfulam Hong Kong China
- The State Key Laboratory of Pharmaceutical Biotechnology, Li Ka Shing Faculty of Medicine; The University of Hong Kong; Pokfulam Hong Kong China
- Research Department of Practice and Policy; UCL School of Pharmacy; London United Kingdom
| | - KCB Tan
- Department of Medicine, Li Ka Shing Faculty of Medicine; The University of Hong Kong; Pokfulam Hong Kong China
| | - AWC Kung
- Department of Medicine, Li Ka Shing Faculty of Medicine; The University of Hong Kong; Pokfulam Hong Kong China
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Katahira M, Ogata H. Thyroglobulin Autoantibodies Are Associated with Refractoriness to Antithyroid Drug Treatment for Graves' Disease. Intern Med 2016; 55:1519-24. [PMID: 27301499 DOI: 10.2169/internalmedicine.55.6095] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022] Open
Abstract
Objective The recurrence rate associated with antithyroid drug (ATD) treatment for Graves' disease (GD) is high compared with that for radioiodine therapy or surgery. It is important to identify patients in whom remission is unlikely, so that they are not given treatment that is destined to fail. The objective of this study was thus to evaluate factors influencing the prognosis of GD patients treated with ATDs. Patients One hundred and sixty-one patients were divided into two groups: 100 patients who could not discontinue ATDs for eight years or more (refractory group) and 61 patients who achieved remission within eight years after starting ATD treatment (nonrefractory group). The groups were compared in terms of age, thyroid function and thyroid-related autoantibodies at diagnosis, and the durations to the recovery of thyroid function and thyroid-related autoantibodies. Results The baseline levels of free triiodothyronine (T3), free thyroxine (T4), thyroid-stimulating antibodies (TSAbs) and thyroid-stimulating hormone (TSH) receptor antibodies (TRAbs) were high, and the age at diagnosis and the baseline level of thyroglobulin autoantibodies (TgAbs) were low in the refractory group compared with those in the nonrefractory group. The durations to the recovery of TSH, free T4, TRAb and TSAb levels were longer in the refractory group than in the nonrefractory group. No significant difference was observed with regard to thyroid peroxidase autoantibodies. Conclusion We compared the clinical features of these two groups in order to identify factors influencing the prognosis of GD patients treated with ATDs. A low baseline level of TgAbs is associated with the refractoriness of GD to ATD treatment.
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Bartalena L, Burch HB, Burman KD, Kahaly GJ. A 2013 European survey of clinical practice patterns in the management of Graves' disease. Clin Endocrinol (Oxf) 2016; 84:115-20. [PMID: 25581877 DOI: 10.1111/cen.12688] [Citation(s) in RCA: 117] [Impact Index Per Article: 14.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/26/2014] [Revised: 11/13/2014] [Accepted: 12/02/2014] [Indexed: 01/10/2023]
Abstract
OBJECTIVE Management of Graves' disease (GD) in Europe was published in 1987. Aim of this survey was to provide an update on clinical practice in Europe, and to compare it with a 2011 American survey. DESIGN Members of the European Thyroid Association (ETA) were asked to participate in a survey on management of GD, using the same questionnaire of a recent American survey. RESULTS A total of 147 ETA members participated. In addition to serum TSH and free T4 assays, most respondents would request TSH-receptor autoantibody (TRAb) measurement (85·6%) and thyroid ultrasound (70·6%) to confirm aetiology, while isotopic studies were selected by 37·7%. Antithyroid drug (ATD) therapy was the preferred first-line treatment (83·8%). Compared to the previous European survey, Europeans currently more frequently use TRAb measurement and thyroid ultrasound for diagnosis and evaluation, but first-line treatment remains ATDs in a similar percentage of respondents. Current clinical practice patterns differ from those in North America, where isotopic studies are more frequently used, and radioiodine (RAI) still is first-line treatment. When RAI treatment is selected in the presence of mild Graves' orbitopathy and/or associated risk factors for its occurrence/exacerbation, steroid prophylaxis is frequently used. The preferred ATD in pregnancy is propylthiouracil in the first trimester and methimazole in the second and third trimesters, similar to North America. CONCLUSIONS Significant changes in clinical practice patterns in Europe were noted compared to the previous European survey, as well as persisting differences in diagnosis and therapy between Europe and North America.
