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Treating Hyperthyroidism: What Are Your Options?

Posted Aug 24 2008 1:49pm
HOLLY ATKINSON, MD: Hello and welcome to our webcast. I'm Dr. Holly Atkinson. Hyperthyroidism is a serious hormonal imbalance which can lead to weight loss, diarrhea, anxiety and other symptoms. Treatments are available and in most cases, they involve attacking the primary cause of hyperthyroidism, which a syndrome called "Grave's Disease," which affects about 2% of women. One of these women was Gail Devers, track star and Olympic gold medallist. After years of misdiagnosis, she was finally treated and the change it brought on was tremendous. Today, we'll talking about the various treatment options for Graves' Disease, and I have with me today two experts to help me do that. Dr. Melissa Katz from the Weill-Cornell Medical College. Welcome, Melissa.

MELISSA KATZ, MD: Thank you.

HOLLY ATKINSON, MD: And Dr. Rick Haber from the Mt. Sinai School of Medicine. Welcome, Rick.


HOLLY ATKINSON, MD: There are some treatment options for Graves'. It's not just one approach. Melissa, give me the general ways we can approach treating Graves' Disease.

MELISSA KATZ, MD: There are basically three treatment options, two of which are used much more commonly.

The first one is radioactive iodide, in which a patient will have a drink or a tablet -- depending on the place that they are treated -- of radioiodine designed to decrease the hyperfunctioning of the thyroid gland.

The second possibility is antithyroid drugs. Two of them are commonly used. Named Tapazole and PTU. And these medications are taken for approximately a two-year course and can effect a cure in a percentage of patients that's quite variable. Let's say from 30-50 percent. And the third option is surgery, which is not commonly used, but there are special circumstances in which it might be recommended.

HOLLY ATKINSON, MD: Rick, what are the most common approaches today?

RICHARD HABER, MD: As Melissa said, I think the two most common in the United States are either the antithyroid drugs -- the route of taking medication for a year or two in hopes of inducing a remission of the underlying disease -- or definitively curing the disease by basically getting rid of your thyroid gland, which is what the radioiodine does. And that --

HOLLY ATKINSON, MD: Well, is there a preponderance of which approach is used now?

MELISSA KATZ, MD: In the United --

HOLLY ATKINSON, MD: Drugs versus --

MELISSA KATZ, MD: I think in the United States, radioiodine is most commonly used. Whereas in Europe and Japan, antithyroid medication is more common.

RICHARD HABER, MD: Europeans also like to use surgery, which is something that's become much less popular in the United States. That is, to cut out most of the thyroid rather than destroy it with radioiodine. The end result is the same, it's just a question of preference.

HOLLY ATKINSON, MD: Now, well, how do you go about making the decision of what is the right approach for a given individual? Someone listening to this may say, "Oh, my goodness, I'm confused, which should I have? And how do I make that decision?" Melissa, how do you go about making that decision?

MELISSA KATZ, MD: I make the decision with the patient, and ultimately I think it is the patient that makes the decision as to what they prefer. There are many things to take into consideration.

If somebody were to opt for antithyroid medication, you'd have to think about other medications that they were on. There are certain -- there are certain side effects that antithyroid medication, although quite rare, there could be--


MELISSA KATZ, MD: Some liver toxicity, in addition to some bone-marrow toxicity. Those are rare, but they can be quite serious. There could also be some joint aches and some rashes that could develop.

The side effects to radioiodine therapy are predominantly hypothyroidism. The majority of patients treated have they thyroid essentially destroyed and they are rendered hypothyroid, requiring taking levothyroxine for the rest of their life. And some patients decline to do that because they really don't want to have to take medication for the rest of their life.

And so I think it's an individual decision. Certainly somebody that has mild hyperthyroidism, someone that has a smaller gland, may respond well to antithyroid medication.

HOLLY ATKINSON, MD: Rick, are there any patient profiles in which you strongly recommend one or the other course?

RICHARD HABER, MD: Yeah, there are. I think that when somebody -- a patient -- is older, which could mean over 50. Or they've had cardiac manifestations of hyperthyroidism, such as cardiac arrhythmias, like the first President Bush had when he became hyperthyroid. In that case -- because the disease is potential life-threatening in an older person with heart problems -- I think it should be definitively and permanently cured, and the safest way to do that is with radioiodine.

The route of treating with antithyroid drugs -- which only sometimes gives a permanent cure is not for those patients. We save that for some of our younger patients. Those with the milder cases, smaller thyroid glands rather than very, very large thyroid glands. The people who have the best chance of being in the 30-50 percent to get some long-term remission from these drugs.

HOLLY ATKINSON, MD: Now, what about a pregnant woman, what would you recommend?

MELISSA KATZ, MD: Well, clearly, radioiodide therapy is out of the question for a pregnant woman. I usually advise most women to have their hyperthyroidism cured prior to conceiving. I think that's the ideal way of doing it. Certainly there's about nine months that I advise waiting to become pregnant after having radioiodine therapy, if that is the choice.

Antithyroid drugs can be used -- PTU would be the one to used during pregnancy. Hopefully -- I like to not use anything in the first trimester if possible. In the second trimester, it can be used. In the trimester, Graves' Disease really goes into remission, as do many other autoimmune conditions during pregnancy. Certainly there can be a post-partum flair.

I think that surgery is indicated for certain women who may be older, who may be undergoing in vitro fertilization who just really need to put the thyroid issue behind them --

HOLLY ATKINSON, MD: And they don't have that time to wait.

MELISSA KATZ, MD: And they don't have the time frame, exactly.

HOLLY ATKINSON, MD: Rick, why is surgery not as popular? What's the downside to surgery?

RICHARD HABER, MD: Well, surgery -- any time people have surgery and general anesthesia, there's a small risk of something going seriously awry. But, beyond that, there's some more specific problems that can occur with thyroid surgery. There are basically two things.

One is that the nerve to the vocal cord -- which allows you to speak -- runs right behind the thyroid on each side, and it can be damaged during thyroid surgery. Not too often, but even in the best hands it occasionally occurs. That can cause, in some cases, permanent hoarseness.

The second feared complication of thyroid surgery is damage to the parathyroid glands. These are tiny glands right behind the thyroid which maintain the calcium level in your blood. If all four are permanently damaged, the calcium goes to low -- which can cause muscle spasms and even seizures and requires lifelong treatment with large doses of vitamin D and calcium.

So there are things that can happen with thyroid surgery, and for this reason, we feel that the option of radioactive iodine -- in addition to being less painful and not involving a scar, also safer.

HOLLY ATKINSON, MD: Is there anyone you would say should have surgery over the other two options?

MELISSA KATZ, MD: There are occasional patients with very, very, very large goiters. And I think that in those situations, you need to treat them medically and certainly nobody can go into the operating hyperthyroid, that would be very risky.

RICHARD HABER, MD: I agree with Melissa on that and I would just add occasionally somebody with hyperthyroidism also has a growth in their thyroid -- what we call a nodule. Occasionally those growths sometimes can be thyroid cancers. And in those cases, you can kill two birds with one stone by doing thyroid surgery. Curing the hyperthyroidism, getting rid of the growth.

HOLLY ATKINSON, MD: Thank you both very much for your comments. And thank you for joining us. I'm Dr. Holly Atkinson.

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