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{{Toxic multinodular goiter}}
{{Toxic multinodular goiter}}
{{CMG}}; {{AE}}  
{{CMG}}; {{AE}} {{SKA}},{{MMF}}


==Overview==
==Overview==
*There is no treatment for [disease name]; the mainstay of therapy is supportive care.
The mainstay of treatment for Toxic multinodular goiter is [[Surgery]]. Patients with symptomatic [[hyperthyroidism]], sub-clinical [[hyperthyroid]] patients with expected compilations and patients refusing surgical therapy are treated with [[beta blockers]] and [[antithyroid|anti-thyroid pharmacological groups]].
*Supportive therapy for [disease name] includes [therapy 1], [therapy 2], and [therapy 3].
*The majority of cases of [disease name] are self-limited and require only supportive care.


*[Disease name] is a medical emergency and requires prompt treatment.
==Medical Therapy==
===Indications===
Symptomatic therapy for toxic multinodular goiter (TMG) is recommended for the patients with the following:<ref name="pmid3753814">{{cite journal| author=Laurberg P, Buchholtz Hansen PE, Iversen E, Eskjaer Jensen S, Weeke J| title=Goitre size and outcome of medical treatment of Graves' disease. | journal=Acta Endocrinol (Copenh) | year= 1986 | volume= 111 | issue= 1 | pages= 39-43 | pmid=3753814 | doi= | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=3753814  }} </ref><ref>name="pmid1283983">{{cite journal| author=van Soestbergen MJ, van der Vijver JC, Graafland AD| title=Recurrence of hyperthyroidism in multinodular goiter after long-term drug therapy: a comparison with Graves' disease. | journal=J Endocrinol Invest | year= 1992 | volume= 15 | issue= 11 | pages= 797-800 | pmid=1283983 | doi=10.1007/BF03348807 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=1283983  }} </ref><ref name="pmid4107462">{{cite journal| author=Becker DV, Hurley JR| title=Complications of radioiodine treatment of hyperthyroidism. | journal=Semin Nucl Med | year= 1971 | volume= 1 | issue= 4 | pages= 442-60 | pmid=4107462 | doi= | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=4107462  }} </ref>
*[[Thyroid storm]]
*Overt [[hyperthyroidism]]
*[[Hyperthyroidism]] with cardiovascular complications
*[[Hyperthyroidism]] with [[central nervous system]] complications
*Elderly patients
*Patient with coexisting [[cardiac]] condition
 
=== Pharmacological drug therapy ===
Following are drugs used in the symptomatic management of toxic multinodular goiter:
*[[Propanolol]]
*[[Atenolol]]
*[[Metoprolol]]
*[[Nadolol]]
*[[Esmolol]]
 
Following are antithyroid medicines used in  the management of TMG:
*[[Propylthiouracil]]
*[[Methimazole]]


*The mainstay of treatment for [disease name] is [therapy].
Anti-thyroid therapy for toxic multinodular goiter (TMG) is recommended for the patients with the following:
 
*Patients refusing [[radiation therapy]]
*The optimal therapy for [malignancy name] depends on the stage at diagnosis.
*Patients refusing [[surgery]]
* [Therapy] is recommended among all patients who develop [disease name].
*Patients on peri-operative preparation
*Pharmacologic medical therapy is recommended among patients with [disease subclass 1], [disease subclass 2], and [disease subclass 3].
*Pregnancy with caution as [[Antithyroid agents|anti-thyroid]] medication is [[teratogenic]]
*Pharmacologic medical therapies for [disease name] include (either) [therapy 1], [therapy 2], and/or [therapy 3].
*Recently gone through [[surgery]] or [[radiation]]  
*Empiric therapy for [disease name] depends on [disease factor 1] and [disease factor 2].
*Unfit for [[radiation]] of [[surgery]]
*Patients with [disease subclass 1] are treated with [therapy 1], whereas patients with [disease subclass 2] are treated with [therapy 2].
*Lack of professional expertise or medical facilities.
*Limited life expectancy


==Medical Therapy==
Treatment of TMG should be decided on:
*Pharmacologic medical therapy is recommended among patients with [disease subclass 1], [disease subclass 2], and [disease subclass 3].
*Severity of disease
*Pharmacologic medical therapies for [disease name] include (either) [therapy 1], [therapy 2], and/or [therapy 3].
*[[Biochemical]] evaluation of [[Thyroid|thyroid profile]] level of [[TSH]], [[T3]], and [[T4]]
*Empiric therapy for [disease name] depends on [disease factor 1] and [disease factor 2].
*Cardiac evaluation```([[echo-cardiogram]], [[electrocardiogram]], [[Holter monitor]], or [[myocardial perfusion studies]])
*Patients with [disease subclass 1] are treated with [therapy 1], whereas patients with [disease subclass 2] are treated with [therapy 2].
*[[Neuromuscular]] complications
===Disease Name===
*Age
*[[Goiter]] size
*Physical examination including vitals as [[pulse rate]] and [[respiratory rate]]
 
