Endocrinol Metab Clin North Am. 2009;38:355-71
Treatment of Graves' hyperthyroidism: evidence-based and emerging modalities.
Currently there are three well-established treatment options for hyperthyroid Graves' disease (GD): antithyroid drug therapy with thionamides (ATD), radioactive iodine treatment with (131)I, and thyroid surgery. This article reviews the current evidence so the reader can evaluate advantages and disadvantages of these treatment modalities. Surgery is rarely used, except for patients who have a large goiter or ophthalmopathy. Fewer than 50% of patients treated with ATD remain in long-term remission. Therefore, radioactive iodine is used increasingly. No data as yet support the routine use of biologic therapies (eg, rituximab). Prospective, randomized studies comparing available and any novel therapeutic options for GD are needed. The focus of these studies should include, but not be limited to, cost and quality of life.
Cochrane Database Syst Rev. 2008:CD006294.
Radioiodine treatment for pediatric Graves' disease.
Ma C, Kuang A, Xie J, Liu G.
BACKGROUND: Pediatric Graves' disease (GD) is an autoimmune disease in which excessive amounts of thyroid hormones circulate in the blood. Treatments for pediatric GD include antithyroid drugs (ATD), thyroidectomy and radioiodine. Up to date, the optimal therapy remains controversial. OBJECTIVES: To assess the effects of radioiodine treatment for pediatric GD. SEARCH STRATEGY: Studies were obtained from computerized searches of MEDLINE, EMBASE, The Cochrane Library, China National Infrastructure (CNKI) and paper collections of conferences held in Chinese. SELECTION CRITERIA: Randomised controlled trials, controlled clinical trials and prospective cohort studies comparing the effects of radioiodine with ATD or thyroidectomy with a duration of follow-up at least one year. DATA COLLECTION AND ANALYSIS: Two authors independently assessed study quality, extracted data and interviewed authors of all potentially relevant studies by telephone or electronic mail to verify randomization procedures. One author entered data into a data extraction form and another author verified the results of this procedure. MAIN RESULTS: Two prospective controlled clinical trials involving 167 patients were included. All of them were of low quality. Radioiodine treatment versus ATD showed benefits in achieving euthyroidism (relative risk (RR) 1.70, 95% confidence interval (CI) 1.29 to 2.24). Radioiodine treatment showed a higher incidence of hypothyroidism compared with ATD (RR 6.46, 95% CI 1.16 to 35.81). No significant differences in modifying Graves' opthalmopathy (worsening or appearance) between radioiodine treatment and ATD (RR 1.30, 95% CI 0.56 to 3.00) were observed. No trial evaluated mortality, health related quality of life, economic outcomes or compliance with treatments. AUTHORS' CONCLUSIONS: The limited results in Chinese suggest that a gland specific lower dosage of radioiodine treatment is potentially effective for pediatric GD, but a significant higher incidence of hypothyroidism compared with ATD was observed. However, we could not identify a well-designed trial to provide strong evidence for radioiodine in the treatment of pediatric GD. High-quality randomised controlled clinical trials are needed to guide treatment choice.
World J Surg. 2008;32:1269-77
Surgical treatment of Graves' disease: evidence-based approach.
Stålberg P, Svensson A, Hessman O, Akerström G, Hellman P.