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Affiliation(s)
- L Bartalena
- Department of Clinical and Experimental Medicine, University of Insubria, Varese, Italy
| | - H B Burch
- Endocrinology, Diabetes, and Metabolism Service, Walter Reed National Military Medical Center, Bethesda, MD, USA
| | - K D Burman
- Endocrine Section, Medstar Washington Hospital Center, Washington, DC, USA
| | - G J Kahaly
- Department of Medicine I, Johannes Gutenberg University Medical Center, Mainz, Germany
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Isaia F, Aragoni MC, Arca M, Bettoschi A, Caltagirone C, Castellano C, Demartin F, Lippolis V, Pivetta T, Valletta E. Zinc(II)-methimazole complexes: synthesis and reactivity. Dalton Trans 2015; 44:9805-14. [PMID: 25928254 DOI: 10.1039/c5dt00917k] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
The tetrahedral S-coordinated complex [Zn(MeImHS)4](ClO4)2, synthesised from the reaction of [Zn(ClO4)2] with methimazole (1-methyl-3H-imidazole-2-thione, MeImHS), reacts with triethylamine to yield the homoleptic complex [Zn(MeImS)2] (MeImS = anion methimazole). ESI-MS and MAS (13)C-NMR experiments supported MeImS acting as a (N,S)-chelating ligand. The DFT-optimised structure of [Zn(MeImS)2] is also reported and the main bond lengths compared to those of related Zn-methimazole complexes. The complex [Zn(MeImS)2] reacts under mild conditions with methyl iodide and separates the novel complex [Zn(MeImSMe)2I2] (MeImSMe = S-methylmethimazole). X-ray diffraction analysis of the complex shows a ZnI2N2 core, with the methyl thioethers uncoordinated to zinc. Conversely, the reaction of [Zn(MeImS)2] with hydroiodic acid led to the formation of the complex [Zn(MeImHS)2I2] having a ZnI2S2 core with the neutral methimazole units S-coordinating the metal centre. The Zn-coordinated methimazole can markedly modify the coordination environment when changing from its thione to thionate form and vice versa. The study of the interaction of the drug methimazole with the complex [Zn(MeIm)4](2+) (MeIm = 1-methylimidazole) - as a model for Zn-enzymes containing a N4 donor set from histidine residues - shows that methimazole displaces only one of the coordinated MeIm molecules; the formation constant of the mixed complex [Zn(MeIm)3(MeImHS)](2+) was determined.
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Affiliation(s)
- Francesco Isaia
- Dipartimento di Scienze Chimiche e Geologiche, Università degli Studi di Cagliari, Cittadella Universitaria, 09042 Monserrato (CA), Italy.
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31
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Li X, Liu GY, Ma JL, Zhou L. Risk of congenital anomalies associated with antithyroid treatment during pregnancy: a meta-analysis. Clinics (Sao Paulo) 2015; 70:453-9. [PMID: 26106966 PMCID: PMC4462563 DOI: 10.6061/clinics/2015(06)12] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/18/2014] [Accepted: 03/10/2015] [Indexed: 11/18/2022] Open
Abstract
To evaluate the association of either propylthiouracil or methimazole treatment for hyperthyroidism during pregnancy with congenital malformations, relevant studies were identified by searching Medline, PubMed, the Cochrane Library and EMBASE. We intended to include randomized controlled trials, but no such trials were identified. Thus, we included cohort studies and case-control studies in this meta-analysis. A total of 7 studies were included in the meta-analyses. The results revealed an increased risk of birth defects among the group of pregnant women with hyperthyroidism treated with methimazole compared with the control group (odds ratio 1.76, 95% confidence interval 1.47-2.10) or the non-exposed group (odds ratio 1.71, 95% confidence interval 1.39-2.10). A maternal shift between methimazole and propylthiouracil was associated with an increased odds ratio of birth defects (odds ratio 1.88, 95% confidence interval 1.27-2.77). An equal risk of birth defects was observed between the group of pregnant women with hyperthyroidism treated with propylthiouracil and the non-exposed group (odds ratio 1.18, 95% confidence interval 0.97-1.42). There was only a slight trend towards an increased risk of congenital malformations in infants whose mothers were treated with propylthiouracil compared with in infants whose mothers were healthy controls (odds ratio 1.29, 95% confidence interval 1.07-1.55). The children of women receiving methimazole treatment showed an increased risk of adverse fetal outcomes relative to those of mothers receiving propylthiouracil treatment. We found that propylthiouracil was a safer choice for treating pregnant women with hyperthyroidism according to the risk of birth defects but that a shift between methimazole and propylthiouracil failed to provide protection against birth defects.
