New draft hyperthyroidism treatment guidelines from the American Thyroid Association and the American Association of Clinical Endocrinologists emphasize that although radioactive iodine is a good treatment for the disorder, patients need to consult with their physicians about all three available treatment options: radioactive iodine, surgery, and antithyroid medications, according to Dr. Rebecca Bahn.
“Physicians in the United States have long considered radioactive iodine to be the preferred treatment for Grave's disease,” Dr. Bahn, chair of the guideline task force, said in an interview. “We're recommending that the patient and the physician have a careful and clear discussion about the three treatment options, and that any of the three options are viable.” Dr. Bahn presented the draft guidelines at the annual meeting of the American Thyroid Association in Palm Beach, Fla.
That is not to say that there aren't some situations in which one procedure is preferable, said Dr. Bahn, professor of medicine and a consultant in endocrinology at the Mayo Clinic, Rochester, Minn. “Pregnant women should not receive radioactive iodine, and patients with medical problems that put them at high risk for surgery should not choose surgery. But our overall recommendation is that the patient and the physician should make the decision following a careful discussion.”
Another major change in the guidelines deals with antithyroid drug therapy. “It used to be that propylthiouracil (PTU) or methimazole could be used interchangeably, but there's now good evidence that there's a very serious hepatic necrosis associated with PTU; it's rare, but it's not at all associated with methimazole,” she said. “So our guidelines will say that if you're going to use antithyroid drugs you should use methimazole except in certain instances. This is especially true of children, who are particularly susceptible to [this liver complication].”
On the other hand, women who have Grave's disease that is diagnosed in the first trimester of pregnancy should be started on PTU, because methimazole is associated with certain birth defects such as cutis aplasia and choanal or esophageal atresia, Dr. Bahn said.
“Also, if the patient is found to have minor side effects with methimazole, in some cases PTU might be used,” she continued.
In the case of hyperthyroidism caused by nodules, “for definitive treatment we don't recommend antithyroid drugs because the patient would have to be on those essentially forever,” she said.
“In some instances, such as patients with a relatively short life expectancy or iodine-induced disease, these medications may be used, but in general, the treatment is surgery or RAI.” In particular, the task force is recommending that for toxic multinodular goiter, near-total or total thyroidectomy should be performed, preferably by a high-volume thyroid surgeon.
Dr. Bahn said that she expected a final draft of the guidelines to be ready to submit to both Thyroid and Endocrine Practice early this year for eventual simultaneous publication.
Dr. Bahn reported having no conflicts to declare with regard to the guidelines.