===Drug Regimens===
Pharmacological medical therapy for toxic multinodular goiter is primarily based on [[beta blockers]] and [[antithyroid|anti-thyroid drugs]].<ref name="pmid27521067">{{cite journal| author=Ross DS, Burch HB, Cooper DS, Greenlee MC, Laurberg P, Maia AL et al.| title=2016 American Thyroid Association Guidelines for Diagnosis and Management of Hyperthyroidism and Other Causes of Thyrotoxicosis. | journal=Thyroid | year= 2016 | volume= 26 | issue= 10 | pages= 1343-1421 | pmid=27521067 | doi=10.1089/thy.2016.0229 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=27521067  }} </ref>
 
#'''Toxic Multinodular Goiter'''
#* '''Thyroid storm'''<ref name="pmid3753814">{{cite journal| author=Laurberg P, Buchholtz Hansen PE, Iversen E, Eskjaer Jensen S, Weeke J| title=Goitre size and outcome of medical treatment of Graves' disease. | journal=Acta Endocrinol (Copenh) | year= 1986 | volume= 111 | issue= 1 | pages= 39-43 | pmid=3753814 | doi= | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=3753814  }} </ref>
#** Preferred regimen (1):  [[Propylthiouracil]] 500–1000 mg load, then 250 mg PO / IV 4 hourly '''PLUS''' [[Propranolol]] 60–80 mg PO 4 hourly(Consider invasive monitoring in [[congestive heart failure]] patients) '''PLUS''' [[Hydrocortisone]] 300 mg [[Intravenous therapy|intravenous]] load, then 100 mg 8 hourly '''PLUS''' [[Cholestyramin]]e 4 g PO 6 hourly '''PLUS''' Iodine (saturated solution of [[potassium iodide]] 5 drops (0.25 mL or 250 mg) orally 6 hourly(start Iodine after 1 hour of administration of [[Thalidomide]] to so that iodine may not be used as [[substrate]]) 
#** Alternative regimen (1): [[Methimazole]]  60–80 mg PO in 24 hours  '''PLUS''' [[Propranolol]] 60–80 mg PO 4 hourly(Consider invasive monitoring in congestive heart failure patients) '''PLUS''' [[Hydrocortisone]] 300 mg intravenous load, then 100 mg 8 hourly '''PLUS'''  [[Cholestyramine]] 4 g PO 6 hourly '''PLUS''' [[Iodine]] (saturated solution of [[potassium iodide]] 5 drops (0.25 mL or 250 mg) orally 6 hourly (start [[Iodine]] after 1 hour of administration of [[Thalidomide]] to so that iodine may not be used as [[substrate]])
 
#* '''Hyperthyroidism'''<ref name="pmid1283983">{{cite journal| author=van Soestbergen MJ, van der Vijver JC, Graafland AD| title=Recurrence of hyperthyroidism in multinodular goiter after long-term drug therapy: a comparison with Graves' disease. | journal=J Endocrinol Invest | year= 1992 | volume= 15 | issue= 11 | pages= 797-800 | pmid=1283983 | doi=10.1007/BF03348807 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=1283983  }} </ref>
#** Preferred regimen (1): [[Propylthiouracil]] 500–1000 mg load, then 250 mg PO / IV 4 hourly '''PLUS''' [[Propranolol]] 60–80 mg PO 4 hourly(Consider invasive monitoring in [[congestive heart failure]] patients) '''PLUS''' [[Iodine]] (saturated solution of [[potassium iodide]] 5 drops (0.25 mL or 250 mg) orally 6 hourly(start Iodine after 1 hour of administration of [[Thalidomide]] to so that iodine may not be used as substrate) 
#** Alternative regimen (1): [[Methimazole]]  60–80 mg PO in 24 hours  '''PLUS''' [[Propranolol]] 60–80 mg PO 4 hourly(Consider invasive monitoring in [[congestive heart failure]] patients) '''PLUS''' [[Iodine]] (saturated solution of potassium iodide 5 drops (0.25 mL or 250 mg) orally 6 hourly (start [[Iodine]] after 1 hour of administration of [[Thalidomide]] to so that [[iodine]] may not be used as [[substrate]]) 
#* '''Subclinical hyperthyroidism with comorbid conditions such as diabetes mellitus, heart failure or CNS abnormality'''<ref name="pmid4107462">{{cite journal| author=Becker DV, Hurley JR| title=Complications of radioiodine treatment of hyperthyroidism. | journal=Semin Nucl Med | year= 1971 | volume= 1 | issue= 4 | pages= 442-60 | pmid=4107462 | doi= | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=4107462  }} </ref>
#** Preferred regimen (1): [[Propylthiouracil]] 5-10 mg q24h PO for long term to avoid remission with 3 month review of [[TSH]] 
#** Alternative regimen (1): [[Methimazole]] 5-10 mg q24h PO for long term to avoid remission with 3 month review of [[TSH]] 
#* '''Subclinical hyperthyroidism without comorbid conditions'''
#** Preferred: Monitoring/Review of [[TSH]] every 3 month
#** Alternative regimen (1):[[Propylthiouracil]] 5-10 mg q24h PO for long term to avoid remission with review of [[TSH]] every 3 month