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Affiliation(s)
- Xiang Li
- *Xiang LiCorresponding author: E-mail:
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Wang MT, Lee WJ, Huang TY, Chu CL, Hsieh CH. Antithyroid drug-related hepatotoxicity in hyperthyroidism patients: a population-based cohort study. Br J Clin Pharmacol 2015; 78:619-29. [PMID: 25279406 DOI: 10.1111/bcp.12336] [Citation(s) in RCA: 64] [Impact Index Per Article: 7.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022] Open
Abstract
AIMS The evidence of hepatotoxicity of antithyroid drugs (ATDs) is limited to case reports or spontaneous reporting. This study aimed to quantify the incidence and comparative risks of hepatotoxicity for methimazole (MMI)/carbimazole (CBM) vs. propylthiouracil (PTU) in a population-based manner. METHODS We conducted a cohort study of hyperthyroidism patients initially receiving MMI/CBM or PTU between 1 January 2004 and 31 December 2008 using the Taiwan National Health Insurance Research Database. The examined hepatotoxicity consisted of cholestasis, non-infectious hepatitis, acute liver failure and liver transplant, with the incidences and relative risks being quantified by Poisson exact methods and Cox proportional hazard models, respectively. RESULTS The study cohort comprised 71 379 ATD initiators, with a median follow-up of 196 days. MMI/CBM vs. PTU users had a higher hepatitis incidence rate (3.17/1000 vs. 1.19/1000 person-years) but a lower incidence of acute liver failure (0.32/1000 vs. 0.68/1000 person-years). The relative risk analysis indicated that any use of MMI/CBM was associated with a 2.89-fold (95% CI 1.81, 4.60) increased hepatitis risk compared with PTU, with the risk increasing to 5.08-fold for high dose MMI/CBM (95% CI 3.15, 8.18). However, any MMI/CBM use vs. PTU was not related to an increased risk of cholestasis (adjusted hazard ratio [HR] 1.14, 95% CI 0.40, 3.72) or acute liver failure (adjusted HR 0.54, 95% CI 0.24, 1.22). CONCLUSIONS MMI/CBM and PTU exert dissimilar incidence rates of hepatotoxicity. Compared to PTU, MMI/CBM are associated in a dose-dependent manner with an increased risk for hepatitis while the risks are similar for acute liver failure and cholestasis.
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Bartalena L, Macchia PE, Marcocci C, Salvi M, Vermiglio F. Effects of treatment modalities for Graves' hyperthyroidism on Graves' orbitopathy: a 2015 Italian Society of Endocrinology Consensus Statement. J Endocrinol Invest 2015; 38:481-7. [PMID: 25722226 PMCID: PMC4374116 DOI: 10.1007/s40618-015-0257-z] [Citation(s) in RCA: 41] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/28/2015] [Accepted: 02/07/2015] [Indexed: 12/11/2022]
Affiliation(s)
- L Bartalena
- Endocrine Unit, Department of Clinical and Experimental Medicine, University of Insubria, Ospedale di Circolo, Viale Borri, 57, 21100, Varese, Italy.
