What are the treatment options for hyperthyroidism?

From the Guidelines

Hyperthyroidism treatment typically involves medications, radioactive iodine therapy, or surgery depending on the cause, severity, and patient factors. The first-line treatment is often anti-thyroid medications such as methimazole (starting at 10-30 mg daily) or propylthiouracil (PTU, 100-300 mg daily in divided doses), which block thyroid hormone production. These medications are usually taken for 12-18 months, with regular monitoring of thyroid function every 4-6 weeks initially, then every 2-3 months. Beta-blockers like propranolol (10-40 mg, 3-4 times daily) can be added to control symptoms such as rapid heart rate and tremors while waiting for anti-thyroid medications to take effect, as noted in the study 1. For definitive treatment, radioactive iodine (RAI) therapy is often recommended, which destroys thyroid tissue and typically leads to hypothyroidism requiring lifelong levothyroxine replacement. Thyroidectomy (surgical removal of the thyroid) is another definitive option, particularly for patients with large goiters, suspected cancer, or pregnancy planning. Treatment choice depends on the underlying cause of hyperthyroidism, with Graves' disease often responding well to all three approaches, while toxic nodules may be better treated with RAI or surgery. Some key points to consider in hyperthyroidism treatment include:

• The use of anti-thyroid medications as the first line of treatment
• The addition of beta-blockers to control symptoms
• The role of RAI therapy and thyroidectomy as definitive treatment options
• The importance of monitoring for potential side effects of anti-thyroid medications, including rash, liver problems, and rare but serious agranulocytosis (drop in white blood cells), and seeking immediate medical attention if fever, sore throat, or unusual infections develop. It's also important to note that the optimal screening interval for thyroid dysfunction is unknown, and the USPSTF found no direct evidence that treatment of thyroid dysfunction based on risk level alters final health outcomes, as mentioned in the studies 1. However, the most recent study 1 provides guidance on the use of beta-blockers in patients with thyrotoxicosis, hyperthyroidism, thyroiditis, and Graves’ disease.

From the FDA Drug Label

Propylthiouracil is indicated: in patients with Graves’ disease with hyperthyroidism or toxic multinodular goiter who are intolerant of methimazole and for whom surgery or radioactive iodine therapy is not an appropriate treatment option. Propylthiouracil is a prescription medicine used to treat people who have Graves’ disease with hyperthyroidism or toxic multinodular goiter.

Hyperthyroidism Treatment: Propylthiouracil is used to treat hyperthyroidism in patients with Graves’ disease or toxic multinodular goiter who are intolerant of methimazole and for whom surgery or radioactive iodine therapy is not an appropriate treatment option 2.

• It is used to decrease symptoms of hyperthyroidism in preparation for a thyroidectomy or radioactive iodine therapy.
• Propylthiouracil may be used when an antithyroid drug is needed during or just before the first trimester of pregnancy 2.

From the Research

Hyperthyroid Treatment Options

• Hyperthyroidism can be treated with antithyroid medications, radioactive iodine ablation of the thyroid gland, or surgical thyroidectomy 3
• The choice of treatment depends on the underlying diagnosis, the presence of contraindications to a particular treatment modality, the severity of hyperthyroidism, and the patient's preference 3

Antithyroid Medications

• Methimazole (MMI) and propylthiouracil (PTU) are the main antithyroid drugs used for hyperthyroidism 4
• MMI is the drug of choice due to its widespread availability, longer half-life, and small number of severe side effects 4
• Other medications that can be used as second-choice options include potassium perchlorate, beta blockers, iodine, lithium carbonate, and glucocorticoids 4

Radioiodine Therapy

• Radioiodine therapy is a method used in primary hyperthyroidism, based on short-range beta radiation emitted from radioactive iodine 5
• Indications for radioiodine therapy include recurrent hyperthyroidism after thyrostatic treatment or thyroidectomy, and side-effects observed during thyrostatic treatment 5
• Absolute contraindications for radioiodine treatment are pregnancy and lactation, while relative contraindications include thyroid nodules suspected of malignancy and age under 15 years 5

Considerations for Radioiodine Therapy

• Radioiodine therapy may increase the inflammatory process and exacerbate ophthalmological symptoms in patients with Graves-Basedow disease and thyroid-associated orbitopathy 5
• However, thyroid-associated orbitopathy cannot be considered as a contraindication for isotope therapy 5
• The potential carcinogenic properties of radioiodine have not been confirmed 5