Hyperthyroidism - Treatments

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How is hyperthyroidism treated?

The options for treating hyperthyroidism include:

  • Treating the symptoms
  • Antithyroid drugs
  • Radioactive iodine
  • Surgery treating symptoms

Treating the symptoms

There are medications available to immediately treat the symptoms caused by excessive thyroid hormones, such as a rapid heart rate. One of the main classes of drugs used to treat these symptoms is the beta-blockers [for example, propranolol (Inderal), atenolol (Tenormin), metoprolol (Lopressor)]. These medications counteract the effect of thyroid hormone to increase metabolism, but they do not alter the levels of thyroid hormones in the blood. A doctor determines which patients to treat based on a number of variables including the underlying cause of hyperthyroidism, the age of the patient, the size of the thyroid gland, and the presence of coexisting medical illnesses.

Antithyroid Drugs

There are two main antithyroid drugs available for use in the United States, methimazole (Tapazole) and propylthiouracil (PTU). These drugs accumulate in the thyroid tissue and block production of thyroid hormones. PTU also blocks the conversion of T4 hormone to the more metabolically active T3 hormone. The major risk of these medications is occasional suppression of production of white blood cells by the bone marrow (agranulocytosis). (White cells are needed to fight infection.) It is impossible to tell if and when this side effect is going to occur, so regular determination of white blood cells in the blood are not useful.

It is important for patients to know that if they develop a fever, a sore throat, or any signs of infection while taking methimazole or propylthiouracil, they should see a doctor immediately. While a concern, the actual risk of developing agranulocytosis is less than 1%. In general, patients should be seen by the doctor at monthly intervals while taking antithyroid medication. The dose is adjusted to maintain the patient in as close to a normal thyroid state as possible (euthyroid). Once the dosing is stable, patients can be seen at three month intervals if long-term therapy is planned.

Usually, long-term antithyroid therapy is only used for patients with Graves' disease, since this disease may actually go into remission under treatment without requiring treatment with thyroid radiation or surgery. If treated from one to two years, data shows remission rates of 40%-70%. When the disease is in remission, the gland is no longer overactive, and antithyroid medication is not needed.

Recent studies also have shown that adding a pill of thyroid hormone to the antithyroid medication actually results in higher remission rates. The rationale for this may be that by providing an external source for thyroid hormone, higher doses of antithyroid medications can be given, which may suppress the overactive immune system in persons with Graves' disease. This type of therapy remains controversial, however. When long-term therapy is withdrawn, patients should continue to be seen by the doctor every three months for the first year, since a relapse of Graves' disease is most likely in this time period. If a patient does relapse, antithyroid drug therapy can be restarted, or radioactive iodine or surgery may be considered.

Radioactive Iodine

Radioactive iodine is given orally (either by pill or liquid) on a one-time basis to ablate a hyperactive gland. The iodine given for ablative treatment is different from the iodine used in a scan. (For treatment, the isotope iodine 131 is used, while for a routine scan, iodine 123 is used.) Radioactive iodine is given after a routine iodine scan, and uptake of the iodine is determined to confirm hyperthyroidism. The radioactive iodine is picked up by the active cells in the thyroid and destroys them. Since iodine is only picked up by thyroid cells, the destruction is local, and there are no widespread side effects with this therapy.

Radioactive iodine ablation has been safely used for over 50 years, and the only major reasons for not using it are pregnancy and breast-feeding. This form of therapy is the treatment of choice for recurring Graves' disease, patients with severe cardiac involvement, those with multinodular goiter or toxic adenomas, and patients who cannot tolerate antithyroid drugs. Radioactive iodine must be used with caution in patients with Graves' related eye disease since recent studies have shown that the eye disease may worsen after therapy. If a woman chooses to become pregnant after ablation, it is recommended she wait 8-12 months after treatment before conceiving.

In general, more than 80% of patients are cured with a single dose of radioactive iodine. It takes between 8 to 12 weeks for the thyroid to become normal after therapy. Permanent hypothyroidism is the major complication of this form of treatment. While a temporary hypothyroid state may be seen up to six months after treatment with radioactive iodine, if it persists longer than six months, thyroid replacement therapy (with T4 or T3) usually is begun.

Surgery

Surgery to partially remove the thyroid gland (partial thyroidectomy) was once a common form of treatment for hyperthyroidism. The goal is to remove the thyroid tissue that was producing the excessive thyroid hormone. However, if too much tissue is removed, an inadequate production of thyroid hormone (hypothyroidism) may result. In this case, thyroid replacement therapy is begun. The major complication of surgery is disruption of the surrounding tissue, including the nerves supplying the vocal cords and the four tiny glands in the neck that regulate calcium levels in the body (the parathyroid glands). Accidental removal of these glands may result in low calcium levels and require calcium replacement therapy.

With the introduction of radioactive iodine therapy and antithyroid drugs, surgery for hyperthyroidism is not as common as it used to be. Surgery is appropriate for:

  • pregnant patients and children who have major adverse reactions to antithyroid medications.
  • patients with very large thyroid glands and in those who have symptoms stemming from compression of tissues adjacent to the thyroid, such as difficulty swallowing, hoarseness, and shortness of breath.
Return to Hyperthyroidism

See what others are saying

Comment from: Cherie, 25-34 Female (Patient) Published: December 24

I began having trouble with intolerance to cold and heat, but mostly cold. I would also wake up with near extreme night sweats to where I would have to change my gown. I had trouble getting to sleep or staying asleep; low energy, an all over weak feeling as if I had low blood pressure, dizziness, and memory problems. I would also get these weird tingly sensations down my arms and legs and part of my body. I had hand tremors that varied from light to ridiculous. My hair, when in health, was fine and thick. By the time I finally got medical attention, my hair was course and thinning fast. I also had a lump or swelling in my neck. Often, in the area of my thyroid there was pain to the touch (on a scale 1 to 10, usually 1 to 4). I had trouble getting my doctor to do anything about it. When I found out that I could go to a specialist without his referral, I went on my own (much to his chagrin afterwards). My TSH was low, and I took the medicine for 3 months. Upon my follow-up, my ENT specialist took me off it because it raised my levels too high from the lowest dose he had prescribed. All this happened in September 2012 to April 2013. Oh, by the way, the ultrasound revealed nodules in my thyroid, biopsies were benign. The specialist said he would just watch it. After all this, the night sweats, temperature intolerance, memory stuff all but went away or stopped. Then fall of 2015, night sweats began again, I finally just butchered my hair because it looked so ragged. The swelling never did go away, nor did the on and off again soreness, but my TSH levels were always normal. And the temperature intolerance began, so I went to my new doctor. I just had another ultrasound, lots of nodules this time, TSH levels still normal, so now it's off to the biopsies again.

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Comment from: Cupienana, 45-54 Male (Patient) Published: June 01

I have high blood pressure, but recently became very ill, facing diarrhea and getting weaker and weaker. After four days, I was so weak I and had to give in and call an ambulance and go to a hospital. I had severe sepsis, E. coli and serious dehydration. I was dismissed from the hospital after 10 days and my blood pressure dropped to both under 100 and my pulse in the 40s. I got no stronger. In my return visit to my cardiologist (when I was still very weak, and 5 weeks after my most recent hospitalization) I now had critically-low potassium level. I had taken potassium prescription to counteract loss of potassium due to taking Lasix to prevent congestive heart failure. Increased potassium prescription treatment has resulted in my feeling better than I have in months, but my high blood pressure has returned to 166/106, pulse 60 and I do feel stronger!

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