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Ермолаева АС, Фадеев ВВ. [Type 2 amiodarone-induced thyrotoxicosis: efficacy of glucocorticoid therapy, a retrospective analysis]. PROBLEMY ENDOKRINOLOGII 2024; 69:17-27. [PMID: 38311991 PMCID: PMC10848191 DOI: 10.14341/probl13267] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/27/2023] [Revised: 07/09/2023] [Accepted: 07/19/2023] [Indexed: 02/06/2024]
Abstract
BACKGROUND Type 2 amiodarone-induced thyrotoxicosis remains a significant problem of endocrinology and cardiology. Due to the increase a life expectancy of the population, the prevalence of cardiac arrhythmias and prescribing of amiodarone are increasing. Thyrotoxicosis aggravates the existing cardiovascular disease in patients, leads to the progression of left ventricular dysfunction, relapses of arrhythmias, increasing the risk of adverse outcomes. The tactic of further management of patients is complicated: it is necessary to resolve the issue of canceling or continuing the use of antiarrhythmic drugs necessary for a patient with a history of cardiac arrhythmia, as well as competent therapy of the thyroid pathology that has arisen. Oral glucocorticoids are the first-line drugs for the treatment of patients with moderate and severe type 2 amiodarone-induced thyrotoxicosis. Despite the appearance of clinical recommendations, opinions on the management of patients are differ, both among cardiologists and among endocrinologists. Often thyrostatics are prescribed to patients simultaneously with glucocorticoids, although it doesn't have pathogenetic basis. AIM To evaluate the efficacy of various therapy options in patients with type 2 amiodarone-induced thyrotoxicosis. MATERIALS AND METHODS The retrospective study included 38 patients (20 men and 18 women aged 35 to 85 years) with type 2 amiodarone-induced thyrotoxicosis. All patients underwent an analysis of anamnestic, anthropometric data, complex laboratory and instrumental diagnostics. According to the treatment options, 3 groups were retrospectively formed: without therapy (n=19), taking glucocorticoids (n=11) and combination of glucocorticoids and thyrostatics (n=8). The follow-up period was 6-18 months, including the treatment. The efficacy of treatment in the groups was evaluated by the time of reaching euthyroidism on the background of glucocorticoid therapy and duration of thyrotoxicosis; the search was conducted for potential predictors of delayed response to glucocorticoid therapy and long-term course of thyrotoxicosis. RESULTS The average age was 62.0 [52.9; 66.3] years. The level of free thyroxine was significantly decreased after 1 month from the start of therapy in both groups: from 38.1 [32.1; 58.4] to 23.4 [19.6; 29.3] pmol/l (p<0.001) in the group taking glucocorticoids; from 73.9 [42.2; 75.6] to 39.3 [22.4; 47.2] pmol/l (p<0.001) in the combination therapy group. The time of reaching euthyroidism was longer in the combination therapy group (p=0.047), didn't depend on the dose (p=0.338) and duration of taking thiamazole (p=0.911), the delayed response to therapy correlated with age (p=-0.857; p=0.007) and time interval from the appearance of clinical symptoms of thyrotoxicosis to the start of glucocorticoid therapy (p=0.881; p<0.001). CONCLUSION The results demonstrate the dependence of glucocorticoid response on the age of the patient and start time of therapy relative to the duration of thyrotoxicosis, inexpediency of additional prescribing thyrostatics in type 2 amiodarone-induced thyrotoxicosis.
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Affiliation(s)
- А. С. Ермолаева
- Первый Московский государственный медицинский университет им. И.М. Сеченова (Сеченовский Университет)
| | - В. В. Фадеев
- Первый Московский государственный медицинский университет им. И.М. Сеченова (Сеченовский Университет)
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Amador F, Mendonça F, da Costa C, Canha M, Neves JS, Pinto R, Amorim S, Souto S, Freitas P, Carvalho D. Total thyroidectomy in a patient awaiting heart transplant with amiodarone-induced thyrotoxicosis: A case report. Clin Case Rep 2023; 11:e6892. [PMID: 36789324 PMCID: PMC9909169 DOI: 10.1002/ccr3.6892] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/28/2022] [Revised: 11/13/2022] [Accepted: 01/03/2023] [Indexed: 02/11/2023] Open
Abstract
Thyroid function may have a severe impact in cardiac function. Herein, we present the case report of a 53-year-old male patient awaiting heart transplant with amiodarone induced thyrotoxicosis that presented a marked improvement of his cardiac function after total thyroidectomy.
