aace italianchaptercourse 4 current approach to thyroid ... · roma, 7-10 novembre 2019 if131i...

Roma, 7-10 novembre 2019

AACE Italian Chapter Course 4Current approach to thyroid dysfunction

CURRENT MANAGEMENT OF GRAVES’ DISEASE

Jeffrey Garber (USA) & Massimo Salvatori 1. Real clinical practice (Andrea Frasoldati) 2. Natural history and long-term clinical consequences (Laszlo Hegedus, DK) 3. Efficacy and limits of treatment options: •• Medical treatment (Hossein Gharib, USA) •• Radioiodine treatment (Maurilio Deandrea) •• Surgery (Celestino Pio Lombardi) 4. THM (Andrea Frasoldati)


Diagnostic Algorithm

Kahaly et al. , Eur Thyroid J 2018;7:167–186

Usually, diagnosis of Graves’ disease is notan issue …


• Matteo, 16 year old volley ball player. Euthyroidism fully restored, but “thyroid inferno” on US and initial mild GO.

Case 1 - Matteo

Which treament?

•ATD•Surgery•131I


Case 2 - Sara

• Sara, 36 year old, hairdresser. Graves’ recurrence. Hyperthyroidism well controlled. She is planning a pregnancy

Which treament?

•ATD•Surgery•131I


Anti-thyroidal drugsAdvantages Disadvantages

Restoration of thyroid function Long time required for stableremission

Control of thyrotoxicosisachieved in a few weeks, TSH detectable after 2-4 months

Recurrence rate in 50-60% ofpatients

Positive effects on ThyroidAutoimmunity

5% risk of minor side effects

No contraindications in GOCareful use in Pregnancy

0.2-0.5% risk of severe side effects

Low costEasily available

Low compliance


Radio-Iodine

Advantages DisadvantagesOutpatient procedure, low cost

Eventual hypothyroidism

Recurrence rate virtually 0.0% low cost, few side effects

Minor complications in 1-2% ofpatients

Few side effectsReduction of thyroid volume

Contraindicated in active GOContraindicated in pregnancy

Low cost Limited availability (Europe) Fear of potential radiation hazards

Roma, 7-10 novembre 2019Surgery

Advantages DisadvantagesRecurrence rate virtually 0.0% Hypothyroidism

Rapid effectiveness Minor complications in 1-2% of patients

No contraindications in GOPossibile during pregnancy (2nd

trimester)

Major complications in 1-4% ofpatients

Histologic result available High costsHigh-volume surgeons needed


Treatment Optionsfor Graves’ Hyperthyroidism

ATD 131-I SurgeryHigh likelihood of remission ++ + +

Major adverse reactions to ATD NO ++ ++

High surgical risk ++ ++ NO

Active GO ++ NO ++

Pregnancy +/- NO +/-

Lack of a high volume surgeon ++ ++ --

Congestive heart failure ++ ++ --

Liver disease +/- ++ +

Thyroid malignancy suspected -- NO ++

Large thyroid nodules + -- ++

Modified from ATA guidelines. Ross et al., Thyroid, 2016


Management Algorithm

Kahaly et al. , Eur Thyroid J 2018;7:167–186


ATD as the first option

• Patients with newly diagnosed Graves’ hyperthyroidismshould be treated with ATD. RAI therapy or thyroidectomymay be considered in selected patients.

• MMI (CBZ) should be preferentially used in non-pregnantpatient. MMI is usually administered for 12–18 monthsthen discontinued if the TSH and TSH-R-Ab levels arenormal.

• Measurement of TSH-R-Ab levels prior to stopping ATDtherapy is recommended.

Adapted from Kahaly et al. , Eur Thyroid J 2018;7:167–186


Before startingantithyroid drugs

• If the chance of remission is low, Tx or RAI might be a betteroption.

• Factors associated with a low remission rate as suggested inmany but not all studies, are male sex, young age (<40 years),smoking, severe hyperthyroidism, highTBII, large goiter size,and the presence of GO.

• The predictive value of each of these risk factors is too low foraccurate assessment of the remission chance before startingATD in the individual patient …

Wiersinga et al. Endocrinol Metab 2019;34:29-38


The GREAT score andthe relapse risk

Struja et al., European Journal of Endocrinology (2017) 176, 413–419

Roma, 7-10 novembre 2019If 131I is the chosen option …

• Often recommended for patients with side-effects to ATD or in case of disease recurrence.

• ATD should be stopped around 1 week before and after therapy.

• A fixed dose of RAI can usually be administered.• Patients should be informed that repeated doses may be

needed.• Conception should be postponed until at least 6 months

after RAI in both males and females.Adapted from Kahaly et al., Eur Thyroid J 2018;7:167–186


When surgery is selected …

• Total thyroidectomy is the procedure of choice, andshould be performed by a skilled “high-volume” surgeon.

• Euthyroidism should be restored by ATD prior to surgery.

• A solution containing potassium iodide can be given for 10 days prior to surgery.

Adapted from Kahaly et al. , Eur Thyroid J 2018;7:167–186


Implication for research• More long-term, high-quality randomized controlled clinical trials

comparing radioiodine with antithyroid medications for Graves diseaseare required. Data for children are lacking.

• Future trials should include all-cause mortality, health-related qualityof life, socioeconomic effects and information on bone mineral density,as well as data on co-medications to treat Graves’ ophthalmopathysuch as steroids.

• No long-term data exist on other antithyroid medications such aspropylthiouracil for the treatment of Graves’ disease.

Ma et al., Radioiodine therapy versus antithyroidmedications for Graves’ disease . Cochrane Database of Systematic Reviews 2016


THMs: the final cut

THANK YOU FOR YOUR ATTENTION!

aace italianchaptercourse 4 current approach to thyroid ... · roma, 7-10 novembre 2019 if131i...

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