Abstract
Preoperative management of hyperthyroid patients with Graves' disease who are unable to tolerate thionamides or have poor adherence to therapy is a challenging clinical problem. The goal of our study was to demonstrate the clinical efficacy of a rapid preoperative thyroid hormone blocking protocol and to assess specific surgical and treatment-related complications. Ten patients with thyrotoxicosis due to Graves' disease were treated with a rapid thyroid hormone blocking protocol of Lugol's solution, dexamethasone and a beta-blocker. Two patients continued to receive antithyroid therapy with carbimazole. Adrenal function was assessed 4-6 weeks postoperatively with a low dose (1 µg) adrenocorticotrophic hormone-stimulation test. Before treatment, all patients had severe hyperthyroidism. Baseline median and interquartile range (IQR) of fT4 was 68.9 (45.7-92.1) pmol/l, and baseline median fT3 and IQR, 30 (19.1-40.9) pmol/l. After 10 days of treatment, the levels of free hormones were significantly reduced with fT4 concentrations slightly elevated (fT4, 26.7 [17-36.4] pmol/l, p <0.001 compared with corresponding pretreatment values), and the fT3 concentration was normal in 8/10 patients (fT3, 6.1 [4.6-7.6] pmol/l, p <0.001 compared with corresponding pretreatment values). All patients were clinically euthyroid with a heart rate of <80/min. Drug tolerability was excellent, and there were no side effects or exacerbation of hyperthyroidism. The peri- and postoperative course was uneventful in all cases. Adrenal function was normal in 7 out of 10 patients 4-6 weeks postoperatively. Three patients showed prolonged secondary adrenal insufficiency with normalisation of adrenal function after 3 to 6 months. Rapid and effective preoperative preparation of patients with Graves' disease is achievable with Lugol's solution, dexamethasone and a beta-blocker. The risk of temporary hypothalamic-pituitary-adrenal axis suppression has to be taken into account.
Highlights
Graves’ disease is the most common cause of hyperthyroidism
The goal of our study was to demonstrate the clinical efficacy of a rapid preoperative thyroid hormone blocking protocol and to assess specific surgical and treatment-related complications
Rapid and effective preoperative preparation of patients with Graves' disease is achievable with Lugol's solution, dexamethasone and a beta-blocker
Summary
Graves’ disease is the most common cause of hyperthyroidism. antithyroid drugs and radioactive iodine are favoured treatment options [1], total thyroidectomy is the therapy of choice for a subset of patients. Thyroid storm is a rare but severe complication of thyrotoxicosis with a high rate of mortality and deleterious effects on the cardiovascular system. It may occur in patients with uncontrolled hyperthyroidism who undergo nonthyroid or thyroid surgery. Alternative thionamide-free regimens for controlling hyperthyroidism and a rapid thyroid hormone blocking protocol have been studied extensively in patients with Graves’ disease [5,6,7] or as preparation before thyroidectomy [8–12]. Most rapid thyroid hormone blocking protocols are based on multimodal approaches that target thyroid hormone synthesis and secretion (iodine containing preparations, i.e. iodinated oral cholecystographic agents [OCAs]), inhibit peripheral conversion to T3 (glucocorticoids, OCAs), and
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