From the Guidelines
The treatment for toxic multinodular goiter typically involves radioactive iodine therapy (RAI) as the preferred definitive treatment, with antithyroid medications and beta-blockers used initially to control hyperthyroidism and symptoms. When considering treatment options, it's essential to evaluate the thyroid morphology and function. According to the American College of Radiology 1, US is the best imaging study to evaluate thyroid morphology and can be a helpful adjunct study to a radioiodine uptake.
Treatment Approaches
- Antithyroid medications like methimazole or propylthiouracil are often used initially to control hyperthyroidism.
- Beta-blockers such as propranolol can help manage symptoms like tachycardia and tremors.
- Radioactive iodine therapy (RAI) is commonly recommended as a definitive treatment, destroying overactive thyroid tissue.
- Surgical intervention, typically total thyroidectomy, is another definitive option, especially for large goiters causing compressive symptoms, suspected malignancy, or when RAI is contraindicated.
Considerations
- Treatment choice depends on factors including patient age, goiter size, symptom severity, comorbidities, and patient preference.
- Regular monitoring of thyroid function is essential during and after treatment to ensure proper hormone levels are maintained.
- Following definitive treatment, patients usually require lifelong thyroid hormone replacement with levothyroxine 1.
From the FDA Drug Label
Methimazole tablets, USP are indicated: In patients with Graves’ disease with hyperthyroidism or toxic multinodular goiter for whom surgery or radioactive iodine therapy is not an appropriate treatment option. The treatment for toxic multinodular goiter includes methimazole for patients for whom surgery or radioactive iodine therapy is not an appropriate treatment option 2.
From the Research
Treatment Options for Toxic Multinodular Goiter
The treatment for toxic multinodular goiter (TMNG) can vary depending on several factors, including the severity of the condition, patient preferences, and the presence of contraindications to certain treatments. The following are some of the treatment options available:
- Antithyroid medications, such as methimazole (MMI) and propylthiouracil, which can help reduce the production of thyroid hormones 3
- Radioactive iodine (RAI) ablation of the thyroid gland, which can help destroy part or all of the thyroid gland and reduce hormone production 4, 5, 6
- Surgical thyroidectomy, which involves the removal of part or all of the thyroid gland 5, 7
- Ethanol ablation of toxic nodules, which can be used in patients who are unfit for surgery 5
Efficacy and Safety of Treatment Options
Studies have compared the efficacy and safety of different treatment options for TMNG. For example:
- A study published in 2019 found that long-term MMI treatment was a safe and effective method for treating TMNG, and was not inferior to RAI treatment 4
- A study published in 2022 found that long-term MMI treatment was superior to RAI treatment in achieving and maintaining euthyroidism in patients with TMNG 6
- A study published in 2008 found that surgery and RAI were both supported by level IV evidence in the treatment of solitary toxic nodules and toxic multinodular goiter, and that treatment should be determined by symptoms and co-morbidities 5
- A study published in 1998 found that surgical treatment was more effective than RAI treatment in achieving euthyroidism or hypothyroidism in patients with TMNG, but that the probability of post-treatment hypothyroidism was higher in surgically treated patients 7
Considerations for Treatment
When considering treatment options for TMNG, several factors should be taken into account, including:
- The severity of the condition and the presence of symptoms or co-morbidities 5
- The patient's preferences and values 3
- The potential risks and benefits of each treatment option, including the risk of hypothyroidism or other complications 4, 6, 7
- The availability and accessibility of different treatment options 5