What are the treatment options for a patient with hyperthyroidism?

Treatment Options for Hyperthyroidism

For patients with hyperthyroidism, treatment should be initiated with beta-blockers for immediate symptom control, followed by definitive therapy with either antithyroid drugs (methimazole preferred), radioactive iodine, or thyroidectomy, depending on the underlying cause, patient characteristics, and contraindications. 1

Immediate Symptomatic Management

Start beta-blockers immediately in all patients with hyperthyroidism to control cardiac symptoms while diagnostic workup and definitive treatment planning proceed. 1

• Atenolol 25-50 mg daily is the preferred agent, targeting a heart rate <90 bpm if blood pressure allows 1
• Propranolol is an alternative beta-blocker option for symptomatic relief, particularly effective for tremor and tachycardia 1, 2
• Beta-blockers are especially critical in elderly patients or those with cardiovascular disease to prevent atrial fibrillation and heart failure 1
• Cardiovascular complications are the chief cause of death in patients over 50 years with hyperthyroidism, making prompt beta-blocker initiation essential 1

Definitive Treatment Options

Antithyroid Drugs (Thioamides)

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

• Continue beta-blockers until thioamide therapy reduces thyroid hormone levels to the therapeutic range 1
• Monitor thyroid function every 2-3 weeks initially, then every 4-6 weeks during maintenance 1
• Treatment duration is typically 12-18 months for Graves' disease, with approximately 50% recurrence rate after discontinuation 4
• Long-term treatment (5-10 years) is associated with fewer recurrences (15%) compared to short-term treatment 4

Critical safety monitoring for thioamides: 5, 6

• Patients must report immediately: sore throat, fever, skin eruptions, or general malaise (agranulocytosis risk) 5, 6
• For propylthiouracil specifically: monitor for hepatic dysfunction symptoms (anorexia, jaundice, right upper quadrant pain, dark urine) especially in first 6 months 6
• Both drugs require immediate discontinuation if agranulocytosis, hepatitis, vasculitis, or thrombocytopenia develop 1
• Monitor prothrombin time before surgical procedures due to potential bleeding risk 5, 6

Propylthiouracil is reserved for specific situations: 1, 6

• First trimester of pregnancy (methimazole may cause fetal abnormalities) 1, 6
• Patients who cannot tolerate methimazole 6
• Thyroid storm requiring rapid control 1
• Switch to methimazole for second and third trimesters due to propylthiouracil's hepatotoxicity risk 1, 6

Radioactive Iodine Therapy

Radioactive iodine is increasingly used as first-line definitive therapy, particularly effective for toxic nodular goiter. 1, 7, 3

• Most widely used treatment in the United States 3
• Well tolerated with primary long-term consequence being hypothyroidism requiring lifelong thyroid hormone replacement 1
• Absolutely contraindicated during pregnancy and lactation 1
• Pregnancy must be avoided for 4 months following administration 7
• May worsen Graves' ophthalmopathy; corticosteroid cover can reduce this risk 7
• Preferred treatment for toxic nodular goiter 1, 7

Surgical Thyroidectomy

Near-total or total thyroidectomy is recommended for patients with large goiters causing compressive symptoms, suspicious nodules, or severe ophthalmopathy. 1

• Requires lifelong thyroid hormone replacement post-operatively 1
• Limited but specific role: large goiters with compression symptoms (dysphagia, orthopnea, voice changes), refusal of radioactive iodine, or suspicious nodules 1, 8, 7
• Goal is to cure underlying pathology while potentially leaving residual thyroid tissue to maintain euthyroidism 7

Special Clinical Scenarios

Thyroiditis-Induced Hyperthyroidism

Thyroiditis is self-limited and typically resolves in weeks with supportive care alone—do NOT use antithyroid drugs. 1

• Focus on symptom management with beta-blockers rather than antithyroid medications 1
• Most patients transition to primary hypothyroidism requiring close monitoring and eventual thyroid hormone replacement 1
• Observation and supportive care are usually the only treatments needed 9

Severe Hyperthyroidism or Thyroid Storm

Thyroid storm requires mandatory hospitalization and aggressive management. 1

• High-dose antithyroid drugs (propylthiouracil preferred for rapid action) 1
• Beta-blockers for cardiac symptoms 1
• Hydration and supportive care 1, 2
• Consider additional therapies: steroids, SSKI (saturated solution of potassium iodide), or possible surgery 1
• Endocrine consultation is mandatory 1

Pregnancy Considerations

Maintain FT4 or free thyroxine index in the high-normal range using the lowest possible thioamide dosage. 1

• Monitor FT4 or FTI every 2-4 weeks during pregnancy 1
• Propylthiouracil is preferred in first trimester; switch to methimazole for second and third trimesters 1, 6
• Women treated with either drug can breastfeed safely 1
• Untreated hyperthyroidism increases risk of severe preeclampsia, preterm delivery, heart failure, and adverse fetal outcomes 2, 8

Moderate Hyperthyroidism

Consider holding immune checkpoint inhibitors if applicable until symptoms return to baseline, with endocrine consultation recommended. 1

• Manage with beta-blockers, hydration, and supportive care 1
• Continue monitoring thyroid function closely 1

Monitoring and Follow-up

Regular monitoring of thyroid function tests is essential throughout treatment. 1

• Initial monitoring every 4-6 weeks during dose titration 1
• Adjust doses based on clinical response and laboratory values 1
• Long-term follow-up necessary even after successful treatment due to risk of recurrence or development of hypothyroidism 1
• During maintenance phase: monitor every 3 months in first year, then every 6 months thereafter 1

Common Pitfalls to Avoid

• Never use radioactive iodine in pregnancy or within 4 months of planned conception 1, 7
• Do not use antithyroid drugs for thyroiditis—it is self-limited and requires only supportive care 1, 9
• Do not overlook cardiac monitoring in elderly patients—cardiovascular complications are the leading cause of death 1
• Failing to distinguish between Graves' disease (requires definitive therapy) and thyroiditis (requires only observation) leads to unnecessary treatment 9
• Underestimating the need for lifelong thyroid hormone replacement after radioactive iodine or surgery 1