| | - P E Macchia
- Department of Clinical Medicine and Surgery, University of Naples "Federico II", Naples, Italy
| | - C Marcocci
- Department of Clinical and Experimental Medicine, University of Pisa, Pisa, Italy
| | - M Salvi
- Department of Clinical Sciences and Community Health, Graves' Orbitopathy Center, Fondazione Ca' Granda IRCCS and University of Milan, Milan, Italy
| | - F Vermiglio
- Department of Clinical and Experimental Medicine, University of Messina, Messina, Italy
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Heidari R, Niknahad H, Jamshidzadeh A, Azarpira N, Bazyari M, Najibi A. Carbonyl Traps as Potential Protective Agents against Methimazole-Induced Liver Injury. J Biochem Mol Toxicol 2014; 29:173-81. [DOI: 10.1002/jbt.21682] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/05/2014] [Revised: 11/03/2014] [Accepted: 11/10/2014] [Indexed: 11/11/2022]
Affiliation(s)
- Reza Heidari
- Pharmaceutical Sciences Research Center; Shiraz University of Medical Sciences; Shiraz Iran
- Gerash School of Paramedical Sciences; Shiraz University of Medical Sciences; Gerash Iran
| | - Hossein Niknahad
- Pharmaceutical Sciences Research Center; Shiraz University of Medical Sciences; Shiraz Iran
- Department of Pharmacology and Toxicology; Shiraz University of Medical Sciences; Shiraz Iran
| | - Akram Jamshidzadeh
- Pharmaceutical Sciences Research Center; Shiraz University of Medical Sciences; Shiraz Iran
- Department of Pharmacology and Toxicology; Shiraz University of Medical Sciences; Shiraz Iran
| | - Negar Azarpira
- Transplant Research Center; Shiraz University of Medical Sciences; Shiraz Iran
| | - Mandana Bazyari
- Department of Pharmacology and Toxicology; Shiraz University of Medical Sciences; International Branch (Kish); Shiraz Iran
| | - Asma Najibi
- Pharmaceutical Sciences Research Center; Shiraz University of Medical Sciences; Shiraz Iran
- Department of Pharmacology and Toxicology; Shiraz University of Medical Sciences; Shiraz Iran
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Marinò M, Latrofa F, Menconi F, Chiovato L, Vitti P. An update on the medical treatment of Graves' hyperthyroidism. J Endocrinol Invest 2014; 37:1041-8. [PMID: 25185644 DOI: 10.1007/s40618-014-0136-z] [Citation(s) in RCA: 30] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/30/2014] [Accepted: 07/09/2014] [Indexed: 12/12/2022]
Abstract
Medical treatment of Graves' hyperthyroidism is based on the use of thionamides; namely, methimazole and propylthiouracil. In the past, methimazole was preferred by European endocrinologists, whereas propylthiouracil was the first choice for the majority of their North American colleagues. However, because of the recent definition of a better side-effect profile, methimazole is nowadays the first choice world while. Although thionamides are quite effective for the short-term control of Graves' hyperthyroidism, a relatively high proportion of patients relapses after thionamide withdrawal. Other possible medical treatments, include iodine and compounds containing iodine, perchlorate, lithium (as an adjuvant in patients undergoing radioiodine therapy), β-adrenergic antagonists, glucocorticoids, and some new molecules still under investigation. Management of Graves' hyperthyroidism using thionamides as well as the other available medical treatments is here reviewed in detail, with a special mention of situations such as pregnancy and lactation, as well as neonatal and fetal thyrotoxicosis.
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Affiliation(s)
- Michele Marinò
- Department of Clinical and Experimental Medicine, University of Pisa, Pisa, Italy,
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36
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Pérez-Fernández V, Marchese S, Gentili A, García MÁ, Curini R, Caretti F, Perret D. Analysis of antithyroid drugs in surface water by using liquid chromatography–tandem mass spectrometry. J Chromatogr A 2014; 1367:78-89. [DOI: 10.1016/j.chroma.2014.09.045] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/24/2014] [Revised: 09/13/2014] [Accepted: 09/18/2014] [Indexed: 11/29/2022]
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Heidari R, Niknahad H, Jamshidzadeh A, Abdoli N. Factors affecting drug-induced liver injury: antithyroid drugs as instances. Clin Mol Hepatol 2014; 20:237-48. [PMID: 25320726 PMCID: PMC4197171 DOI: 10.3350/cmh.2014.20.3.237] [Citation(s) in RCA: 37] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/03/2013] [Revised: 05/03/2014] [Accepted: 05/12/2014] [Indexed: 12/22/2022] Open
Abstract
Methimazole and propylthiouracil have been used in the management of hyperthyroidism for more than half a century. However, hepatotoxicity is one of the most deleterious side effects associated with these medications. The mechanism(s) of hepatic injury induced by antithyroid agents is not fully recognized yet. Furthermore, there are no specific tools for predicting the occurrence of hepatotoxicity induced by these drugs. The purpose of this article is to give an overview on possible susceptibility factors in liver injury induced by antithyroid agents. Age, gender, metabolism characteristics, alcohol consumption, underlying diseases, immunologic mechanisms, and drug interactions are involved in enhancing antithyroid drugs-induced hepatic damage. An outline on the clinically used treatments for antithyroid drugs-induced hepatotoxicity and the potential therapeutic strategies found to be effective against this complication are also discussed.
