What are the management options for hyperthyroidism?

Management of Hyperthyroidism

Start beta-blockers immediately for all symptomatic patients with hyperthyroidism, then determine the underlying etiology to guide definitive treatment—antithyroid drugs for Graves' disease, radioactive iodine for toxic nodular goiter, or supportive care for self-limited thyroiditis. 1

Immediate Symptomatic Management

All symptomatic patients require beta-blockade as first-line therapy regardless of etiology. 1

• Atenolol or propranolol should be initiated immediately for symptomatic relief, particularly in patients with cardiovascular manifestations including tachycardia, palpitations, hypertension, and anxiety 2, 1
• Beta-blockers are essential for rate control in patients presenting with atrial fibrillation secondary to hyperthyroidism 1
• Non-dihydropyridine calcium channel blockers (diltiazem or verapamil) are alternatives when beta-blockers are contraindicated 1

Diagnostic Workup to Guide Definitive Treatment

Confirm biochemical hyperthyroidism first, then establish the specific etiology:

• Measure TSH (suppressed), free T4, and free T3 to confirm hyperthyroidism 3, 4
• TSH receptor antibodies distinguish Graves' disease from other causes 1, 3
• Thyroid ultrasound identifies nodular disease 3
• Thyroid scintigraphy is recommended if nodules are present or etiology is unclear 4

Definitive Treatment Based on Etiology

Graves' Disease (Most Common: 70% of Cases)

Antithyroid drugs are the preferred initial treatment for Graves' disease. 3

• Methimazole is the antithyroid drug of choice (propylthiouracil is reserved for first trimester pregnancy or thyroid storm) 5, 6, 3
• Standard course is 12-18 months, though approximately 50% of patients experience recurrence after discontinuation 3, 4
• Long-term antithyroid drug therapy (5-10 years) reduces recurrence rates to 15% and is a viable option for select patients 3
• Risk factors for recurrence include: age <40 years, FT4 ≥40 pmol/L, TSH-binding inhibitory immunoglobulins >6 U/L, and goiter size ≥WHO grade 2 3

Radioactive iodine (¹³¹I) is the most widely used definitive treatment in the United States but should be avoided in patients with Graves' ophthalmopathy as it may worsen eye disease 7, 6, 8

• Contraindicated in pregnancy and lactation; pregnancy should be avoided for 4 months post-treatment 7
• The only long-term sequela is radioiodine-induced hypothyroidism 7
• Recent studies raise concern for increased secondary cancer risk 8

Surgery (total thyroidectomy) is indicated for:

• Concurrent thyroid cancer 8
• Pregnancy when antithyroid drugs fail or are contraindicated 8
• Large goiters causing compressive symptoms 7, 8
• Graves' ophthalmopathy (where radioiodine is contraindicated) 8
• Patient refusal of radioiodine 7

Toxic Nodular Goiter (16% of Cases)

Radioactive iodine is the treatment of choice for toxic nodular goiter. 7, 3

• Antithyroid drugs do not cure toxic nodular goiter and are used only for temporary control before definitive therapy 7
• Surgery (total thyroidectomy for multinodular goiter, lobectomy for solitary toxic adenoma) is an alternative 8
• Radiofrequency ablation is rarely used 3

Destructive Thyroiditis (3% of Cases)

Destructive thyroiditis is self-limited and resolves within weeks with supportive care alone. 1, 3

• Beta-blockers provide symptomatic relief during the hyperthyroid phase 2, 1
• Monitor thyroid function every 2-3 weeks to detect transition to hypothyroidism, which is the most common outcome 2, 1
• Steroids are reserved only for severe cases 3
• Persistent thyrotoxicosis beyond 6 weeks warrants endocrine consultation 2

Severity-Based Management Algorithm

Grade 1-2 (Asymptomatic or Mild Symptoms)

• Continue immune checkpoint inhibitors if applicable 2
• Start beta-blocker for symptomatic relief 2
• Monitor thyroid function every 2-3 weeks 2

Grade 2 (Moderate Symptoms, Able to Perform ADL)

• Consider holding immune checkpoint inhibitors until symptoms resolve 2
• Beta-blocker therapy 2
• Endocrine consultation recommended 2
• Hydration and supportive care 2

Grade 3-4 (Severe or Life-Threatening)

Hospitalization is mandatory for severe hyperthyroidism. 2, 1

• Hold immune checkpoint inhibitors until symptoms resolve 2
• Endocrine consultation is mandatory 2, 1
• Beta-blocker, hydration, and supportive care 2, 1
• Consider additional therapies: steroids, SSKI (saturated solution of potassium iodide), or thionamides (methimazole or propylthiouracil) 2, 1
• Surgery may be necessary in refractory cases 2

Special Considerations

Hyperthyroidism with Atrial Fibrillation

• Beta-blockers are essential for rate control 1
• Anticoagulation decisions should be guided by CHA₂DS₂-VASc score, not hyperthyroidism status alone 1

Preoperative Preparation

• Patients must be rendered euthyroid with antithyroid medications before surgery 8
• Continue beta-blockers perioperatively for cardiovascular manifestations 8

Common Pitfalls

• Do not use radioactive iodine in Graves' ophthalmopathy—it worsens eye disease 8
• Do not assume all hyperthyroidism requires definitive ablative therapy—thyroiditis is self-limited 1, 3
• Do not delay beta-blocker initiation while awaiting etiology workup—symptomatic control is immediate priority 1