What are the treatment options for managing hyperthyroidism?

Management of Hyperthyroidism

The primary treatment options for hyperthyroidism include antithyroid medications (thionamides), radioactive iodine ablation, and surgery (thyroidectomy), with the choice depending on the underlying cause, patient factors, and disease severity. 1

Diagnosis and Evaluation

• Confirm hyperthyroidism with:
  • Thyroid function tests: Low TSH, elevated free T4 and/or free T3 1
  • Consider TSH receptor antibody testing if Graves' disease is suspected 2
  • Thyroid ultrasound and/or radioactive iodine uptake scan to determine etiology 1

Treatment Options Based on Etiology

1. Graves' Disease (70% of hyperthyroidism cases) 3

• First-line treatment: Antithyroid drugs (thionamides)
  • Methimazole (preferred) or propylthiouracil (PTU)
  • PTU should be reserved for patients who cannot tolerate methimazole or during first trimester of pregnancy 4
  • Treatment duration: 12-18 months (standard course) 3
  • Long-term treatment (5-10 years) associated with fewer recurrences (15% vs 50%) 3
• Second-line options (if recurrence after medication or contraindications):
  • Radioactive iodine ablation (avoid in patients with significant ophthalmopathy) 5
  • Total thyroidectomy 5

2. Toxic Nodular Goiter/Toxic Adenoma (16% of cases) 3

• Preferred treatments:
  • Radioactive iodine ablation
  • Surgery (total thyroidectomy for multinodular goiter; lobectomy for single toxic adenoma) 5
• Antithyroid medications typically used as preparation for definitive treatment 5

3. Thyroiditis (3% of cases) 3

• Supportive care for mild cases
• Beta-blockers for symptomatic relief
• Monitor for transition to hypothyroidism 2
• Steroids only in severe cases 3

Symptomatic Management

• Beta-blockers (propranolol or atenolol/metoprolol) for cardiovascular symptoms (tachycardia, palpitations) 6, 2
• In symptomatic hyperthyroidism, interrupt any immune checkpoint inhibitor therapy if applicable 6

Special Considerations

Pregnancy

• Propylthiouracil preferred in first trimester due to lower risk of birth defects 4
• Switch to methimazole after first trimester 4
• Surgery may be considered in select cases 5

Elderly Patients

• Treatment recommended even for subclinical hyperthyroidism in patients >65 years due to increased risk of osteoporosis and cardiovascular disease 1
• More aggressive management of cardiovascular symptoms with beta-blockers 5

Thyroid Storm (Medical Emergency)

• Requires multidisciplinary approach 5
• Treatment includes:
  • High-dose antithyroid drugs
  • Beta-blockers
  • Corticosteroids
  • Supportive care
  • Definitive treatment of hyperthyroidism once stabilized 5

Monitoring and Follow-up

• Monitor thyroid function every 2-3 weeks initially, then regularly during treatment 2
• For patients on antithyroid medications, monitor for side effects including:
  • Severe liver injury (fever, loss of appetite, nausea, abdominal pain, dark urine, jaundice) 4
  • Low white blood cell counts (fever, sore throat) 4
  • Vasculitis (skin changes, abnormal urine, breathing difficulties) 4

Treatment Complications

• Antithyroid medications: Risk of liver injury, agranulocytosis, vasculitis 4
• Radioactive iodine: Risk of permanent hypothyroidism, potential concern for secondary cancers 5
• Surgery: Risks include hypoparathyroidism, recurrent laryngeal nerve injury 5

Long-term Prognosis

Untreated hyperthyroidism is associated with increased mortality, cardiac arrhythmias, heart failure, osteoporosis, and adverse pregnancy outcomes. Prognosis improves with rapid and sustained control of hyperthyroidism 3, 1.