Toxic multinodular goiter medical therapy: Difference between revisions
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==Overview== | ==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. | 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]]. | ||
==Medical Therapy== | ==Medical Therapy== | ||
===Indications=== | ===Indications=== | ||
Symptomatic therapy for toxic multinodular goiter (TMG) is recommended for the patients with the following: | 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 | *[[Thyroid storm]] | ||
*Overt hyperthyroidism | *Overt [[hyperthyroidism]] | ||
*Hyperthyroidism with | *[[Hyperthyroidism]] with cardiovascular complications | ||
*Hyperthyroidism with | *[[Hyperthyroidism]] with [[central nervous system]] complications | ||
*Elderly patients | *Elderly patients | ||
*Patient with coexisting cardiac condition | *Patient with coexisting [[cardiac]] condition | ||
Following are drugs used in the symptomatic management of | === Pharmacological drug therapy === | ||
*Propanolol | Following are drugs used in the symptomatic management of toxic multinodular goiter: | ||
*Atenolol | *[[Propanolol]] | ||
*Metoprolol | *[[Atenolol]] | ||
*Nadolol | *[[Metoprolol]] | ||
*Esmolol | *[[Nadolol]] | ||
*[[Esmolol]] | |||
Following are antithyroid medicines used in the management of TMG: | |||
*[[Propylthiouracil]] | |||
*[[Methimazole]] | |||
Anti-thyroid therapy for toxic multinodular goiter (TMG) is recommended for the patients with the following: | Anti-thyroid therapy for toxic multinodular goiter (TMG) is recommended for the patients with the following: | ||
*Patients refusing radiation therapy | *Patients refusing [[radiation therapy]] | ||
*Patients refusing surgery | *Patients refusing [[surgery]] | ||
*Patients on peri-operative preparation | *Patients on peri-operative preparation | ||
*Pregnancy with caution as anti-thyroid medication is teratogenic | *Pregnancy with caution as [[Antithyroid agents|anti-thyroid]] medication is [[teratogenic]] | ||
*Recently gone through surgery or radiation | *Recently gone through [[surgery]] or [[radiation]] | ||
*Unfit for radiation of surgery | *Unfit for [[radiation]] of [[surgery]] | ||
*Lack of professional expertise or medical facilities. | *Lack of professional expertise or medical facilities. | ||
*Limited life expectancy | *Limited life expectancy | ||
Treatment of TMG should be decided on: | |||
* | *Severity of disease | ||
* | *[[Biochemical]] evaluation of [[Thyroid|thyroid profile]] level of [[TSH]], [[T3]], and [[T4]] | ||
*Cardiac evaluation```([[echo-cardiogram]], [[electrocardiogram]], [[Holter monitor]], or [[myocardial perfusion studies]]) | |||
*[[Neuromuscular]] complications | |||
*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 | |||
'''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> | |||
* 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. | |||
*It is a safe procedure without serious complications | |||
*Some of complications are | |||
**[[ethanol]] leakage into the surrounding tissues | |||
**local pain | |||
**[[dysphonia]] | |||
**[[flushing]] | |||
**[[dizziness]] | |||
**recurrent [[nerve palsy]] | |||
**[[Horner's syndrome|Horner’s syndrome]] | |||
**necrosis of the [[larynx]] and [[skin]] | |||
**local [[fibrosis]] | |||
==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]
- 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:
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:
- Patients refusing radiation therapy
- Patients refusing surgery
- Patients on peri-operative preparation
- Pregnancy with caution as anti-thyroid medication is teratogenic
- Recently gone through surgery or radiation
- Unfit for radiation of surgery
- Lack of professional expertise or medical facilities.
- Limited life expectancy
Treatment of TMG should be decided on:
- Severity of disease
- Biochemical evaluation of thyroid profile level of TSH, T3, and T4
- Cardiac evaluation```(echo-cardiogram, electrocardiogram, Holter monitor, or myocardial perfusion studies)
- Neuromuscular complications
- 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 anti-thyroid drugs.[4]
- Toxic Multinodular Goiter
- Thyroid storm[1]
- 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 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)
- 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)
- Thyroid storm[1]
- Hyperthyroidism[5]
- 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[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
- Hyperthyroidism[5]
Ultrasound-Guided percutaneous ethanol injection (PEI):[6]
- Patients Toxic Multinodular Goiter differing treatment with surgery, antithyroid medication and radiation therapy can benefit from injection of ethanol to destroy autonomous functioning thyroid nodules to decrease production of thyroid and also considerable reduction in thyroid gland size.
- It is a safe procedure without serious complications
- Some of complications are
- ethanol leakage into the surrounding tissues
- local pain
- dysphonia
- flushing
- dizziness
- recurrent nerve palsy
- Horner’s syndrome
- necrosis of the larynx and skin
- local fibrosis
References
- ↑ 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.
- ↑ 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.
- ↑ 3.0 3.1 Becker DV, Hurley JR (1971). "Complications of radioiodine treatment of hyperthyroidism". Semin Nucl Med. 1 (4): 442–60. PMID 4107462.
- ↑ 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.
- ↑ 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.
- ↑ 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.