Management of Hyperthyroidism: Multiple Choice Questions
Question 1: First-Line Antithyroid Drug Selection
Which antithyroid drug is preferred as first-line therapy for most patients with hyperthyroidism?
A. Propylthiouracil throughout treatment
B. Methimazole, except in first trimester pregnancy
C. Radioactive iodine immediately
D. Beta-blockers alone
Correct Answer: B
Methimazole is the preferred first-line antithyroid drug due to superior efficacy and safety profile, with propylthiouracil reserved for the first trimester of pregnancy. 1 Propylthiouracil carries a black box warning for severe liver injury and acute liver failure, including cases requiring liver transplantation and death, and should only be used when patients cannot tolerate methimazole or when radioactive iodine therapy or surgery are inappropriate. 2 During pregnancy, propylthiouracil is preferred in the first trimester, with the goal of maintaining FT4 in the high-normal range using the lowest possible thioamide dosage. 3
Question 2: Symptomatic Management
A 35-year-old woman presents with newly diagnosed hyperthyroidism, tachycardia at 110 bpm, and tremor. What is the most appropriate initial symptomatic management while awaiting thyroid hormone normalization?
A. Immediate radioactive iodine therapy
B. Beta-blockers such as atenolol 25-50 mg daily or propranolol
C. Corticosteroids
D. Observation only
Correct Answer: B
Beta-blockers provide essential symptomatic relief for tachycardia and tremor while waiting for antithyroid medications to take effect. 3, 1 Beta-blockers such as atenolol 25-50 mg daily or propranolol are recommended for symptomatic relief in patients with hyperthyroidism, particularly those with cardiac symptoms. 3 They can be used until thioamide therapy reduces thyroid hormone levels to the therapeutic range. 3 This approach has a high strength of evidence and is recommended by multiple professional societies. 3
Question 3: Thyroiditis-Induced Hyperthyroidism
A patient presents with hyperthyroidism due to destructive thyroiditis. Which treatment approach is most appropriate?
A. Methimazole 15 mg three times daily
B. Immediate thyroidectomy
C. Beta-blockers for symptom management without antithyroid drugs
D. High-dose propylthiouracil
Correct Answer: C
Thyroiditis-induced hyperthyroidism is self-limited and requires symptom management with beta-blockers rather than antithyroid drugs. 3 Destructive thyroiditis typically resolves in weeks with supportive care alone, focusing on beta-blockers for symptomatic relief with no indication for antithyroid drugs. 1 Most patients transition to primary hypothyroidism, requiring close monitoring and eventual thyroid hormone replacement. 3 Antithyroid drugs are ineffective because thyroiditis involves passive release of preformed thyroid hormones rather than increased synthesis. 1
Question 4: Radioactive Iodine Therapy Contraindications
In which clinical scenario is radioactive iodine therapy absolutely contraindicated?
A. Male patient age 45
B. Pregnant patient
C. Patient with mild ophthalmopathy
D. Patient with toxic multinodular goiter
Correct Answer: B
Radioactive iodine therapy is absolutely contraindicated during pregnancy and lactation. 3 Pregnancy should be avoided for 4 months following radioactive iodine administration. 4 Patients who undergo radioactive iodine therapy often develop hypothyroidism requiring lifelong thyroid hormone replacement, with a high strength of evidence. 3 Radioactive iodine may cause deterioration in Graves' ophthalmopathy, and corticosteroid cover may reduce this risk. 4
Question 5: Surgical Indications
Which patient scenario represents the strongest indication for thyroidectomy?
A. Mild Graves' disease in a compliant patient
B. Large goiter with compressive symptoms and suspicious nodules
C. Subclinical hyperthyroidism
D. Thyroiditis with mild symptoms
Correct Answer: B
Near-total or total thyroidectomy is recommended for patients with large goiters, suspicious nodules, or severe ophthalmopathy. 3 Surgery has specific but limited roles in hyperthyroidism management, particularly when there is a large goiter causing compression symptoms in the neck or when radioactive iodine has been refused. 4 Thyroidectomy requires lifelong thyroid hormone replacement post-surgery with high strength of evidence. 3 The goal is to cure the underlying pathology while addressing compressive symptoms. 4
Question 6: Severe Hyperthyroidism Management
A patient presents to the emergency department with severe hyperthyroidism/thyroid storm. What is the most appropriate management approach?