BACKGROUND: The optimal treatment of Graves disease (GD) is still controversial. Surgery is one treatment option along with radioactive iodine (RAI) and antithyroid medication. In this evidence-based review, we examine four issues:(1) Is surgery better than RAI or long-term antithyroid medication? (2) What is the recommended surgical approach? (3) How does the presence of Graves'ophthalmopathy (GO) influence the role of surgery? (4) What is the role of surgery in children with GD? METHODS: We conducted a systematic review of the literature using evidence-based criteria regarding these four issues. RESULTS: (1) There are no recommendations reaching any grade of evidence for which treatment to choose for adults with GD. (2) Total thyroidectomy has complication rates equal to those seen with lesser resections but it has higher cure rates and negligible recurrence rates (Level I-IV data leading to a grade A recommendation). (3) Data support surgery when severe GO is present, but RAI combined with glucocorticoids may be equally safe (Level II-IV data, grade B recommendation). The extent of thyroid resection does not influence the outcome of GO (Level II data, grade B recommendation). (4) Based on the available data, definitive treatment can be advocated for children (Level IV data, grade C recommendation) using either RAI or surgery. No recommendation can be given as to whether RAI or surgery is preferred owing to the lack of studies addressing this issue. Increased cancer risk with RAI in children below the age of 5 years supports surgery in this setting (Level I data, grade A recommendation). CONCLUSION: If surgery is considered for definitive management, evidence-based criteria support total thyroidectomy as the surgical technique of choice for GD. Available evidence also supports surgery in the presence of severe endocrine GO. Children with GD should be treated with an ablative strategy. Whether this is achieved by total thyroidectomy or RAI may still be debatable. Data on long-term cancer risk are missing or conflicting; and until RAI has proven harmless in children, we continue to recommend surgery in this group.
Eur J Endocrinol. 2009;160:1-8
Management of Graves' hyperthyroidism in pregnancy: focus on both maternal and foetal thyroid function, and caution against surgical thyroidectomy in pregnancy.
Laurberg P, Bournaud C, Karmisholt J, Orgiazzi J.
Graves' disease is a common autoimmune disorder in women in fertile ages. The hyperthyroidism is caused by generation of TSH-receptor activating antibodies. In pregnancy both the antibodies and the antithyroid medication given to the mother pass the placenta and affect the foetal thyroid gland. Thyroid function should be controlled not only in the mother with Graves' hyperthyroidism but also in her foetus.The review includes two cases illustrating some of the problems in managing Graves' disease in pregnancy. Major threats to optimal foetal thyroid function are inadequate or over aggressive antithyroid drug therapy of the mother. It should be taken into account that antithyroid drugs tend to block the foetal thyroid function more effectively than the maternal thyroid function, and that levothyroxin (L-T(4)) given to the mother will have only a limited effect in the foetus. Surgical thyroidectomy of patients with Graves' hyperthyroidism does not lead to immediate remission of the autoimmune abnormality, and the combination thyroidectomy+withdrawal of antithyroid medication+L-T(4) replacement of the mother involves a high risk of foetal hyperthyroidism. Conclusion Antithyroid drug therapy of pregnant women with Graves' hyperthyroidism should be balanced to control both maternal and foetal thyroid function. Surgical thyroidectomy of a pregnant woman with active disease may lead to isolated foetal hyperthyroidism.
Consensus statement of the European group on Graves' orbitopathy (EUGOGO) on management of Graves' orbitopathy.
Bartalena L, Baldeschi L, Dickinson AJ, Eckstein A, Kendall-Taylor P, Marcocci C, Mourits MP, Perros P, Boboridis K, Boschi A, Currò N, Daumerie C, Kahaly GJ, Krassas G, Lane CM, Lazarus JH, Marinò M, Nardi M, Neoh C, Orgiazzi J, Pearce S, Pinchera A, Pitz S, Salvi M, Sivelli P, Stahl M, von Arx G, Wiersinga WM.
Endocrinol Metab Clin North Am. 2009;38:373-88
Thyroid-associated orbitopathy: who and how to treat.
Dickinson J, Perros P.
Thyroid-associated orbitopathy is the most frequent and troublesome nonthyroidal complication of Graves' disease. It is mandatory to determine whether sight-threatening orbitopathy is present, as this requires prompt and aggressive treatment. Therapies for non-sight-threatening disease range from supportive measures only to medical therapies for active eye disease and surgical rehabilitation for burnt-out disease. Intravenous steroids and orbital radiotherapy are the mainstays of medical therapy. Rehabilitative surgery is frequently a staged process that may involve sequentially: orbital decompression, strabismus surgery, and eyelid procedures. Smoking cessation is recommended at all disease stages. Treatment within a multidisciplinary team consisting of both endocrinologists and ophthalmologists may lead to optimal patient outcomes.