What is the next step in managing a patient with Graves' disease on Neomercazole (Carbimazole) 10 mg bd and Ciplar LA (Propranolol) 40 mg od who develops nasal regurgitation of food and increased thyroid swelling?

Management of Graves' Disease Patient with Nasal Regurgitation and Increased Thyroid Swelling

The patient with Graves' disease presenting with nasal regurgitation of food and increased thyroid swelling should be urgently referred to an endocrinologist for evaluation of thyroid storm and possible compressive symptoms requiring surgical intervention.

Assessment of Current Situation

The patient's presentation raises several concerning issues:

1. Nasal regurgitation of food:

   • This symptom suggests potential neuromuscular dysfunction which can be a rare but documented manifestation of severe hyperthyroidism 1
   • May indicate compression of esophageal structures by an enlarging goiter

2. Increased thyroid swelling:

   • Suggests potential treatment failure or disease progression despite current therapy
   • May indicate development of compressive symptoms requiring urgent intervention

3. Current medication regimen:

   • Neomercazole (Carbimazole) 10 mg twice daily - standard antithyroid medication
   • Ciplar LA (Propranolol) 40 mg once daily - beta-blocker for symptom control

Immediate Management Steps

1. Assess for thyroid storm/crisis:

   • Check vital signs (tachycardia, fever, hypertension)
   • Evaluate for altered mental status, heart failure, or GI symptoms
   • Order immediate thyroid function tests (TSH, free T4, free T3)

2. Evaluate for compressive symptoms:

   • Assess for dysphagia, dyspnea, hoarseness, stridor
   • If severe compressive symptoms present, consider emergency imaging (CT/MRI neck)

3. Medication adjustment:

   • Increase Carbimazole dose to 30-40 mg daily as the current dose may be insufficient 2, 3
   • Consider single daily dosing for better compliance 2
   • Continue Propranolol for symptom control

Further Management Based on Severity

If Thyroid Storm Suspected:

• Hospitalize immediately
• Increase Carbimazole to higher doses (up to 60-80 mg/day)
• Increase beta-blocker dose
• Consider adding corticosteroids (prednisolone 20-40 mg/day) 4
• Supportive care with IV fluids, cooling if febrile

If Compressive Symptoms Present:

• Urgent surgical consultation for possible thyroidectomy
• Consider radioactive iodine as definitive treatment once stabilized

If Medication Resistance Suspected:

• Trial of higher dose Carbimazole (up to 75 mg/day) 4
• Consider adding prednisolone temporarily (20 mg/day for 2 weeks, then taper) 4
• Plan for definitive treatment (radioactive iodine or surgery)

Monitoring and Follow-up

• Recheck thyroid function tests within 1-2 weeks
• Monitor for medication side effects, particularly with increased doses:
  • Complete blood count to check for neutropenia
  • Liver function tests
• Schedule follow-up within 2 weeks to assess response

Potential Pitfalls and Considerations

1. Medication side effects:

   • Higher doses of Carbimazole increase risk of side effects 3
   • Monitor for agranulocytosis, hepatotoxicity, and skin reactions
   • Warn patient to report sore throat, fever, or jaundice immediately

2. Differential diagnosis:

   • Consider other causes of nasal regurgitation (neurological disorders, myasthenia gravis)
   • Evaluate for concurrent autoimmune conditions that may affect swallowing

3. Long-term planning:

   • If patient fails to respond to increased medical therapy, definitive treatment with radioactive iodine or surgery should be considered
   • The American Thyroid Association recommends definitive treatment for patients with persistent or recurrent hyperthyroidism 5

4. Special considerations:

   • If the patient is pregnant or planning pregnancy, management approach would need modification
   • Elderly patients or those with cardiac conditions require careful dose adjustments

Regular thyroid function monitoring is essential, with tests every 4-6 weeks until stable, then every 3-6 months 5.