Toxic multinodular goiter medical therapy: Difference between revisions
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*physical examination including vitals as pulse rate and respiratory rate | *physical examination including vitals as pulse rate and respiratory rate | ||
===Pharmacological drug therapy===<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> | === Pharmacological drug therapy === | ||
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> | |||
* '''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> | *'''Toxic Multinodular Goiter''' | ||
** 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) | ** '''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> | ||
** 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) | *** 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'''<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 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'''<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'''(patients with dibeties malletis, heart failure or CNS abnormality)''' | |||
*** Alternative regimen (1): Methimazole 5-10 mg q24h PO for long term to avoid remission with 3 month review of TSH'''(patients with dibeties malletis, heart failure or CNS abnormality)''' | |||
** '''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 | |||
==References== | ==References== | ||
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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:
- Thyroid storm
- Overt hyperthyroidism
- Hyperthyroidism with CVS complications
- Hyperthyroidism with CNS complications
- Elderly patients
- Patient with coexisting cardiac condition
Following are medicine used in symtopatic managmen of TMG:
- Propanolol
- Atenolol
- Metoprolol
- Nadolol
- Esmolol
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
Following are antithyroid medicines used in management of TMG:
- Propylthiouracil
- Methimazole
Treatment of TMG is based on:
- Treatment 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
Pharmacological drug therapy
Pharmacological medical therapy for toxic multinodular goiter is primarily based on beta blockers and anti-thyroid drugs.[1]
- Toxic Multinodular Goiter
- Thyroid storm[2]
- 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[3]
- 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[4]
- Preferred regimen (1): Propylthiouracil 5-10 mg q24h PO for long term to avoid remission with 3 month review of TSH(patients with dibeties malletis, heart failure or CNS abnormality)
- Alternative regimen (1): Methimazole 5-10 mg q24h PO for long term to avoid remission with 3 month review of TSH(patients with dibeties malletis, heart failure or CNS abnormality)
- 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[2]
References
- ↑ 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.
- ↑ 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.
- ↑ 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.
- ↑ Becker DV, Hurley JR (1971). "Complications of radioiodine treatment of hyperthyroidism". Semin Nucl Med. 1 (4): 442–60. PMID 4107462.