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Hyperthyroidism:
Treatment
(Professional Guide to Diseases (Eighth Edition))
A number of approaches are used to treat hyperthyroidism, primarily antithyroid drugs, 131I, and surgery. Appropriate treatment depends on the size of the goiter, the causes, the patient’s age and parity, and how long surgery will be delayed (if the patient is an appropriate candidate for surgery).
Antithyroid drug therapy is used for children, young adults, pregnant females, and patients who refuse surgery or 131I treatment. Thyroid hormone antagonists are given to block thyroid hormone synthesis. Although hypermetabolic symptoms subside within 4 to 8 weeks after such therapy begins, the patient must continue the medication for 6 months to 2 years, depending on the clinical circumstances. Beta-adrenergic blockers may be given concomitantly to manage tachycardia and other peripheral effects of excessive hypersympathetic activity.
During pregnancy, antithyroid medication should be kept at the minimum dosage required to keep maternal thyroid function within the high-normal range until delivery and to minimize the risk of fetal hypothyroidism — even though most infants of hyperthyroid mothers are born with mild and transient hyperthyroidism. (Neonatal hyperthyroidism may even necessitate treatment with antithyroid medications and propranolol for 2 to 3 months.) Because hyperthyroidism is sometimes exacerbated in the puerperal period, continuous control of maternal thyroid function is essential. Approximately 3 to 6 months postpartum, antithyroid drug administration can be gradually tapered and thyroid function reassessed. The mother receiving low-dose antithyroid treatment may breast-feed as long as the infant’s thyroid function is checked periodically. Small amounts of the drug can be found in breast milk.
A single oral dose of 131I is the treatment of choice for patients not planning to have children. (Patients of reproductive age must not be pregnant and should give informed consent for this treatment because small amounts of 131I concentrate in the gonads. However, there have been no reports of damage to subsequently conceived children in more than 50 years of 131I use.) During treatment with 131I, the thyroid gland picks up the radioactive element as it would regular iodine. Subsequently, the radioactivity destroys some of the cells that normally concentrate iodine and produce T4, thus decreasing thyroid hormone production and normalizing thyroid size and function. In most patients, hypermetabolic symptoms diminish from 6 to 8 weeks after such treatment. However, some patients may require a second dose.
Subtotal (partial) thyroidectomy, which decreases the thyroid gland’s capacity for hormone production, is indicated for patients with a large goiter whose hyperthyroidism has repeatedly relapsed after drug therapy or patients who refuse or aren’t candidates for 131I treatment. Preoperatively, the patient may receive iodides (Lugol’s solution or saturated solution of potassium iodide), antithyroid drugs, or high doses of propranolol, to help prevent thyroid storm. If euthyroidism isn’t achieved, surgery should be delayed and propranolol administered to decrease the systemic effects (cardiac arrhythmias) caused by hyperthyroidism. After ablative treatment with 131I or surgery, patients require regular medical supervision for the rest of their lives because they usually develop hypothyroidism, sometimes as long as several years after treatment.
Therapy for hyperthyroid ophthalmopathy includes local applications of topical medications but may require high doses of corticosteroids. A patient with severe exophthalmos that causes pressure on the optic nerve may require external beam radiation therapy or surgical decompression to lessen pressure on the orbital contents.
Treatment of thyroid storm includes administration of an antithyroid drug, propranolol I.V. to block sympathetic effects, a corticosteroid to inhibit the conversion of T4 to T3 and to replace depleted cortisol levels, and an iodide to block the release of thyroid hormone. Supportive measures include administration of nutrients, vitamins, fluids, and sedatives.
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Source: Professional Guide to Diseases (Eighth Edition), 2005
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