* '''1 Stage 1 - Name of stage'''
'''Ultrasound-Guided percutaneous ethanol injection (PEI)''':<ref name="pmid27375551">{{cite journal| author=Felício JS, Conceição AM, Santos FM, Sato MM, Bastos Fde A, Braga de Souza AC et al.| title=Ultrasound-Guided Percutaneous Ethanol Injection Protocol to Treat Solid and Mixed Thyroid Nodules. | journal=Front Endocrinol (Lausanne) | year= 2016 | volume= 7 | issue=  | pages= 52 | pmid=27375551 | doi=10.3389/fendo.2016.00052 | pmc=4893597 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=27375551  }} </ref>
** 1.1 '''Specific Organ system involved 1'''
* Patients [[Toxic multinodular goiter|Toxic Multinodular Goiter]] differing treatment with surgery, [[Antithyroid agents|antithyroid medication]] and [[radiation therapy]] can benefit from [[injection]] of [[ethanol]] to destroy [[Autonomous agent|autonomous]] functioning [[thyroid]] nodules to decrease production of thyroid and also considerable reduction in [[thyroid gland]] size.
*** 1.1.1 '''Adult'''
*It is a safe procedure without serious complications
**** Preferred regimen (1): [[drug name]] 100 mg PO q12h for 10-21 days '''(Contraindications/specific instructions)''' 
*Some of complications are
**** Preferred regimen (2): [[drug name]] 500 mg PO q8h for 14-21 days
**[[ethanol]] leakage into the surrounding tissues
**** Preferred regimen (3): [[drug name]] 500 mg q12h for 14-21 days
**local pain
**** Alternative regimen (1): [[drug name]] 500 mg PO q6h for 7–10 days 
**[[dysphonia]]
**** Alternative regimen (2): [[drug name]] 500 mg PO q12h for 14–21 days
**[[flushing]]
**** Alternative regimen (3): [[drug name]] 500 mg PO q6h for 14–21 days
**[[dizziness]]
*** 1.1.2 '''Pediatric'''
**recurrent [[nerve palsy]]
**** 1.1.2.1 (Specific population e.g. '''children < 8 years of age''')
**[[Horner's syndrome|Horner’s syndrome]]
***** Preferred regimen (1): [[drug name]] 50 mg/kg PO per day q8h (maximum, 500 mg per dose) 
**necrosis of the [[larynx]] and [[skin]]
***** Preferred regimen (2): [[drug name]] 30 mg/kg PO per day in 2 divided doses (maximum, 500 mg per dose)
**local [[fibrosis]]
***** Alternative regimen (1): [[drug name]]10 mg/kg PO q6h (maximum, 500 mg per day)
***** Alternative regimen (2): [[drug name]] 7.5 mg/kg PO q12h (maximum, 500 mg per dose)
***** Alternative regimen (3): [[drug name]] 12.5 mg/kg PO q6h (maximum, 500 mg per dose)
****1.1.2.2 (Specific population e.g. ''''''children < 8 years of age'''''')
***** Preferred regimen (1): [[drug name]] 4 mg/kg/day PO q12h（maximum, 100 mg per dose）
***** Alternative regimen (1): [[drug name]] 10 mg/kg PO q6h (maximum, 500 mg per day)
***** Alternative regimen (2): [[drug name]] 7.5 mg/kg PO q12h (maximum, 500 mg per dose) 
***** Alternative regimen (3): [[drug name]] 12.5 mg/kg PO q6h (maximum, 500 mg per dose)
** 2.1 '''Specific Organ system involved 2'''
*** 2.1.1 '''Adult'''
**** Preferred regimen (1): [[drug name]] 500 mg PO q8h
*** 2.1.2  '''Pediatric'''
**** Preferred regimen (1): [[drug name]] 50 mg/kg/day PO q8h (maximum, 500 mg per dose)