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Affiliation(s)
- Reza Heidari
- Pharmaceutical Sciences Research Center, Shiraz University of Medical Sciences, Shiraz, Iran
| | - Hossein Niknahad
- Pharmaceutical Sciences Research Center, Shiraz University of Medical Sciences, Shiraz, Iran. ; Pharmacology and Toxicology Department, Faculty of Pharmacy, Shiraz University of Medical Sciences, Shiraz, Iran
| | - Akram Jamshidzadeh
- Pharmaceutical Sciences Research Center, Shiraz University of Medical Sciences, Shiraz, Iran. ; Pharmacology and Toxicology Department, Faculty of Pharmacy, Shiraz University of Medical Sciences, Shiraz, Iran
| | - Narges Abdoli
- Pharmacology and Toxicology Department, Faculty of Pharmacy, Tabriz University of Medical Sciences, Tabriz, Iran
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Akmal A, Kung J. Propylthiouracil, and methimazole, and carbimazole-related hepatotoxicity. Expert Opin Drug Saf 2014; 13:1397-406. [PMID: 25156887 DOI: 10.1517/14740338.2014.953796] [Citation(s) in RCA: 39] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
INTRODUCTION Propylthiouracil (PTU) has been used for the treatment of hyperthyroidism since the 1940s, but over the years reports of significant hepatotoxicity have come forth, particularly in children. This led to a black box warning being issued by the US FDA in 2009, followed by a similar warning by the European Medicines Agency and the United Kingdom Medicines and Healthcare Regulatory Agency later that year. AREAS COVERED This article provides a concise review of the data on hepatotoxicity associated with the currently available antithyroid drugs: PTU, methimazole (MMI) and carbimazole. The differences in mechanism are examined in detail, as well as clinical presentation, management and monitoring. Use in special populations and trends in use of antithyroid medication are also discussed. EXPERT OPINION PTU is known to cause severe hepatic failure, particularly in children. Its use in children should be avoided. In adults, it is beneficial to use in the first trimester of pregnancy and thyroid storm. In the rest of the adult population, it should be used with caution. Carbimazole and MMI are associated with less severe hepatic injury and should be preferred when choosing thionamides as a treatment option.
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Affiliation(s)
- Anam Akmal
- Tufts Division of Endocrinology , 800 Washington St Box 268, Boston, MA 02111 , USA +1 617 636 1216 ; +1 617 636 4719 ;
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Muldoon BT, Mai VQ, Burch HB. Management of Graves' disease: an overview and comparison of clinical practice guidelines with actual practice trends. Endocrinol Metab Clin North Am 2014; 43:495-516. [PMID: 24891174 DOI: 10.1016/j.ecl.2014.02.001] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
Over the last century, much has been learned about the pathogenesis, manifestations, and management of Graves' disease leading to the establishment of evidence-based clinical practice guidelines. The joint clinical practice guidelines from the American Thyroid Association and the American Association of Clinical Endocrinologists give recommendations on both the diagnosis and treatment of hyperthyroidism. A survey of clinicians performed that same year, however, revealed that current practices diverge from these recently published guidelines in multiple areas. These differences will need to be assessed serially to determine the impact of the guidelines on future clinical practice and perhaps vice versa.
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Affiliation(s)
- Becky T Muldoon
- Endocrinology Service, Department of Medicine, Walter Reed National Military Medical Center, 8901 Wisconsin Avenue, Building 19, 5th Floor, Bethesda, MD 20889-5600, USA; Department of Medicine, Uniformed Services University of the Health Sciences, 4301 Jones Bridge Road, Bethesda, MD 20814, USA
| | - Vinh Q Mai
- Endocrinology Service, Department of Medicine, Walter Reed National Military Medical Center, 8901 Wisconsin Avenue, Building 19, 5th Floor, Bethesda, MD 20889-5600, USA; Department of Medicine, Uniformed Services University of the Health Sciences, 4301 Jones Bridge Road, Bethesda, MD 20814, USA
| | - Henry B Burch
- Endocrinology Service, Department of Medicine, Walter Reed National Military Medical Center, 8901 Wisconsin Avenue, Building 19, 5th Floor, Bethesda, MD 20889-5600, USA; Endocrinology Division, Uniformed Services University of the Health Sciences, 4301 Jones Bridge Road, Bethesda, MD 20814, USA.