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Affiliation(s)
- Filipa Amador
- Department of CardiologyCentro Hospitalar e Universitário de São JoãoPortoPortugal
| | - Fernando Mendonça
- Department of Endocrinology, Diabetes and MetabolismCentro Hospitalar Universitário de São João, Faculty of Medicine e Instituto de Investigação e Inovação em Saude, Universidade do PortoPortoPortugal
| | - Catarina da Costa
- Department of CardiologyCentro Hospitalar e Universitário de São JoãoPortoPortugal
| | - Marta Canha
- Department of Endocrinology, Diabetes and MetabolismCentro Hospitalar Universitário de São João, Faculty of Medicine e Instituto de Investigação e Inovação em Saude, Universidade do PortoPortoPortugal
| | - João Sérgio Neves
- Department of Endocrinology, Diabetes and MetabolismCentro Hospitalar Universitário de São João, Faculty of Medicine e Instituto de Investigação e Inovação em Saude, Universidade do PortoPortoPortugal
| | - Roberto Pinto
- Department of CardiologyCentro Hospitalar e Universitário de São JoãoPortoPortugal
| | - Sandra Amorim
- Department of CardiologyCentro Hospitalar e Universitário de São JoãoPortoPortugal
| | - Selma Souto
- Department of Endocrinology, Diabetes and MetabolismCentro Hospitalar Universitário de São João, Faculty of Medicine e Instituto de Investigação e Inovação em Saude, Universidade do PortoPortoPortugal
| | - Paula Freitas
- Department of Endocrinology, Diabetes and MetabolismCentro Hospitalar Universitário de São João, Faculty of Medicine e Instituto de Investigação e Inovação em Saude, Universidade do PortoPortoPortugal
| | - Davide Carvalho
- Department of Endocrinology, Diabetes and MetabolismCentro Hospitalar Universitário de São João, Faculty of Medicine e Instituto de Investigação e Inovação em Saude, Universidade do PortoPortoPortugal
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de Souza LVF, Campagnolo MT, Martins LCB, Scanavacca MI. Amiodarone-Induced Thyrotoxicosis - Literature Review & Clinical Update. Arq Bras Cardiol 2021; 117:1038-1044. [PMID: 34817015 PMCID: PMC8682089 DOI: 10.36660/abc.20190757] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/06/2019] [Revised: 09/16/2020] [Accepted: 11/04/2020] [Indexed: 01/21/2023] Open
Abstract
Amiodarone is widely used in treating atrial and ventricular arrhythmias; however, due to its high iodine concentration, the chronic use of the drug can induce thyroid disorders. Amiodarone-induced thyrotoxicosis (AIT) can decompensate and exacerbate underlying cardiac abnormalities, leading to increased morbidity and mortality, especially in patients with left ventricular ejection fraction <30%. AIT cases are classified into two subtypes that guide therapeutic management. The risks and benefits of maintaining the amiodarone must be evaluated individually, and the therapeutic decision should be taken jointly by cardiologists and endocrinologists. Type 1 AIT treatment is similar to that of spontaneous hyperthyroidism, using antithyroid drugs (methimazole and propylthiouracil) at high doses. Type 1 AIT is more complicated since it has proportionally higher recurrences or even non-remission, and definitive treatment is recommended (total thyroidectomy or radioiodine). Type 2 AIT is generally self-limited, yet due to the high mortality associated with thyrotoxicosis in cardiac patients, the treatment should be implemented for faster achievement of euthyroidism. Furthermore, in well-defined cases of type 2 AIT, the treatment with corticosteroids is more effective than treatment with antithyroid drugs. In severe cases, regardless of subtype, immediate restoration of euthyroidism through total thyroidectomy should be considered before the patient progresses to excessive clinical deterioration, as delayed surgery indication is associated with increased mortality.
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Affiliation(s)
| | - Maria Thereza Campagnolo
- Centro Universitário LusiadaFaculdade de Ciências Médicas de SantosSantosSPBrasilCentro Universitário Lusiada Faculdade de Ciências Médicas de Santos, Santos, SP – Brasil
| | - Luiz Claudio Behrmann Martins
- Universidade de São Paulo InstitutoInstituto do Coração - Arrritmia e MarcapassoSão PauloSPBrasilUniversidade de São Paulo Instituto do Coração - Arrritmia e Marcapasso, São Paulo, SP – Brasil
| | - Maurício Ibrahim Scanavacca
- Universidade de São Paulo InstitutoInstituto do Coração - Arrritmia e MarcapassoSão PauloSPBrasilUniversidade de São Paulo Instituto do Coração - Arrritmia e Marcapasso, São Paulo, SP – Brasil
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Chua MWJ, Mok SF. Amiodarone Induced Thyrotoxicosis and Treatment Complications in a Man With Cyanotic Congenital Heart Disease: A Case Report. Front Cardiovasc Med 2020; 7:574391. [PMID: 33330642 PMCID: PMC7673448 DOI: 10.3389/fcvm.2020.574391] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/06/2020] [Accepted: 09/28/2020] [Indexed: 12/04/2022] Open
Abstract
Background and Case: Amiodarone induced thyrotoxicosis (AIT) is a potentially life-threatening condition that exists in two main subtypes – AIT Type 1 (AIT1) and AIT Type 2 (AIT2). AIT1 is a form of iodine-induced hyperthyroidism with increased thyroid hormone synthesis, while AIT2 is a form of destructive thyroiditis with increased release of pre-formed thyroid hormone. This case report describes a patient with cyanotic congenital heart disease, who developed AIT with severe biochemical thyrotoxicosis. Due to complications to corticosteroids and thionamides, second-line treatment with cholestyramine and lithium was given which eventually restored euthyroidism, averting the need for thyroidectomy and its associated risks. Due to the presence of both typical and unusual features, the final diagnosis of AIT2 could only be retrospectively elucidated after a prolonged clinical course. Conclusion: Corticosteroids are well-recognized to be the first-line treatment for AIT2. This case illustrates a rare phenomenon: successful treatment of AIT2 with lithium and cholestyramine. In patients who develop complications from first-line therapy, prompt treatment with alternative agents may successfully avert thyroidectomy and its associated risks.
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Affiliation(s)
- Marvin Wei Jie Chua
- Department of General Medicine, Sengkang General Hospital, Singapore, Singapore
| | - Shao Feng Mok
- Division of Endocrinology, Department of Medicine, National University Health System, Singapore, Singapore
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Abstract
Amiodarone-induced thyrotoxicosis (AIT) are not uncommon endocrinopathies. Clinicians are sometimes faced with difficult diagnostic and therapeutic situations. The disease pathophysiology is partially understood, explaining the lack of predictive factors for occurrence. Different international recommendations for their management have been published: the most recent in 2018 by the European Thyroid Association (ETA) (Ross et al., 2016; Bartalena et al., 2018). The purpose of this paper is to present the essential concepts for their management and to review the literature since 2018.
