Toxic multinodular goiter medical therapy
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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 CVS complications
- Hyperthyroidism with CNS complications
- Elderly patients
- Patient with coexisting cardiac condition
Pharmacological drug therapy
Following are drugs used in the symptomatic management of TMG:
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 is based on:
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 Thaimolide 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 Thaimolide to so that iodine may not be used as substrate)
- 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 Thaimolide 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 Thaimolide to so that iodine may not be used as substrate)
- Subclinical hyperthyroidism with comorbid conditions such as dibeties 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 regimen (1):3 month review of TSH
- Alternative regimen (1):Propylthiouracil 5-10 mg q24h PO for long term to avoid remission with 3 month review of TSH
- Thyroid storm[1]
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.