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40
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Rajaii F, Gupta S, Douglas RS. Endocrinologic management of hyperthyroidism and the impact on thyroid eye disease. Taiwan J Ophthalmol 2014. [DOI: 10.1016/j.tjo.2014.03.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022] Open
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Affiliation(s)
- John H Lazarus
- Thyroid Research Group, Institute of Molecular Medicine, University Hospital of Wales, Cardiff University Medical School, Heath Park, Cardiff, CF14 4XN, UK,
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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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Rijntjes E, Scholz PM, Mugesh G, Köhrle J. Se- and s-based thiouracil and methimazole analogues exert different inhibitory mechanisms on type 1 and type 2 deiodinases. Eur Thyroid J 2013; 2:252-8. [PMID: 24783056 PMCID: PMC3923599 DOI: 10.1159/000355288] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/17/2013] [Revised: 08/20/2013] [Indexed: 11/19/2022] Open
Abstract
The thioamide anti-thyroid drugs methimazole (MMI) and propylthiouracil (PTU) play a pivotal role in the treatment of hyperthyroidism. MMI exerts its effect via inhibiting one of the key enzymes involved in synthesis of thyroid hormones (TH), thyroid peroxidase (TPO). PTU is both an inhibitor of TPO and type 1 deiodinase (D1), which catalyzes TH deiodination at both aromatic rings. In contrast, no selective inhibitors are known for type 2 deiodinase (D2) or type 3 deiodinase, which deiodinate TH at the phenolic or tyrosyl ring, respectively. We aimed to identify specific inhibitors for D1 or D2. New Se- and S-based PTU and MMI-like compounds have been generated. The D1 and D2 inhibiting capacity of several compounds was tested in vitro. Our data show that compounds based on a PTU and MMI backbone can differentially influence the reaction kinetics of deiodinases. For inhibition of D1, the addition of a phenyl group to the PTU backbone increases potency by at least 10-fold over PTU. For inhibition of D2, the addition of an aromatic ring structure to MMI and its Se isomer increases inhibitory potency by an order of magnitude. Furthermore, S-methylation of the MMI changes its reaction kinetics from non-competitive to uncompetitive with respect to the cofactor dithiothreitol. These results open perspectives for further investigations on identifying specific inhibitors of the deiodinase isoenzymes, potentially based on the addition of aromatic ring structures or alkyl groups to PTU and MMI.
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Affiliation(s)
- Eddy Rijntjes
- Institut für Experimentelle Endokrinologie, Charité-Universtätsmedizin Berlin, Berlin, Germany
| | - Philip Moritz Scholz
- Institut für Experimentelle Endokrinologie, Charité-Universtätsmedizin Berlin, Berlin, Germany
| | - Govindasamy Mugesh
- Department of Inorganic and Physical Chemistry, Indian Institute of Science, Bangalore, India
| | - Josef Köhrle
- Institut für Experimentelle Endokrinologie, Charité-Universtätsmedizin Berlin, Berlin, Germany
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Abstract
Changes in thyroid hormone concentrations that are characteristic of hyperthyroidism must be distinguished from physiological changes in thyroid hormone economy that occur in pregnancy, especially in the first trimester. Approximately one to two cases of gestational hyperthyroidism occur per 1000 pregnancies. Identification of hyperthyroidism in a pregnant woman is important because adverse outcomes can occur in both the mother and the offspring. Graves' disease, which is autoimmune in nature, is the usual cause; but hyperthyroidism in pregnancy can be caused by any type of hyperthyroidism--eg, toxic multinodular goitre or solitary autonomously functioning nodule. Gestational transient thyrotoxicosis is typically reported in women with hyperemesis gravidarum, and is mediated by high circulating concentrations of human chorionic gonadotropin. Post-partum thyroiditis occurs in 5-10% of women, and many of those affected ultimately develop permanent hypothyroidism. Antithyroid drug treatment of hyperthyroidism in pregnant women is controversial because the usual drugs--methimazole or carbimazole--are occasionally teratogenic; and the alternative--propylthiouracil--can be hepatotoxic. Fetal hyperthyroidism can be life-threatening, and needs to be recognised as soon as possible so that treatment of the fetus with antithyroid drugs via the mother can be initiated. In this Review, we discuss physiological and pathophysiological changes in thyroid hormone economy in pregnancy, the diagnosis and management of hyperthyroidism during pregnancy, severe life-threatening thyrotoxicosis in pregnancy, neonatal thyrotoxicosis, and post-partum hyperthyroidism.