A. Outpatient beta-blockers and follow-up in one week
B. Mandatory hospitalization with beta-blockers, high-dose antithyroid drugs, hydration, supportive care, and consideration of steroids
C. Observation only
D. Immediate thyroidectomy without medical stabilization
Correct Answer: B
Severe hyperthyroidism or thyroid storm requires hospitalization and aggressive management, including beta-blockers, high-dose antithyroid drugs, and supportive care. 3 Mandatory hospitalization and endocrine consultation are required, with aggressive management using beta-blockers, high-dose antithyroid drugs, hydration, and supportive care, plus consideration of additional therapies including steroids, SSKI, or possible surgery. 3 This has a high strength of evidence level and represents a medical emergency requiring immediate intervention. 3
Question 7: Monitoring Frequency
What is the recommended initial monitoring frequency for thyroid function tests after starting antithyroid drug therapy?
A. Every 12 months
B. Every 6 months
C. Every 4-6 weeks initially, then every 2-4 weeks during pregnancy
D. No monitoring needed if asymptomatic
Correct Answer: C
Regular monitoring of thyroid function tests is necessary, with initial monitoring every 4-6 weeks, and dose adjustments based on clinical response and laboratory values. 3 During pregnancy, FT4 or FTI should be monitored every 2-4 weeks. 3 Long-term follow-up is necessary even after successful treatment due to the risk of recurrence or development of hypothyroidism, with high strength of evidence. 3
Question 8: Propylthiouracil Safety Monitoring
A patient on propylthiouracil develops fever, sore throat, and chills. What is the most concerning potential complication?
A. Hypothyroidism
B. Agranulocytosis with low white blood cell counts
C. Weight gain
D. Mild fatigue
Correct Answer: B
Low white blood cell counts (agranulocytosis) usually occur within the first 3 months of propylthiouracil treatment and can be life-threatening. 2 Patients have a higher chance of getting infections when white blood cell count is low, and should call their doctor immediately if they develop symptoms of infection such as fever, chills, or sore throat. 2 Thioamide side effects requiring immediate discontinuation include agranulocytosis, hepatitis, vasculitis, and thrombocytopenia. 3 This represents a critical safety consideration requiring immediate medical attention. 2
Question 9: Drug Interactions
A patient on warfarin is started on methimazole for hyperthyroidism. What adjustment is most likely needed?
A. No adjustment necessary
B. Warfarin dose reduction due to increased anticoagulation effect
C. Warfarin dose increase
D. Discontinue warfarin completely
Correct Answer: B
Warfarin dose adjustments are needed due to increased anticoagulation effect when taking antithyroid drugs. 1 Beta-blockers may need dose reduction when the patient becomes euthyroid, and theophylline clearance decreases when euthyroid. 1 Patients should inform their doctors about all medications they take, especially blood thinners like warfarin, as antithyroid drugs may affect how other medicines work. 2
Question 10: Pregnancy Management
A woman with hyperthyroidism becomes pregnant during her first trimester. Which antithyroid drug should be used?
A. Methimazole throughout pregnancy
B. Propylthiouracil during first trimester, then consider switching to methimazole
C. No antithyroid drugs during pregnancy
D. Radioactive iodine immediately
Correct Answer: B
Propylthiouracil is preferred during the first trimester of pregnancy when an antithyroid drug is indicated. 2 Propylthiouracil may be the treatment of choice when an antithyroid drug is indicated during or just prior to the first trimester of pregnancy, though it carries risks of liver problems and potential harm to the unborn baby. 2 The goal is maintaining FT4 in the high-normal range using the lowest possible thioamide dosage, with monitoring every 2-4 weeks during pregnancy. 3 Women treated with propylthiouracil or methimazole can breastfeed safely. 3