What are the treatment options for a patient with hyperthyroidism?

Treatment Options for Hyperthyroidism

Immediate Symptomatic Management

Start beta-blockers immediately for all patients with symptomatic hyperthyroidism to control cardiac manifestations and adrenergic symptoms while initiating diagnostic workup and definitive treatment. 1

• Atenolol 25-50 mg daily is the preferred beta-blocker to achieve a heart rate below 90 bpm (if blood pressure tolerates), particularly important in elderly patients or those with cardiovascular disease to prevent atrial fibrillation and heart failure 1
• Propranolol is an alternative beta-blocker option for controlling heart rate and reducing tremors 2
• Beta-blockers provide symptomatic relief while waiting for antithyroid medications to reduce thyroid hormone levels to therapeutic range 1
• In patients over 50 years, cardiovascular complications are the chief cause of death, making prompt beta-blocker initiation critical 1

Definitive Treatment Modalities

Antithyroid Drugs (Thionamides)

Methimazole is the preferred antithyroid drug for most patients with hyperthyroidism due to Graves disease or toxic nodular goiter. 1, 3

• Methimazole should be initiated while monitoring thyroid function every 2-3 weeks initially, then every 4-6 weeks once stable 1
• Propylthiouracil is reserved for specific situations: first trimester of pregnancy (due to methimazole's association with rare fetal abnormalities), patients who cannot tolerate methimazole, or thyroid storm 1, 4
• Critical safety monitoring required: Patients must immediately report sore throat, fever, skin eruptions, or general malaise due to risk of agranulocytosis 3, 4
• Liver function monitoring is essential, particularly with propylthiouracil which carries risk of severe hepatotoxicity including hepatic failure requiring transplantation or resulting in death 4
• Patients must report symptoms of hepatic dysfunction: anorexia, pruritus, jaundice, light-colored stools, dark urine, or right upper quadrant pain 4
• Vasculitis is a serious complication requiring immediate discontinuation if patients develop new rash, hematuria, decreased urine output, dyspnea, or hemoptysis 3, 4
• Treatment duration typically 12-18 months for Graves disease, though recurrence occurs in approximately 50% of patients 5
• Long-term treatment (5-10 years) is associated with fewer recurrences (15%) compared to short-term treatment 5

Radioactive Iodine Therapy

Radioactive iodine is increasingly used as first-line definitive therapy, particularly effective for toxic nodular goiter, and resolves hyperthyroidism in more than 90% of patients. 1, 6

• Absolute contraindication in pregnancy 1
• Pregnancy must be avoided for 4 months following administration 7
• Primary long-term consequence is development of hypothyroidism requiring lifelong thyroid hormone replacement, occurring in most patients within 1 year after treatment 1, 6
• Preferred treatment for toxic nodular goiter 7

Surgical Thyroidectomy

Near-total or total thyroidectomy is recommended for patients with large goiters causing compressive symptoms (dysphagia, orthopnea, voice changes), suspicious nodules, or severe ophthalmopathy. 1, 8

• Requires lifelong thyroid hormone replacement post-operatively 1
• Treatment of choice when compressive symptoms are present 6
• Limited role in Graves disease unless radioiodine refused or contraindicated 7

Special Clinical Scenarios

Pregnancy

Propylthiouracil may be preferred during the first trimester of pregnancy due to rare congenital malformations associated with methimazole during organogenesis. 1, 4

• Switch from propylthiouracil to methimazole for second and third trimesters due to maternal hepatotoxicity risk with propylthiouracil 1, 4
• Goal is maintaining FT4 in high-normal range using lowest possible thioamide dosage 1
• Monitor FT4 every 2-4 weeks during pregnancy 1
• Women treated with propylthiouracil or methimazole can breastfeed safely 1
• Untreated hyperthyroidism increases risk of severe preeclampsia, preterm delivery, heart failure, spontaneous abortion, and stillbirth 2, 4

Thyroiditis-Induced Hyperthyroidism

Thyroiditis-induced hyperthyroidism is self-limited and typically resolves within weeks with supportive care alone. 1

• Focus on symptom management with beta-blockers rather than antithyroid drugs 1
• Most patients transition to primary hypothyroidism requiring close monitoring and eventual thyroid hormone replacement 1
• Steroids only needed in severe cases 5

Severe Hyperthyroidism/Thyroid Storm

Mandatory hospitalization with aggressive management including beta-blockers, high-dose antithyroid drugs, hydration, supportive care, and consideration of steroids or SSKI. 1

• Endocrine consultation required 1
• Life-threatening emergency requiring immediate intervention 2

Monitoring and Follow-up

• Initial monitoring every 4-6 weeks with dose adjustments based on clinical response and laboratory values 1
• During maintenance phase: monitor thyroid function every 3 months in first year, then every 6 months thereafter 1
• Long-term follow-up necessary even after successful treatment due to risk of recurrence or development of hypothyroidism 1
• Rising serum TSH indicates need for lower maintenance dose 3, 4

Drug Interactions Requiring Dose Adjustments

• Oral anticoagulants (warfarin): Increased activity requiring additional PT/INR monitoring, especially before surgical procedures 3, 4
• Beta-blockers: Dose reduction may be needed when hyperthyroid patient becomes euthyroid due to decreased clearance 3, 4
• Digitalis glycosides: Reduced dose may be needed as serum levels increase when patient becomes euthyroid 3, 4
• Theophylline: Reduced dose may be needed due to decreased clearance when euthyroid 3, 4