treatment

Last edited 12/2019 and last reviewed 11/2021

All new onset thyrotoxicosis cases should be referred to secondary care for assessment and to establish the cause and to agree on a management plan (1)

Treatment of thyroid disease is a popular examination question since it is multidisciplinary.

There are three treatment options available:

• drug treatment
• surgery
• radioiodine (1)

All three options can be used to treat Graves’ disease (1).

In toxic adenoma or toxic multinodular goitre, either radioactive iodine therapy or surgery is effective since these patients rarely go into remission (1)

Thyroiditis leading to thyrotoxicosis is usually temporary

• antithyroid drugs are ineffective and should not be used
• symptom control with β blockers may be the only management
• in subacute thyroiditis – NSAIDs and occasionally systemic glucocorticoids may be required to control pain (1,2)

Also extrathyroid complications must be treated.

NICE state with respect to management of adults with Grave's disease (3):

• radioactive iodine should be offered as first-line definitive treatment for adults with Graves' disease, unless antithyroid drugs are likely to achieve remission (see below), or it is unsuitable (for example, there are concerns about compression, malignancy is suspected, they are pregnant or trying to become pregnant or father a child within the next 4 to 6 months, or they have active thyroid eye disease)
  
  
• a choice of antithyroid drugs (a 12- to 18-month course) or radioactive iodine should be offered as first-line definitive treatment for adults with Graves' disease if antithyroid drugs are likely to achieve remission (for example, mild and uncomplicated Graves' disease)
  
  
• antithyroid drugs (a 12- to 18-month course) should be offered as first-line definitive treatment for adults with Graves' disease if radioactive iodine and surgery are unsuitable
  
  
• offer total thyroidectomy as first-line definitive treatment for adults with Graves' disease if:
• there are concerns about compression, or
• thyroid malignancy is suspected, or
• radioactive iodine and antithyroid drugs are unsuitable
  
  
• radioactive iodine or surgery should be considered for adults with Graves' disease who have had antithyroid drugs but have persistent or relapsed hyperthyroidism

NICE state with respect to management of children with Grave's disease (3):

• antithyroid drugs, for at least 2 years and possibly longer should be offered as first-line definitive treatment for children and young people with Graves' disease
• consider continuing or restarting antithyroid drugs or discussing radioactive iodine or surgery (total thyroidectomy) for children and young people with Graves' disease who have had a course of antithyroid drugs but have relapsed hyperthyroidism

Reference:

• (1) Vaidya B, Pearce SH. Diagnosis and management of thyrotoxicosis. BMJ. 2014;349:g5128
• (2) De Leo S, Lee SY, Braverman LE. Hyperthyroidism. Lancet (London, England). 2016;388(10047):906-918.
• (3) NICE (November 2019). Thyroid disease: assessment and management