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Ozdemir Baser O, Cetin Z, Catak M, Koseoglu D, Berker D. The role of therapeutic plasmapheresis in patients with hyperthyroidism. Transfus Apher Sci 2020; 59:102744. [PMID: 32201205 DOI: 10.1016/j.transci.2020.102744] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2019] [Revised: 01/27/2020] [Accepted: 02/20/2020] [Indexed: 01/10/2023]
Abstract
BACKGROUND Hyperthyroidism is characterized by excess hormone secretion from the thyroid gland. Anti-thyroid drugs (ATDs), surgery, and radioactive iodine can be used in treatment. Plasmapheresis is a rapid and effective treatment option in cases where rapid euthyroidism is needed to be obtained due to complications of thyrotoxicosis and major adverse effects of ATDs. MATERIAL AND METHOD We present patients receiving plasmapheresis to provide immediate euthyroidism due to severe hyperthyroidism, adverse effects of ATDs, or non-thyroid surgery from January 2012 to December 2016. RESULTS This study included 18 patients. The etiology of hyperthyroidism was TDG in seven patients, TDMNG in two, TA in two, TMNG in four, and one patient had AIT. Plasmapheresis was performed to achieve euthyroidism before surgery in two patients. The mean plasmapheresis session was 5.35. The mean number of sessions needed for patients with TDG and TDMNG was 4, whereas it was 6.5 for patients with TA and TMNG (p = 0.07). The decrease of mean free thyroxine and free triiodothyronine were 57 % and 73 %, respectively (p < 0.001). After plasmapheresis, total thyroidectomy was performed in 14 patients. Euthyroidism was achieved with RAI in one patient and with medical therapy in three patients. CONCLUSIONS Plasmapheresis therapy is a reliable and effective treatment option for patients who cannot use ATDs because of their adverse events and those with hyperthyroidism that does not resolve with these drugs, or to achieve euthyroidism before total thyroidectomy, RAI or non-thyroid emergency surgery. However, it cannot be used widely because it is expensive and invasive.
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Affiliation(s)
- Ozden Ozdemir Baser
- Endocrinology and Metabolism Department, Yozgat City Hospital, Yozgat, Turkey.
| | - Zeynep Cetin
- Endocrinology and Metabolism Department, Amasya University Sabuncuğlu Serefeddin Education and Research Hospital, Amasya, Turkey
| | - Merve Catak
- Endocrinology and Metabolism Department, Tokat Public Hospital, Tokat, Turkey
| | - Derya Koseoglu
- Endocrinology and Metabolism Department, Erol Olçok Education and Research Hospital, Hitit University, Corum, Turkey
| | - Dilek Berker
- Endocrinology and Metabolism Department, University of Medical Sciences Ankara City Hospital, Ankara, Turkey
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Tauveron I, Batisse-Lignier M, Maqdasy S. [Challenges in the management of amiodarone-induced thyrotoxicosis]. Presse Med 2018; 47:746-756. [PMID: 30274916 DOI: 10.1016/j.lpm.2018.09.001] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/26/2018] [Revised: 07/30/2018] [Accepted: 09/05/2018] [Indexed: 11/28/2022] Open
Abstract
Amiodarone, a benzofuranic iodine-rich pan antiarrhythmic drug, is frequently associated with thyroid dysfunction. This side effect is heterogeneous and unpredicted, motivating regular evaluation of thyroid function tests. In contrary to hypothyroidism, amiodarone-induced thyrotoxicosis (AIT) is a challenging situation owing to the risk of deterioration of the general and cardiac status of such debilitating patients. Classically, AIT is either an iodine-induced thyrotoxicosis in patients with an abnormal thyroid (type I), or due to a subacute thyroiditis on a "healthy" thyroid (type II). Even if many studies tried to better identify the types of AIT, the diagnostic dilemma of type of AIT could be present, and many patients are treated by an association of antithyroid drugs (useful for type I AIT) with corticoids (useful for type II AIT). Being the main etiological factor in AIT, amiodarone is supposed to be stopped, but it could remain the only anti-arrhythmic option that is needed to be either continued or reintroduced to improve the cardiovascular survival. Recently, many studies demonstrated that amiodarone could be continued or reintroduced in patients with history of type II AIT. Nevertheless, in the other patients, amiodarone maintenance complicates the therapeutic response to the antithyroid drugs and increases the risk of AIT recurrence. Thus, amiodarone therapy is preferred to be interrupted. In such patients, thyroid ablation is recommended once AIT is under control.
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Affiliation(s)
- Igor Tauveron
- CHU Clermont-Ferrand, service d'endocrinologie, diabétologie et maladies métaboliques, 63003 Clermont-Ferrand, France; Laboratoire GReD : UMR université Clermont Auvergne-CNRS 6293, Inserm U1103, BP 10448, 63177 Aubiere, France.
| | - Marie Batisse-Lignier
- CHU Clermont-Ferrand, service d'endocrinologie, diabétologie et maladies métaboliques, 63003 Clermont-Ferrand, France; Laboratoire GReD : UMR université Clermont Auvergne-CNRS 6293, Inserm U1103, BP 10448, 63177 Aubiere, France
| | - Salwan Maqdasy
- CHU Clermont-Ferrand, service d'endocrinologie, diabétologie et maladies métaboliques, 63003 Clermont-Ferrand, France; Laboratoire GReD : UMR université Clermont Auvergne-CNRS 6293, Inserm U1103, BP 10448, 63177 Aubiere, France
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Maqdasy S, Benichou T, Dallel S, Roche B, Desbiez F, Montanier N, Batisse-Lignier M, Tauveron I. Issues in amiodarone-induced thyrotoxicosis: Update and review of the literature. ANNALES D'ENDOCRINOLOGIE 2018; 80:54-60. [PMID: 30236455 DOI: 10.1016/j.ando.2018.05.001] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/05/2017] [Revised: 04/18/2018] [Accepted: 05/13/2018] [Indexed: 11/15/2022]
Abstract
Amiodarone, a benzofuranic iodine-rich pan-anti-arrhythmic drug, induces amiodarone-induced thyrotoxicosis (AIT) in 7-15% of patients. AIT is a major issue due to its typical severity and resistance to anti-thyroid measures, and to its negative impact on cardiac status. Classically, AIT is either an iodine-induced thyrotoxicosis in patients with abnormal thyroid (type 1), or due to acute thyroiditis in a "healthy" thyroid (type 2). Determination of the type of AIT is a diagnostic dilemma, as characteristics of both types may be present in some patients. As it is the main etiological factor in AIT, it is recommended that amiodarone treatment should be stopped; however, it may be the only anti-arrhythmic option, needing to be either continued or re-introduced to improve cardiovascular survival. Recently, a few studies demonstrated that amiodarone could be continued or re-introduced in patients with history of type-2 AIT. However, in the other patients, it is recommended that amiodarone treatment be interrupted, to improve response to thioamides and to alleviate the risk of AIT recurrence. In such patients, thyroidectomy is recommended once AIT is under control, allowing safe re-introduction of amiodarone.
