From the Guidelines
Hyperthyroidism treatment should involve anti-thyroid medications, such as methimazole, or nonreversible thyroid ablation therapy, like radioactive iodine or surgery, particularly for patients with a TSH level that is undetectable or less than 0.1 mIU/L, especially those with overt Graves disease or nodular thyroid disease 1.
Treatment Options
- Anti-thyroid medications: methimazole (10-30 mg daily) or propylthiouracil (100-300 mg daily divided into multiple doses) are often first-line treatments, working by blocking thyroid hormone production.
- Radioactive iodine therapy: a single oral dose that selectively destroys overactive thyroid tissue, commonly used for definitive treatment.
- Surgery: thyroidectomy may be recommended for patients with large goiters, pregnant women who cannot tolerate anti-thyroid medications, or those with suspected thyroid cancer.
Symptomatic Relief
- Beta-blockers, such as propranolol (20-40 mg 3-4 times daily), can provide relief from palpitations, tremors, and anxiety while waiting for anti-thyroid medications to take effect, especially in patients with thyrotoxicosis, hyperthyroidism, thyroiditis, and Graves’ disease 1.
Considerations
- Treatment choice depends on the patient's age, pregnancy status, severity of hyperthyroidism, and underlying cause, with Graves' disease, toxic nodular goiter, and thyroiditis each potentially requiring different approaches.
- Following radioactive iodine or surgery, many patients develop hypothyroidism and require lifelong thyroid hormone replacement with levothyroxine.
From the FDA Drug Label
Once clinical evidence of hyperthyroidism has resolved, the finding of an elevated serum TSH indicates that a lower maintenance dose of propylthiouracil should be employed. The treatment for hyperthyroidism with propylthiouracil involves:
- Monitoring thyroid function tests periodically during therapy
- Adjusting the dose based on the results of these tests, with the goal of achieving a euthyroid state
- Considering a lower maintenance dose when clinical evidence of hyperthyroidism has resolved and serum TSH is elevated Key considerations for treatment include:
- Close surveillance of patients for signs of illness, particularly sore throat, skin eruptions, fever, headache, or general malaise
- Monitoring for symptoms of hepatic dysfunction, such as anorexia, pruritus, jaundice, and right upper quadrant pain
- Adjusting the dose of propylthiouracil as needed to minimize the risk of adverse effects 2 2
From the Research
Hyperthyroidism Treatment Options
- Hyperthyroidism can be treated with antithyroid medications, radioactive iodine ablation of the thyroid gland, or surgical thyroidectomy 3
- The choice of treatment depends on the underlying diagnosis, the presence of contraindications to a particular treatment modality, the severity of hyperthyroidism, and the patient's preference 3
- Radioactive iodine ablation is the most widely used treatment in the United States 3
Antithyroid Medications
- Methimazole and propylthiouracil are the cornerstones in the management of Graves' disease 4
- Antithyroid drugs can be used as the primary treatment for hyperthyroidism or as preparative therapy before radioiodine treatment or surgery 4
- Methimazole is the drug of choice because major side effects are less common, it can be used as a single dose, it's less expensive, and more available 4
- Propylthiouracil is recommended for the treatment of hyperthyroidism in pregnancy due to the potential association between methimazole and congenital anomalies 4
Comparison of Methimazole and Propylthiouracil
- A study comparing methimazole and propylthiouracil in patients with hyperthyroidism caused by Graves' disease found that methimazole 30 mg/d normalized serum free T4 in more patients than propylthiouracil 300 mg/d and methimazole 15 mg/d 5
- Methimazole 15 mg/d is suitable for mild and moderate Graves' disease, whereas methimazole 30 mg/d is advisable for severe cases 5
- Propylthiouracil is not recommended for initial use due to higher adverse effects, especially mild hepatotoxicity 5
Treatment Considerations
- Treatment options for overt hyperthyroidism from autonomous thyroid nodules or Graves' disease include antithyroid drugs, radioactive iodine ablation, and surgery 6
- Treatment for subclinical hyperthyroidism is recommended for patients at highest risk of osteoporosis and cardiovascular disease, such as those older than 65 years or with persistent serum thyrotropin level less than 0.1 mIU/L 6
- Surgery should be considered for those who have a concurrent cancer, in pregnancy, for compressive symptoms, and in Graves' disease with ophthalmic manifestations 7