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:

  • 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

Pharmacologic medical therapy for toxic multinodular goiter mainly depends on beta blockers and anti-thyroid drugs.

  • Thyroid storm
    • 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
    • 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
    • Preferred regimen (1): drug name 100 mg PO q12h for 10-21 days (Contraindications/specific instructions)
    • Preferred regimen (2): drug name 500 mg PO q8h for 14-21 days
    • Preferred regimen (3): drug name 500 mg q12h for 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
  • Subclinical hyperthyroidism without comorbid conditions
    • Preferred regimen (1): drug name 100 mg PO q12h for 10-21 days (Contraindications/specific instructions)
    • Preferred regimen (2): drug name 500 mg PO q8h for 14-21 days
    • Preferred regimen (3): drug name 500 mg q12h for 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

References

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