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Affiliation(s)
- Salwan Maqdasy
- Service d'endocrinologie, diabétologie et maladies métaboliques, CHU Clermont-Ferrand, 63003 Clermont-Ferrand, France; Laboratoire GReD, UMR Université Clermont Auvergne-CNRS 6293, Inserm U1103, BP 10448, 63177 Aubière, France.
| | - Thomas Benichou
- Service d'endocrinologie, diabétologie et maladies métaboliques, CHU Clermont-Ferrand, 63003 Clermont-Ferrand, France
| | - Sarah Dallel
- Service d'endocrinologie, diabétologie et maladies métaboliques, CHU Clermont-Ferrand, 63003 Clermont-Ferrand, France
| | - Béatrice Roche
- Service d'endocrinologie, diabétologie et maladies métaboliques, CHU Clermont-Ferrand, 63003 Clermont-Ferrand, France
| | - Françoise Desbiez
- Service d'endocrinologie, diabétologie et maladies métaboliques, CHU Clermont-Ferrand, 63003 Clermont-Ferrand, France
| | - Nathanaëlle Montanier
- Service d'endocrinologie, diabétologie et maladies métaboliques, CHU Clermont-Ferrand, 63003 Clermont-Ferrand, France
| | - Marie Batisse-Lignier
- Service d'endocrinologie, diabétologie et maladies métaboliques, CHU Clermont-Ferrand, 63003 Clermont-Ferrand, France; Laboratoire GReD, UMR Université Clermont Auvergne-CNRS 6293, Inserm U1103, BP 10448, 63177 Aubière, France
| | - Igor Tauveron
- Service d'endocrinologie, diabétologie et maladies métaboliques, CHU Clermont-Ferrand, 63003 Clermont-Ferrand, France; Laboratoire GReD, UMR Université Clermont Auvergne-CNRS 6293, Inserm U1103, BP 10448, 63177 Aubière, France
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Yamamoto JM, Katz PM, Bras JA, Shafer LA, Leung AA, Ravandi A, Cordova FJ. Amiodarone-induced thyrotoxicosis in heart failure with a reduced ejection fraction: A retrospective cohort study. Health Sci Rep 2018; 1:e36. [PMID: 30623071 PMCID: PMC6266468 DOI: 10.1002/hsr2.36] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/17/2017] [Revised: 12/15/2017] [Accepted: 02/23/2018] [Indexed: 01/04/2023] Open
Abstract
BACKGROUND Amiodarone-induced thyrotoxicosis (AIT) is associated with significant morbidity and mortality. We aimed to describe AIT and its clinical outcomes in patients with heart failure with reduced ejection fraction (HFrEF). METHODS We performed a retrospective chart review at a heart failure center in Winnipeg, Canada. We screened 1059 consecutive patients seen over a 12-month period (August 2011 to July 2012) for AIT in patients with HFrEF. Using descriptive and Cox proportional hazard analyses, we explored the association between AIT and mortality. RESULTS A total of 110 patients with HFrEF who were exposed to amiodarone were included in the analysis. Of these, 13 (11.8%) were diagnosed with AIT. All AIT patients in our cohort were male. Amiodarone was discontinued in nearly half (46.2%) of patients with AIT. All patients were treated with antithyroid medications, and 5 patients (38.5%) also received prednisone. Euthyroidism was achieved in 2 patients (15.4%), hypothyroidism occurred in 6 patients (46.2%), and 5 patients remained thyrotoxic until death or time of chart review (38.5%). CONCLUSION Thyrotoxicosis is common in patients with HFrEF on amiodarone and is challenging to treat. Due to the sample size, while no association was found in mortality for patients with HFrEF with AIT, a real association could have been missed.
