What is the management for a patient with a history of toxic nodular goiter, non-adherent to antithyroid medication, presenting with palpitations and tachycardia, and a Thyroid-Stimulating Hormone (TSH) level of 0.2?

Management of Toxic Nodular Goiter with Poor Medication Adherence

Total thyroidectomy is the most appropriate management for this patient with toxic nodular goiter who has demonstrated poor medication adherence, presenting with palpitations, tachycardia, and a suppressed TSH of 0.2. 1, 2

Assessment of Current Status

• The patient presents with classic symptoms of hyperthyroidism (palpitations and tachycardia) and laboratory evidence of thyrotoxicosis (TSH 0.2), indicating inadequate control of the toxic nodular goiter 1
• Poor adherence to antithyroid medications is a critical factor in this case, suggesting that medical management alone is unlikely to be successful long-term 3
• Toxic multinodular goiter (TMNG) represents autonomous thyroid function that will persist despite attempts at medical management 1

Treatment Options Analysis

Option A: Total Thyroidectomy

• Total thyroidectomy provides definitive treatment for toxic multinodular goiter, eliminating the source of excess thyroid hormone production 2
• This approach prevents recurrence of thyrotoxicosis and eliminates the need for long-term medication adherence, which has already proven problematic for this patient 2
• Studies show that total thyroidectomy achieves permanent resolution of hyperthyroidism in 100% of patients with toxic multinodular goiter 2
• Complication rates for total thyroidectomy are comparable to less extensive procedures when performed by experienced surgeons 2

Option B: Near-Total Thyroidectomy

• Near-total thyroidectomy achieves hypothyroidism in approximately 92% of patients with toxic multinodular goiter 2
• This approach carries similar complication risks as total thyroidectomy but may leave small remnants of thyroid tissue 2
• While effective, it offers no significant advantage over total thyroidectomy in this non-adherent patient 2

Option C: Antithyroid Drugs for 18 Months

• Continuing antithyroid drugs (methimazole) would require strict adherence, which this patient has already demonstrated difficulty with 3
• Methimazole can effectively control hyperthyroidism but does not provide definitive cure for toxic multinodular goiter 3
• Antithyroid medications are typically used as preparation for more definitive therapy rather than as long-term management for toxic nodular goiter 4
• Poor medication adherence increases the risk of fluctuating thyroid hormone levels, which can lead to cardiac complications 1

Rationale for Recommendation

Total thyroidectomy is the optimal choice for this patient because:

1. It addresses the fundamental issue of medication non-adherence by eliminating the need for daily antithyroid drugs 2
2. It provides definitive treatment for the toxic nodular goiter, preventing recurrent episodes of thyrotoxicosis 2, 5
3. It eliminates the risk of future cardiac complications from uncontrolled hyperthyroidism, which is particularly important given the patient's current presentation with palpitations and tachycardia 6
4. Studies have demonstrated that total thyroidectomy is safe and effective for toxic multinodular goiter, with complication rates similar to less extensive procedures 2

Preoperative Considerations

• The patient should be rendered euthyroid with antithyroid medications before surgery to reduce perioperative risks 7
• Beta-blockers (such as propranolol) should be administered to control tachycardia and other adrenergic symptoms 6
• Thyroid ultrasound should be performed to assess the size and extent of the goiter 1
• Evaluation for potential airway compression may be warranted if the goiter is large 5

Postoperative Management

• Lifelong levothyroxine replacement therapy will be required after total thyroidectomy 2
• TSH levels should be monitored to maintain euthyroidism, with the goal of keeping TSH in the normal range 2
• Calcium levels should be monitored immediately after surgery due to the risk of hypoparathyroidism 7
• Patient education regarding the importance of adherence to thyroid hormone replacement is essential 2

Common Pitfalls to Avoid

• Continuing medical therapy despite documented poor adherence, which risks recurrent episodes of thyrotoxicosis 3, 5
• Performing subtotal thyroidectomy, which has a higher rate of recurrent hyperthyroidism (up to 34%) compared to total or near-total thyroidectomy 2
• Inadequate preoperative preparation, which can increase the risk of thyroid storm during surgery 7
• Failure to recognize that toxic multinodular goiter represents autonomous thyroid function that will not resolve spontaneously 4