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Affiliation(s)
- David S Cooper
- Division of Endocrinology and Metabolism, The Johns Hopkins University School of Medicine, Baltimore, MD, USA.
| | - Peter Laurberg
- Department of Endocrinology, Aalborg University Hospital, Aalborg, Denmark
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Paul KB, Hedge JM, Macherla C, Filer DL, Burgess E, Simmons SO, Crofton KM, Hornung MW. Cross-species analysis of thyroperoxidase inhibition by xenobiotics demonstrates conservation of response between pig and rat. Toxicology 2013; 312:97-107. [DOI: 10.1016/j.tox.2013.08.006] [Citation(s) in RCA: 27] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/20/2013] [Revised: 08/02/2013] [Accepted: 08/09/2013] [Indexed: 10/26/2022]
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Nambiar PR, Palanisamy GS, Okerberg C, Wolford A, Walters K, Buckbinder L, Reagan WJ. Toxicities Associated with 1-month Treatment with Propylthiouracil (PTU) and Methimazole (MMI) in Male Rats. Toxicol Pathol 2013; 42:970-83. [DOI: 10.1177/0192623313502708] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
Thionamides such as propylthiouracil (PTU) and methimazole (MMI) have been used for more than 50 years to treat the more common causes of thyrotoxicosis/hyperthyroidism such as Graves’ disease. Serious adverse effects associated with thionamides in humans include idiosyncratic liver damage, agranulocytosis, aplastic anemia, and vasculitis. Both prospective and retrospective clinical studies with these drugs have failed to identify predictive biomarker for these adverse effects. To assess whether rat is a good model for predicting drug-related adverse events in the liver and in the bone marrow, we conducted a comprehensive study in male rats with multiple doses of PTU and MMI. As expected, euthyroid animals became hypothyroid along with several secondary changes associated with hypothyroidism. There were slight reductions in red blood cell parameters along with some marginal effects on the bone marrow elements. However, there was no evidence of significant neutropenia and liver injury in both PTU-treated and MMI-treated cohorts. MMI-related effects were noted in the seminiferous tubules of the testes. Overall, 1-month daily treatment of euthyroid rats with PTU or MMI resulted in hypothyroidism, minor bone marrow effects, and several secondary effects associated with hypothyroidism, but without any evidence of adverse effects reported in humans including liver injury and agranulocytosis.
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Affiliation(s)
- Prashant R. Nambiar
- Pfizer Inc., Groton, Connecticut, USA
- Both Prashant R. Nambiar and Gopinath S. Palanisamy contributed equally to the article
| | - Gopinath S. Palanisamy
- Pfizer Inc., Groton, Connecticut, USA
- Both Prashant R. Nambiar and Gopinath S. Palanisamy contributed equally to the article
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Vascularite cutanée à anticorps anti-cytoplasme des polynucléaires neutrophiles induite par le benzylthio-uracile : à propos d’un cas et revue de la littérature. Rev Med Interne 2013; 34:561-4. [DOI: 10.1016/j.revmed.2013.05.012] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/07/2012] [Revised: 05/06/2013] [Accepted: 05/27/2013] [Indexed: 11/22/2022]
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Korelitz JJ, McNally DL, Masters MN, Li SX, Xu Y, Rivkees SA. Prevalence of thyrotoxicosis, antithyroid medication use, and complications among pregnant women in the United States. Thyroid 2013; 23:758-65. [PMID: 23194469 PMCID: PMC3675839 DOI: 10.1089/thy.2012.0488] [Citation(s) in RCA: 58] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
BACKGROUND Population-based estimates of the prevalence of thyrotoxicosis (TTX), the frequency of antithyroid drug (ATD) use, and risk of adverse events in pregnant women and their infants are lacking. Therefore, our objective was to obtain epidemiologic estimates of these parameters within a large population-based sample of pregnant women with TTX. METHODS A retrospective claims analysis was performed from the MarketScan Commercial Claims and Encounters health insurance database for the period 2005-2009. Women aged 15-44 years, enrolled for at least 2 years, and who had a pregnancy during the study period were included. Diagnosis of TTX was based on