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Affiliation(s)
| | - Pamela M. Katz
- Department of Internal Medicine, Rady Faculty of Health Science, Max Rady College of MedicineUniversity of ManitobaWinnipegManitobaCanada
- Section of Endocrinology, Rady Faculty of Health Sciences, Max Rady College of MedicineUniversity of ManitobaWinnipegManitobaCanada
| | - James A.F. Bras
- Department of Internal Medicine, Rady Faculty of Health Science, Max Rady College of MedicineUniversity of ManitobaWinnipegManitobaCanada
| | - Leigh Anne Shafer
- Department of Internal Medicine, Rady Faculty of Health Science, Max Rady College of MedicineUniversity of ManitobaWinnipegManitobaCanada
| | - Alexander A. Leung
- Department of MedicineUniversity of CalgaryCalgaryAlbertaCanada
- Department of Community Health SciencesUniversity of CalgaryCalgaryAlbertaCanada
| | - Amir Ravandi
- Department of Internal Medicine, Rady Faculty of Health Science, Max Rady College of MedicineUniversity of ManitobaWinnipegManitobaCanada
- Section of Cardiology, Rady Faculty of Health Sciences, Max Rady College of MedicineUniversity of ManitobaWinnipegManitobaCanada
| | - Francisco J. Cordova
- Department of Internal Medicine, Rady Faculty of Health Science, Max Rady College of MedicineUniversity of ManitobaWinnipegManitobaCanada
- Section of Cardiology, Rady Faculty of Health Sciences, Max Rady College of MedicineUniversity of ManitobaWinnipegManitobaCanada
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Bartalena L, Bogazzi F, Chiovato L, Hubalewska-Dydejczyk A, Links TP, Vanderpump M. 2018 European Thyroid Association (ETA) Guidelines for the Management of Amiodarone-Associated Thyroid Dysfunction. Eur Thyroid J 2018; 7:55-66. [PMID: 29594056 PMCID: PMC5869486 DOI: 10.1159/000486957] [Citation(s) in RCA: 113] [Impact Index Per Article: 18.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/11/2017] [Revised: 01/16/2018] [Indexed: 01/16/2023] Open
Abstract
Treatment with amiodarone is associated with changes in thyroid function tests, but also with thyroid dysfunction (amiodarone-induced hypothyroidism, AIH, and amiodarone-induced thyrotoxicosis, AIT). Both AIH and AIT may develop in apparently normal thyroid glands or in the presence of underlying thyroid abnormalities. AIH does not require amiodarone withdrawal, and is treated with levothyroxine replacement if overt, whereas subclinical forms may be followed without treatment. Two main types of AIT are recognized: type 1 AIT (AIT 1), a form of iodine-induced hyperthyroidism occurring in nodular goitres or latent Graves disease, and type 2 AIT (AIT 2), resulting from destructive thyroiditis in a normal thyroid gland. Mixed/indefinite forms exist due to both pathogenic mechanisms. AIT 1 is best treated with thionamides that may be combined for a few weeks with sodium perchlorate to make the thyroid gland more sensitive to thionamides. AIT 2 is treated with oral glucocorticoids. Once euthyroidism has been restored, AIT 2 patients are followed up without treatment, whereas AIT 1 patients should be treated with thyroidectomy or radioiodine. Mixed/indefinite forms of AIT are treated with thionamides. Oral glucocorticoids can be added from the beginning if a precise diagnosis is uncertain, or after a few weeks if response to thionamides alone is poor. The decision to continue or to stop amiodarone in AIT should be individualized in relation to cardiovascular risk stratification and taken jointly by specialist cardiologists and endocrinologists. In the presence of rapidly deteriorating cardiac conditions, emergency thyroidectomy may be required for all forms of AIT.
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Affiliation(s)
- Luigi Bartalena
- Department of Medicine and Surgery, University of Insubria, Varese, Italy
- *Prof. Luigi Bartalena, Department of Medicine and Surgery, University of Insubria, Endocrine Unit, ASST dei Sette Laghi, Viale Borri 57, IT–21100 Varese (Italy), E-Mail
| | - Fausto Bogazzi
- Department of Clinical and Experimental Medicine, University of Pisa, Pisa, Italy
| | - Luca Chiovato
- Unit of Internal Medicine and Endocrinology, Istituti Clinici Scientifici Maugeri and University of Pavia, Pavia, Italy
| | | | - Thera P. Links
- Department of Endocrinology, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
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Ross DS, Burch HB, Cooper DS, Greenlee MC, Laurberg P, Maia AL, Rivkees SA, Samuels M, Sosa JA, Stan MN, Walter MA. 2016 American Thyroid Association Guidelines for Diagnosis and Management of Hyperthyroidism and Other Causes of Thyrotoxicosis. Thyroid 2016; 26:1343-1421. [PMID: 27521067 DOI: 10.1089/thy.2016.0229] [Citation(s) in RCA: 1284] [Impact Index Per Article: 160.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
BACKGROUND Thyrotoxicosis has multiple etiologies, manifestations, and potential therapies. Appropriate treatment requires an accurate diagnosis and is influenced by coexisting medical conditions and patient preference. This document describes evidence-based clinical guidelines for the management of thyrotoxicosis that would be useful to generalist and subspecialty physicians and others providing care for patients with this condition. METHODS The American Thyroid Association (ATA) previously cosponsored guidelines for the management of thyrotoxicosis that were published in 2011. Considerable new literature has been published since then, and the ATA felt updated evidence-based guidelines were needed. The association assembled a task force of expert clinicians who authored this report. They examined relevant literature using a systematic PubMed search supplemented with additional published materials. An evidence-based medicine approach that incorporated the knowledge and experience of the panel was used to update the 2011 text and recommendations. The strength of the recommendations and the quality of evidence supporting them were rated according to the approach recommended by the Grading of Recommendations, Assessment, Development, and Evaluation Group. RESULTS Clinical topics addressed include the initial evaluation and management of thyrotoxicosis; management of Graves' hyperthyroidism using radioactive iodine, antithyroid drugs, or surgery; management of toxic multinodular goiter or toxic adenoma using radioactive iodine or surgery; Graves' disease in children, adolescents, or pregnant patients; subclinical hyperthyroidism; hyperthyroidism in patients with Graves' orbitopathy; and management of other miscellaneous causes of thyrotoxicosis. New paradigms since publication of the 2011 guidelines are presented for the evaluation of the etiology of thyrotoxicosis, the management of Graves' hyperthyroidism with antithyroid drugs, the management of pregnant hyperthyroid patients, and the preparation of patients for thyroid surgery. The sections on less common causes of thyrotoxicosis have been expanded. CONCLUSIONS One hundred twenty-four evidence-based recommendations were developed to aid in the care of patients with thyrotoxicosis and to share what the task force believes is current, rational, and optimal medical practice.
