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
- anti-thyroid 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 extra-thyroid 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 anti-thyroid 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 anti-thyroid drugs (a 12- to 18-month course) or radioactive iodine should be offered as first-line definitive treatment for adults with Graves' disease if anti-thyroid drugs are likely to achieve remission (for example, mild and uncomplicated Graves' disease)
- anti-thyroid 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 anti-thyroid drugs are unsuitable (radioactive iodine or surgery should be considered for adults with Graves' disease who have had anti-thyroid drugs but have persistent or relapsed hyperthyroidism)
Surgery may also be preferred in: (4)
- women planning a pregnancy in <6 months provided thyroid hormone levels are normal
- symptomatic compression or large goitres
- relatively low uptake of radioactive iodine
- cases when thyroid malignancy is documented or suspected
- large thyroid nodules
- coexisting hyperparathyroidism requiring surgery
- patients with moderate to severe active Graves' disease
NICE state with respect to management of children with Grave's disease (3):
- anti-thyroid 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 anti-thyroid drugs or discussing radioactive iodine or surgery (total thyroidectomy) for children and young people with Graves' disease who have had a course of anti-thyroid drugs but have relapsed hyperthyroidism
References:
- Vaidya B, Pearce SH. Diagnosis and management of thyrotoxicosis. BMJ. 2014 Aug 21;349:g5128
- De Leo S, Lee SY, Braverman LE. Hyperthyroidism. Lancet (London, England). 2016;388(10047):906-918.
- Thyroid disease: assessment and management. NICE guideline NG145. Published: 20 November 2019 Last updated: 12 October 2023
- Ross DS, Burch HB, Cooper DS, et al. 2016 American Thyroid Association guidelines for diagnosis and management of hyperthyroidism and other causes of thyrotoxicosis. Thyroid. 2016 Oct;26(10):1343-421.