International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM) codes using narrow (TTX-1=ICD 242.0) and broad (TTX-2=ICD 242.0 or 242.9) definitions. ATD use was based on prescriptions filled for propylthiouracil (PTU) or methimazole (MMI). Adverse events in mothers and infants were determined from the ICD-9-CM diagnosis codes recorded on submitted claims. RESULTS The database contained 904,497 eligible women. The average yearly prevalence per 1000 pregnant women was 2.46 for TTX-1 and 5.88 for TTX-2. Thirty-nine percent used ATD at any time during the study period. Compared to women without a TTX diagnosis, there was more than a twofold increase for liver disease among women with TTX (odds ratio [OR]=2.08, p<0.001) and a 13% increased risk for congenital anomalies (OR=1.13, p=0.014), but no association was observed with ATD use. The rates of congenital defects (per 1000 infants) associated with ATD use were 55.6 for MMI, 72.1 for PTU, and 65.8 for untreated women with TTX, compared to 58.8 among women without TTX. CONCLUSIONS There was some indication of an elevated risk of liver disease and congenital anomalies in women with TTX, but the risk did not appear to be related to the ATD use. There seems to be a higher pregnancy termination rate for women with TTX on MMI, which likely reflects elective pregnancy terminations.
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Affiliation(s)
- James J Korelitz
- Department of Health Studies, Westat, Rockville, Maryland 20850, USA.
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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: 166] [Impact Index Per Article: 13.8] [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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Burch HB, Burman KD, Cooper DS. A 2011 survey of clinical practice patterns in the management of Graves' disease. J Clin Endocrinol Metab 2012; 97:4549-58. [PMID: 23043191 DOI: 10.1210/jc.2012-2802] [Citation(s) in RCA: 205] [Impact Index Per Article: 17.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/07/2023]
Abstract
CONTEXT More than two decades have passed since members from the American Thyroid Association (ATA), European Thyroid Association, and Japan Thyroid Association were surveyed on management practices for patients with hyperthyroidism due to Graves' disease (GD). OBJECTIVE We sought to document current practices in the management of GD and compare these results both to those documented in earlier surveys and to practice recommendations made in the 2011 ATA/American Association of Clinical Endocrinologists (AACE) hyperthyroidism practice guidelines. Lastly, we sought to examine differences in GD management among international members of U.S.-based endocrine societies. METHODS Members of The Endocrine Society (TES), ATA, and AACE were invited to participate in a web-based survey dealing with testing, treatment preference, and modulating factors in patients with GD. RESULTS A total of 730 respondents participated in the survey, 696 of whom completed all sections. Respondents included 641 TES members, 330 AACE members, and 157 ATA members. The preferred mode of therapy in uncomplicated GD was antithyroid drugs (ATDs) by 53.9% of respondents, radioactive iodine (RAI) therapy by 45.0%, and thyroid surgery in 0.7%. Compared with 1991, fewer U.S. (59.7 vs. 69%) and European (13.3% vs. 25%) respondents would use RAI therapy. Methimazole and carbimazole were the preferred ATDs, with only 2.7% of respondents selecting propylthiouracil. Patients with Graves' ophthalmopathy were treated with ATDs (62.9%) or surgery (18.5%) and less frequently with RAI plus corticosteroids (16.9%) or RAI alone (1.9%). CONCLUSIONS Striking changes have occurred in the management of GD over the past two decades, with a shift away from RAI and toward ATDs in patients with uncomplicated GD. Apparent international differences persist but should be interpreted with caution. Current practices diverge in some areas from recently published guidelines; these differences should be assessed serially to determine the impact of the guidelines on future clinical practice.
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Affiliation(s)
- Henry B Burch
- Endocrinology Service, Department of Medicine, Walter Reed National Military Medical Center, Bethesda, Maryland 20889-5600, USA.
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