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Affiliation(s)
- Douglas S Ross
- 1 Massachusetts General Hospital , Boston, Massachusetts
| | - Henry B Burch
- 2 Endocrinology - Metabolic Service, Walter Reed National Military Medical Center , Bethesda, Maryland
| | - David S Cooper
- 3 Division of Endocrinology, Diabetes, and Metabolism, The Johns Hopkins University School of Medicine , Baltimore, Maryland
| | | | - Peter Laurberg
- 5 Departments of Clinical Medicine and Endocrinology, Aalborg University and Aalborg University Hospital , Aalborg, Denmark
| | - Ana Luiza Maia
- 6 Thyroid Section, Hospital de Clinicas de Porto Alegre, Federal University of Rio Grande do Sul , Porto Alegre, Brazil
| | - Scott A Rivkees
- 7 Pediatrics - Chairman's Office, University of Florida College of Medicine , Gainesville, Florida
| | - Mary Samuels
- 8 Division of Endocrinology, Diabetes and Clinical Nutrition, Oregon Health & Science University , Portland, Oregon
| | - Julie Ann Sosa
- 9 Section of Endocrine Surgery, Duke University School of Medicine , Durham, North Carolina
| | - Marius N Stan
- 10 Division of Endocrinology, Mayo Clinic , Rochester, Minnesota
| | - Martin A Walter
- 11 Institute of Nuclear Medicine, University Hospital Bern , Switzerland
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Stan MN, Sathananthan M, Warnes CA, Brennan MD, Thapa P, Bahn RS. Amiodarone-induced thyrotoxicosis in adults with congenital heart disease--clinical presentation and response to therapy. Endocr Pract 2016; 20:33-40. [PMID: 24013980 DOI: 10.4158/ep13059.or] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
OBJECTIVE The development of amiodarone-induced thyrotoxicosis (AIT) can threaten the hemodynamic stability of adult patients with congenital heart disease (CHD). Here, we describe the natural history and treatment response of AIT in this at-risk population. METHODS We studied retrospectively all cases of AIT that occurred in CHD patients at our institution after a minimum of 3 months on amiodarone. Subjects were identified from the cohort of adults with CHD who were treated at the Mayo Clinic Adult CHD clinic between 1987 and 2009. RESULTS We identified 23 cases of AIT: 7 were type 1, 13 were type 2, and 3 were undefined due to insufficient data. Most patients were symptomatic (17 of 23, 74%), with arrhythmia and weight loss as the most common symptoms. The majority (12 of 23, 52%) were initially observed; 10 patients (43%) were treated medically and 1 patient (5%) underwent thyroidectomy. Four patients from the observation group eventually required active treatment and 3 patients from the medical group required surgery. Asymptomatic patients tended to resolve under observation (5 of 7, 71.4%) rather than progress to active treatment (0 of 4) (P = .06). Discontinuation of amiodarone, AIT type, or use of perchlorate did not impact AIT duration. CONCLUSION AIT in CHD patients exhibits a wide range of severity and sensitivity to medical therapy. Asymptomatic patients display a trend toward AIT resolution with observation alone. Amiodarone continuation does not appear to impact management outcome or disease duration. Additional studies in this high-risk population could identify elements of pathophysiology that would point toward better disease prevention and treatment.
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Affiliation(s)
- Marius N Stan
- Department of Internal Medicine, Division of Endocrinology, Diabetes, Metabolism and Nutrition, Mayo Clinic, Rochester, Minnesota
| | | | - Carole A Warnes
- Department of Internal Medicine, Division of Cardiovascular Diseases, Mayo Clinic, Rochester, Minnesota
| | - Michael D Brennan
- Department of Internal Medicine, Division of Endocrinology, Diabetes, Metabolism and Nutrition, Mayo Clinic, Rochester, Minnesota
| | - Prabin Thapa
- Department of Health Sciences Research, Division of Biostatistics, Mayo Clinic, Rochester, Minnesota
| | - Rebecca S Bahn
- Department of Internal Medicine, Division of Endocrinology, Diabetes, Metabolism and Nutrition, Mayo Clinic, Rochester, Minnesota
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Meerwein C, Vital D, Greutmann M, Schmid C, Huber GF. [Total thyroidectomy in patients with amiodarone-induced hyperthyroidism: when does the risk of conservative treatment exceed the risk of surgery?]. HNO 2014; 62:100-5. [PMID: 24549509 DOI: 10.1007/s00106-013-2806-0] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Abstract
Amiodarone plays a pivotal role in the treatment of ventricular and supraventricular arrhythmias. However, amiodarone-induced hyperthyroidism (AIH) is one of the most feared complications, which necessitates interdisciplinary treatment and careful balancing of the risks of conservative treatment against those of total thyroidectomy. In this article we discuss the pharmacological aspects of amiodarone and its diverse effects on the thyroid. Furthermore, we present diagnostic and therapeutic strategies and report our positive experiences with total thyroidectomy in patients with AIH. Particularly in patients for whom continuation of amiodarone treatment is compulsory, a well-timed total thyroidectomy is a reliable therapeutic option, with minimal complication rates and immediate amelioration of symptoms.