* 2 '''Stage 2 - Name of stage'''
** 2.1 '''Specific Organ system involved 1 '''
**: '''Note (1):'''
**: '''Note (2)''':
**: '''Note (3):'''
*** 2.1.1 '''Adult'''
**** Parenteral regimen
***** Preferred regimen (1): [[drug name]] 2 g IV q24h for 14 (14–21) days
***** Alternative regimen (1): [[drug name]] 2 g IV q8h for 14 (14–21) days
***** Alternative regimen (2): [[drug name]] 18–24 MU/day IV q4h for 14 (14–21) days
**** Oral regimen
***** Preferred regimen (1): [[drug name]] 500 mg PO q8h for 14 (14–21) days
***** Preferred regimen (2): [[drug name]] 100 mg PO q12h for 14 (14–21) days
***** Preferred regimen (3): [[drug name]] 500 mg PO q12h for 14 (14–21) days
***** Alternative regimen (1): [[drug name]] 500 mg PO q6h for 7–10 days 
***** Alternative regimen (2): [[drug name]] 500 mg PO q12h for 14–21 days
***** Alternative regimen (3):[[drug name]] 500 mg PO q6h for 14–21 days
*** 2.1.2 '''Pediatric'''
**** Parenteral regimen
***** Preferred regimen (1): [[drug name]] 50–75 mg/kg IV q24h for 14 (14–21) days (maximum, 2 g)
***** Alternative regimen (1): [[drug name]] 150–200 mg/kg/day IV q6–8h for 14 (14–21) days (maximum, 6 g per day)
***** Alternative regimen (2):  [[drug name]] 200,000–400,000 U/kg/day IV q4h for 14 (14–21) days (maximum, 18–24 million U per day) ''''''(Contraindications/specific instructions)''''''
**** Oral regimen
***** Preferred regimen (1):  [[drug name]] 50 mg/kg/day PO q8h for 14 (14–21) days  (maximum, 500 mg per dose)
***** Preferred regimen (2): [[drug name]] '''(for children aged ≥ 8 years)''' 4 mg/kg/day PO q12h for 14 (14–21) days (maximum, 100 mg per dose)
***** Preferred regimen (3): [[drug name]] 30 mg/kg/day PO q12h for 14 (14–21) days  (maximum, 500 mg per dose)
***** Alternative regimen (1):  [[drug name]] 10 mg/kg PO q6h 7–10 days  (maximum, 500 mg per day)
***** Alternative regimen (2): [[drug name]] 7.5 mg/kg PO q12h for 14–21 days  (maximum, 500 mg per dose)
***** Alternative regimen (3): [[drug name]] 12.5 mg/kg PO q6h for 14–21 days  (maximum,500 mg per dose)
** 2.2  '<nowiki/>'''''Other Organ system involved 2''''''
**: '''Note (1):'''
**: '''Note (2)''':
**: '''Note (3):'''
*** 2.2.1 '''Adult'''
**** Parenteral regimen
***** Preferred regimen (1): [[drug name]] 2 g IV q24h for 14 (14–21) days
***** Alternative regimen (1): [[drug name]] 2 g IV q8h for 14 (14–21) days
***** Alternative regimen (2): [[drug name]] 18–24 MU/day IV q4h for 14 (14–21) days
**** Oral regimen
***** Preferred regimen (1): [[drug name]] 500 mg PO q8h for 14 (14–21) days
***** Preferred regimen (2): [[drug name]] 100 mg PO q12h for 14 (14–21) days
***** Preferred regimen (3): [[drug name]] 500 mg PO q12h for 14 (14–21) days
***** Alternative regimen (1): [[drug name]] 500 mg PO q6h for 7–10 days 
***** Alternative regimen (2): [[drug name]] 500 mg PO q12h for 14–21 days
***** Alternative regimen (3):[[drug name]] 500 mg PO q6h for 14–21 days
*** 2.2.2 '''Pediatric'''
**** Parenteral regimen
***** Preferred regimen (1): [[drug name]] 50–75 mg/kg IV q24h for 14 (14–21) days (maximum, 2 g)
***** Alternative regimen (1): [[drug name]] 150–200 mg/kg/day IV q6–8h for 14 (14–21) days (maximum, 6 g per day)
***** Alternative regimen (2):  [[drug name]] 200,000–400,000 U/kg/day IV q4h for 14 (14–21) days (maximum, 18–24 million U per day)
**** Oral regimen
***** Preferred regimen (1):  [[drug name]] 50 mg/kg/day PO q8h for 14 (14–21) days  (maximum, 500 mg per dose)
***** Preferred regimen (2): [[drug name]] 4 mg/kg/day PO q12h for 14 (14–21) days (maximum, 100 mg per dose)
***** Preferred regimen (3): [[drug name]] 30 mg/kg/day PO q12h for 14 (14–21) days  (maximum, 500 mg per dose)
***** Alternative regimen (1):  [[drug name]] 10 mg/kg PO q6h 7–10 days  (maximum, 500 mg per day)
***** Alternative regimen (2): [[drug name]] 7.5 mg/kg PO q12h for 14–21 days  (maximum, 500 mg per dose)
***** Alternative regimen (3): [[drug name]] 12.5 mg/kg PO q6h for 14–21 days  (maximum,500 mg per dose)


