From the FDA Drug Label
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 patient's management should be surgery, considering the patient has a history of toxic nodular goiter and is not taking antithyroid drugs regularly. The options for surgery are:
- Total thyroidectomy
- Near total thyroidectomy Given the patient's non-adherence to medication and symptoms of hyperthyroidism (palpitations, tachycardia, and low TSH), a more definitive treatment approach is necessary. Between the two surgical options, near total thyroidectomy is often preferred to preserve some thyroid function, but the choice ultimately depends on the patient's specific condition and surgical considerations 1.
From the Research
The patient with toxic nodular goiter who is non-adherent to antithyroid medication and presents with palpitations, tachycardia, and low TSH should be considered for definitive treatment with radioactive iodine therapy (RAI) or thyroidectomy, as these options are more effective in achieving long-term remission and improving quality of life compared to continued antithyroid medication 2. The management of this patient requires a comprehensive approach, including:
- Restarting antithyroid medications such as methimazole or propylthiouracil to block thyroid hormone synthesis
- Adding a beta-blocker like propranolol or metoprolol to control sympathetic symptoms including palpitations and tachycardia
- Considering definitive treatment with RAI or thyroidectomy, as these options are more effective in achieving long-term remission and improving quality of life compared to continued antithyroid medication
- Ensuring the patient is euthyroid prior to definitive treatment to prevent thyroid storm
- Addressing adherence issues through education about the serious consequences of untreated hyperthyroidism, including atrial fibrillation, heart failure, and osteoporosis
- Considering monthly follow-up appointments with TSH, free T4, and free T3 monitoring until stable, then every 3-6 months
- Lifelong thyroid function monitoring is necessary as hypothyroidism commonly develops, requiring levothyroxine replacement. Some key points to consider in the management of this patient include:
- The patient's non-adherence to antithyroid medication increases the risk of complications and reduces the effectiveness of treatment
- Definitive treatment with RAI or thyroidectomy can provide long-term remission and improve quality of life
- The choice between RAI and thyroidectomy depends on individual patient factors, including age, comorbidities, and patient preference
- Therapeutic plasma exchange (TPE) may be considered in patients with contraindication or unresponsiveness to antithyroid drugs, as it can reduce thyroid hormones and improve symptoms 3.