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Affiliation(s)
- C Meerwein
- Klinik für Ohren-, Nasen-, Hals- und Gesichtschirurgie, Universitätsspital Zürich, Frauenklinikstr. 24, 8091, Zürich, Schweiz
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Patel N, Inder WJ, Sullivan C, Kaye G. An audit of amiodarone-induced thyrotoxicosis--do anti-thyroid drugs alone provide adequate treatment? Heart Lung Circ 2014; 23:549-54. [PMID: 24613043 DOI: 10.1016/j.hlc.2014.01.013] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/13/2013] [Revised: 01/11/2014] [Accepted: 01/20/2014] [Indexed: 11/29/2022]
Abstract
INTRODUCTION Amiodarone is a widely used anti-arrhythmic drug. A common long-term complication is amiodarone-induced thyrotoxicosis (AIT). We examined retrospectively the efficacy of anti-thyroid drugs with or without prednisolone and the role of surgical thyroidectomy in the treatment of AIT in a single centre, in an iodine-replete region of Australia. METHODS A retrospective audit of patients with AIT was performed between 2002-2012 at this centre. Twenty-seven patients, mean age 60.9 ± 2.3 years were identified. Medical therapy (anti-thyroid drugs, prednisolone) was commenced according to the treating endocrinologist. The main outcomes were time to euthyroidism and number proceeding to thyroidectomy. RESULTS Of 11 patients commenced on anti-thyroid drugs alone, seven (64%) required the addition of prednisolone. Baseline free T4 was significantly higher in those ultimately treated with prednisolone (58.4 ± 6.3pmol/L) versus those not (31.7 ± 3.4pmol/L, P<0.05). Although similar results were seen with free T3, the difference was not significant (P=0.06). In patients with baseline free T4 <30pmol/L, 75% (3/4) achieved euthyroidism without prednisolone. Neither the use of prednisolone nor continuation of amiodarone significantly influenced time to euthyroidism. Eleven patients (41%) proceeded to surgical thyroidectomy, which was undertaken by an experienced surgical team without significant complications and no mortality. CONCLUSION Patients with AIT generally required glucocorticoids. Mild disease (free T4 <30pmol/L) may be successfully treated with anti-thyroid drugs alone. Surgical thyroidectomy is a safe and effective treatment for those refractive to medical therapy.
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Affiliation(s)
- Nadia Patel
- Department of Diabetes and Endocrinology, Princess Alexandra Hospital, Brisbane, Queensland, Australia
| | - Warrick J Inder
- Department of Diabetes and Endocrinology, Princess Alexandra Hospital, Brisbane, Queensland, Australia; School of Medicine, The University of Queensland, Brisbane, Australia
| | - Clair Sullivan
- Department of Diabetes and Endocrinology, Princess Alexandra Hospital, Brisbane, Queensland, Australia
| | - Gerald Kaye
- School of Medicine, The University of Queensland, Brisbane, Australia; Department of Cardiology, Princess Alexandra Hospital, Brisbane, Queensland, Australia
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Ahmed S, Van Gelder IC, Wiesfeld ACP, Van Veldhuisen DJ, Links TP. Determinants and outcome of amiodarone-associated thyroid dysfunction. Clin Endocrinol (Oxf) 2011; 75:388-94. [PMID: 21535072 DOI: 10.1111/j.1365-2265.2011.04087.x] [Citation(s) in RCA: 38] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
OBJECTIVE Amiodarone is frequently associated with thyroid dysfunction. Identifying predictors for amiodarone-associated thyroid dysfunction and assessing treatment outcome may aid clinicians in daily practice. METHODS We included 303 consecutive patients with amiodarone therapy for cardiac arrhythmias (260 with atrial fibrillation and 43 with ventricular arrhythmias). Thyroid function tests were performed every 6 months. RESULTS Mean age was 63 ± 12 years and 66% was male. After median follow-up of 3·3 (0·1-24) years, 23 (8%) patients developed amiodarone-associated thyrotoxicosis (incidence rate 1·9 per 100 person years) and 18 (6%) hypothyroidism (incidence rate 1·1 per 100 person years). The only predictor for amiodarone-associated thyrotoxicosis was age <62 years [HR = 2·4 (95% CI 1·0-5·7), P = 0·05]. Predictors for amiodarone-associated hypothyroidism were thyroid stimulating hormone >1·4 mU/l at baseline [HR = 5·1 (95% CI 1·1-22·4), P = 0·03], left ventricular ejection fraction <45% [HR = 3·8 (95% CI 1·1-13·3), P = 0·04] and diabetes mellitus at baseline [HR = 3·3 (95% CI 1·1-10·3), P = 0·04]. Gender was not a predictor for amiodarone-associated thyroid dysfunction. Five out of 12 (42%) patients with thyrotoxicosis exhibited spontaneous normalization of thyroid function on continuation of amiodarone therapy. Mean time to normalization in the total group was 6·2 ± 3·3 months, with no difference between continuing or discontinuing amiodarone (6·6 ± 3·8 vs 5·8 ± 2·8 months, P = 0·5). CONCLUSIONS During median follow-up of 3·3 years, the incidence of amiodarone-associated thyrotoxicosis was higher compared to hypothyroidism. Only general predictors for amiodarone-associated thyroid dysfunction were observed. Discontinuation of amiodarone did not influence treatment outcome.
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Affiliation(s)
- Sheba Ahmed
- Department of Cardiology, University Medical Center Groningen, Groningen, The Netherlands
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Abstract
Amiodarone is a benzofuran derivative approved for the treatment of cardiac arrhythmias. Traditionally classified as a class III antiarrhythmic agent, amiodarone possesses electrophysiologic properties of all four Vaughan-Williams classes. This drug, however, has high iodine content, and this feature plus the intrinsic effects on the body make amiodarone especially toxic to the thyroid gland. Treatment can result in a range of effects from mild derangements in thyroid function to overt hypothyroidism or thyrotoxicosis. The diagnosis and treatment of amiodarone-induced hypothyroidism is usually straightforward, whereas that of amiodarone-induced thyrotoxicosis and the ability to distinguish between the type 1 and type 2 forms of the disease are much more challenging. Dronedarone was approved in 2009 for the treatment of patients with atrial fibrillation. As amiodarone, dronedarone is a benzofuran derivative with similar electrophysiologic properties. In contrast to amiodarone, however, dronedarone is structurally devoid of iodine and has a notably shorter half-life. In studies reported before FDA approval, dronedarone proved to be associated with significantly fewer adverse effects than amiodarone, making it a more attractive choice for patients with atrial fibrillation or flutter, who are at risk of developing amiodarone-induced thyroid dysfunction.