==References==
==References==

Latest revision as of 19:48, 13 October 2017

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Sunny Kumar MD [2],Furqan M M. M.B.B.S[3]

Overview

The mainstay of treatment for Toxic multinodular goiter is Surgery. Patients with symptomatic hyperthyroidism, sub-clinical hyperthyroid patients with expected compilations and patients refusing surgical therapy are treated with beta blockers and anti-thyroid pharmacological groups.

Medical Therapy

Indications

Symptomatic therapy for toxic multinodular goiter (TMG) is recommended for the patients with the following:[1][2][3]

Pharmacological drug therapy

Following are drugs used in the symptomatic management of toxic multinodular goiter:

Following are antithyroid medicines used in the management of TMG:

Anti-thyroid therapy for toxic multinodular goiter (TMG) is recommended for the patients with the following:

Treatment of TMG should be decided on:

Drug Regimens

Pharmacological medical therapy for toxic multinodular goiter is primarily based on beta blockers and anti-thyroid drugs.[4]

  1. Toxic Multinodular Goiter
    • Hyperthyroidism[5]
    • Subclinical hyperthyroidism with comorbid conditions such as diabetes mellitus, heart failure or CNS abnormality[3]
      • Preferred regimen (1): Propylthiouracil 5-10 mg q24h PO for long term to avoid remission with 3 month review of TSH
      • Alternative regimen (1): Methimazole 5-10 mg q24h PO for long term to avoid remission with 3 month review of TSH
    • Subclinical hyperthyroidism without comorbid conditions
      • Preferred: Monitoring/Review of TSH every 3 month
      • Alternative regimen (1):Propylthiouracil 5-10 mg q24h PO for long term to avoid remission with review of TSH every 3 month

Ultrasound-Guided percutaneous ethanol injection (PEI):[6]


References

  1. ↑ 1.0 1.1 Laurberg P, Buchholtz Hansen PE, Iversen E, Eskjaer Jensen S, Weeke J (1986). "Goitre size and outcome of medical treatment of Graves' disease". Acta Endocrinol (Copenh). 111 (1): 39–43. PMID 3753814.
  2. ↑ name="pmid1283983">van Soestbergen MJ, van der Vijver JC, Graafland AD (1992). "Recurrence of hyperthyroidism in multinodular goiter after long-term drug therapy: a comparison with Graves' disease". J Endocrinol Invest. 15 (11): 797–800. doi:10.1007/BF03348807. PMID 1283983.
  3. ↑ 3.0 3.1 Becker DV, Hurley JR (1971). "Complications of radioiodine treatment of hyperthyroidism". Semin Nucl Med. 1 (4): 442–60. PMID 4107462.
  4. ↑ Ross DS, Burch HB, Cooper DS, Greenlee MC, Laurberg P, Maia AL; et al. (2016). "2016 American Thyroid Association Guidelines for Diagnosis and Management of Hyperthyroidism and Other Causes of Thyrotoxicosis". Thyroid. 26 (10): 1343–1421. doi:10.1089/thy.2016.0229. PMID 27521067.
  5. ↑ van Soestbergen MJ, van der Vijver JC, Graafland AD (1992). "Recurrence of hyperthyroidism in multinodular goiter after long-term drug therapy: a comparison with Graves' disease". J Endocrinol Invest. 15 (11): 797–800. doi:10.1007/BF03348807. PMID 1283983.
  6. ↑ Felício JS, Conceição AM, Santos FM, Sato MM, Bastos Fde A, Braga de Souza AC; et al. (2016). "Ultrasound-Guided Percutaneous Ethanol Injection Protocol to Treat Solid and Mixed Thyroid Nodules". Front Endocrinol (Lausanne). 7: 52. doi:10.3389/fendo.2016.00052. PMC 4893597. PMID 27375551.

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