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Affiliation(s)
- Janna Cohen-Lehman
- Department of Medicine, North Shore University Hospital, 350 Community Drive, Manhasset, NY 11030, USA
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Abstract
Assessment of TSH and TPO-Ab before starting amiodarone (AM) treatment is recommended. The usefulness of periodic TSH measurement every 6 months during AM treatment is limited by the often sudden explosive onset of AIT, and the spontaneous return of a suppressed TSH to normal values in half of the cases. AM-induced hypothyroidism develops rather early after starting treatment, preferentially in iodine-sufficient areas and in females with TPO-Ab; it is due to failure to escape from the Wolff-Chaikoff effect, resulting in preserved radioiodine uptake. AM-induced thyrotoxicosis (AIT) occurs at any time during treatment, preferentially in iodine-deficient regions and in males. AIT can be classified in type 1 (iodide-induced thyrotoxicosis, best treated by potassium perchlorate in combination with thionamides and discontinuation of AM) and type 2 (destructive thyrotoxicosis, best treated by prednisone; discontinuation of AM may not be necessary). AIT is associated with a higher rate of major adverse cardiovascular events (especially of ventricular arrhythmias). Uncertainty continues to exist with respect to the feasibility of continuation of AM despite AIT, the appropriate methods to distinguish between AIT type 1 and 2 as well as the advantages of AIT classification into subtypes in view of possible mixed cases, and the best policy when AM needs to be restarted.
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Affiliation(s)
- Silvia A Eskes
- Department of Endocrinology and Metabolism, Academic Medical Center, University of Amsterdam, The Netherlands
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Conen D, Melly L, Kaufmann C, Bilz S, Ammann P, Schaer B, Sticherling C, Muller B, Osswald S. Amiodarone-induced thyrotoxicosis: clinical course and predictors of outcome. J Am Coll Cardiol 2007; 49:2350-5. [PMID: 17572251 DOI: 10.1016/j.jacc.2007.02.054] [Citation(s) in RCA: 45] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/23/2006] [Revised: 02/08/2007] [Accepted: 02/12/2007] [Indexed: 11/16/2022]
Abstract
OBJECTIVES This study sought to determine the clinical course and predictors of long-term outcome in patients with documented amiodarone-induced thyrotoxicosis (AIT). BACKGROUND Amiodarone-induced thyrotoxicosis is a condition that is difficult to manage, in particular because of the long half-life of amiodarone. Data on optimal treatment for AIT are scarce. METHODS We performed a retrospective review among patients with documented AIT at a tertiary care center. Baseline characteristics, treatment received, laboratory parameters, and events during follow-up were evaluated. The predefined composite end point consisted of the following AIT-associated complications: death, heart transplantation, hospitalization for heart failure, myocardial infarction, stroke, hospitalization for arrhythmia management, or hospitalization for treatment complications. RESULTS Eighty-four patients were included in the present analysis; 27 patients received prednisone for AIT. There was no difference in time to normalization of free thyroxine between those receiving and those not receiving prednisone. Long-term follow-up showed high morbidity and mortality; 47 patients (56%) reached the primary end point. Patients receiving prednisone had a worse outcome than those not receiving prednisone (p = 0.003). Although patients received prednisone for 84 +/- 65 days, curves started to separate only 12 months after the initial diagnosis. CONCLUSIONS Patients with AIT have a high event rate during follow-up. Prednisone had no effect on time to normalization of thyroxine levels and was associated with an increased event rate. Importantly, AIT-related problems must be expected late, at a time when thyroid function is under control.
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Affiliation(s)
- David Conen
- Department of Cardiology, University Hospital, Basel, Switzerland
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Diehl LA, Romaldini JH, Graf H, Bartalena L, Martino E, Albino CC, Wiersinga WM. Management of amiodarone-induced thyrotoxicosis in Latin America: an electronic survey. Clin Endocrinol (Oxf) 2006; 65:433-8. [PMID: 16984234 DOI: 10.1111/j.1365-2265.2006.02590.x] [Citation(s) in RCA: 25] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
OBJECTIVE To assess diagnostic and therapeutic approaches to amiodarone-induced thyrotoxicosis (AIT) among members of the Latin American Thyroid Society (LATS). METHODS LATS members responded to an online questionnaire that presented an index case (a 62-year-old man on amiodarone, with thyrotoxic symptoms and a nodular goitre) and a variant (same patient, no goitre). RESULTS About 25% of invited members responded to the questionnaire. Most respondents lived in iodine-sufficient areas and observed that amiodarone-induced hypothyroidism (AIH) is more common than AIT. Nearly all assessed TSH, and the most used combination of tests was TSH and free T4 (37%). Thyroid autoimmunity was assessed by about 90%. Interleukin-6 (IL-6) was useful to 80%. Additional tests ordered for the index case were: radioactive iodine uptake (RAIU; 57%), echo-colour Doppler sonography (ECDS; about 50%) and fine-needle aspiration biopsy (FNAB; 44%). For the variant, ECDS and RAIU were judged unhelpful by 16%. Most defined the index case as type I AIT and the variant as type II AIT, but 16% in LATS suggested a mixed form in the index case. As initial treatment, nearly all used thionamides in the index case [with potassium perchlorate (KClO(4)) in one-third], while glucocorticoids were indicated to the variant by 66%. Only about 5% considered amiodarone withdrawal unnecessary. If initial strategy is ineffective in type I AIT, KClO(4) (half) or glucocorticoids (a third) are added; in type II, glucocorticoids are indicated by most. Once euthyroidism is restored, ablative therapy is prescribed by a third of respondents for type I AIT. CONCLUSIONS There are several points of disagreement among thyroidologists regarding AIT management, mainly in the radiological evaluation and the approach to the already stabilized patient if amiodarone needs to be restarted.
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Current awareness: Pharmacoepidemiology and drug safety. Pharmacoepidemiol Drug Saf 2006. [DOI: 10.1002/pds.1182] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
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