Therapy For Hyperthyroidism Research Articles

Gastroschisis Due to Maternal Exposure to Carbimazole in A Term Neonate

Pregnant women with hyperthyroidism need careful management, which is due to the increased risk of maternal and fetal complications. However, safe and effective therapies for hyperthyroidism during pregnancy remain limited. Carbimazole is an anti-thyroid agent and has been used to treat hyperthyroidism. Gastroschisis is a congenital severe abdominal birth defect of the fetus but its etiology remains unclear. Here, we present a case of a female term neonate who developed gastroschisis after being exposed to carbimazole in uteroduring the first and half of the second trimester.

Effects of vitamin D treatment on the heart tissue and adropin levels in thyrotoxicosis rats

Background/Aim: Thyrotoxicosis is a hypermetabolic disease, common in people with iodine deficiency. Cardiac pathologies can be seen in untreated cases. Vitamin D is a supportive therapy for thyrotoxicosis and its deficiency also plays an important role in pathologies including cardiac diseases. Adropin is a peptide hormone regulating the energy homeostasis, and its levels in blood change in cardiac pathologies. Our purpose is to reveal the effects of vitamin D treatment on the heart tissue of rats with thyrotoxicosis and on the adropin levels. Methods: Our study was designed as 25 days. 28 Sprague-Dawley female rats were divided into 4 groups; Control (3ml of distilled water), Thyrotoxicosis (100μg/day L-thyroxine) Treatment (100μg/day L-thyroxine+200IU /day Vit. D), Vit D (200IU/day Vit. D). Firstly, heart tissues were stained with Masson trichrome method. The preparations were examined under the microscope and evaluated semi-quantitatively. After that, serum adropin levels were measured with ELISA method. Malondialdehyde level of heart tissue was evaluated by spectrophotometry. Heart tissue was evaluated in aspects of fibrosis, congestion, edema and impairment of tissue integrity. Results: All of the evaluation parameters of the heart tissue were found highly significantly increased in thyrotoxicosis group, in contrast to the control and vitamin D group. Despite a decrease in the treatment group, there was no significant difference in the thyrotoxicosis group (P<0.001). Serum adropin levels of all groups were found to be decreased in contrast to the thyrotoxicosis group. Similarly, tissue MDA levels were significantly higher in the thyrotoxicosis group compared to the other groups. Conclusion: Consequently, heart tissue damage and differences in adropin levels were found in rats with thyrotoxicosis. It was observed that supportive vitamin D treatment helps to regulate these effects.

Clinical Efficacy And Cure Rate Of Fixed Dose Radioactive Iodine For The Treatment Of Hyperthyroidism: A Single Centre Study

Abstract Introduction Iodine-131 is an effective treatment for thyrotoxicosis. In 2019, the National Institute for Clinical Excellence (NICE) guidelines suggested offering radioactive iodine as first-line definitive treatment for adults with Graves’ disease, toxic nodular and multinodular goitre unless it is unsuitable or anti-thyroid drugs are likely to achieve remission. The aim of this study was to evaluate the clinical outcome one year after using fixed dose Iodine-131 for hyperthyroidism and to identify any associated factors. Methods Electronic patient records were studied retrospectively for all patients who were treated with radioiodine therapy for hyperthyroidism between July 2017 and March 2020 at a district general hospital in the UK. Response to radioiodine therapy was assessed at 6 and 12 months by a dedicated thyroid nurse-led virtual follow-up. Results We identified 67 patients with a mean age of 55.9 years (range 18–84); 48 (72%) females, 19 (28%) males. Of these, 57 (85%) patients were cured at 12 months (93.7% in non-Graves’, 82.3% in Graves’ group). Gender, diagnosis, and pre-treatment disease interval were not significantly associated with treatment success. Non-Graves’ patients had a significantly shorter time to discharge than Graves’ patients receiving Iodine-131 (8 vs 10.3 months, p=0.0174). Conclusions The results of the present study demonstrate that a single fixed dose of Iodine-131 therapy is highly effective and comparable to outcomes from calculated dose therapy in literature. We propose the routine use of scoring system to calculate risk of relapse for all newly diagnosed hyperthyroid patients to tailor treatment modality.

Birth of the Beta-knife Thyroidectomy: The Radiance of Saul Hertz.

This is the story of how one man's life's work allowed for Iodine-131 (I-131) to become a therapy for hyperthyroidism and thyroid cancer. What is now a standard in our times arose from Saul Hertz's rather challenging and humble beginnings. Thyroid lobectomy and total thyroidectomy were therapeutic mainstays for thyroid disease until Hertz treated his first patient with radioactive iodine (RAI) ablation therapy at Massachusetts General Hospital (MGH) on March 31, 1941. His concepts for using beta particle emission from RAI to ablate thyroid tissue were revolutionary. Hertz's RAI therapy translated to research with thyroid cancer by the mid-1940s. The high-energy beta particles produced cytolethal effects on remnant thyroid tissue left behind by total thyroidectomy, thereby accomplishing completion thyroidectomy in some patients. Progressive surgeons from the Hertz era incorporated RAI into their practice. MGH surgery resident Francis Moore took sabbatical from clinical training to do translational research with RAI and other radioisotopes. Irving Ariel of New York became known as a nuclear surgeon in the wake of Hertz's work. George Crile Jr of Cleveland became an RAI advocate for the surgical community, implementing several paradigm-changing concepts in thyroid disease along the way. Hertz was a visionary who sparked this movement, predicting many of the molecular dilemmas with RAI-tumor avidity that clinical researchers continue to navigate today. This timely history for surgical oncologists and endocrine surgeons traces the development of RAI therapy through the life of Saul Hertz, a biographical window influenced by social stigma, political controversy, and mainstream media.

IMPACT OF GRAVES' DISEASE AND ANTITHYROID DRUG THERAPY ON BONE MINERAL DENSITY - PATHOPHYSIOLOGICAL MECHANISMS AND CLINICAL RELEVANCE.

Graves' disease is an autoimmune disease characterized by excessive thyroid hormone production. One of the consequences of that state can be a decrease in bone mineral density (BMD). Graves' disease is often treated with antithyroid drugs (ATD) as first line therapy, which can lead to disease remission. Moreover, recent data show that improvement in BMD can be expected. However, vitamin D deficiency can coexist along with Graves' disease, which is also involved in the process of bone remodeling. It is still not known whether lower values of vitamin D can contribute to onset of Graves' disease and if its supplementation might be helpful in therapy for hyperthyroidism. In the past couple of decades, osteopenia and osteoporosis have become a major health burden not only in post-menopausal women but also as a result of other diseases, leading to extensive research into various pathophysiological mechanisms responsible for bone remodeling. The Wnt (wingless integrated) signaling pathway is a very important factor in bone homeostasis, especially the canonical pathway. Present data indicate that stimulation of the Wnt pathway leads to bone mass increase and, in contrast, its inhibition leads to bone mass decrease. Hence, inhibitors of the canonical Wnt pathway became the focus of interest, in particular sclerostin and dickkopf 1 (DKK1). Hyperthyroidism and osteopenia/osteoporosis are quite common today and can coexist together or as separate entities. In this article, we aimed to give an overview of possible associations and potential mutual pathophysiological mechanisms.

Hardware-software complex concept of radioiodine therapy for thyrotoxicosis

Hardware-software complex concept of radioiodine therapy for thyrotoxicosis

Analiza farmakoterapijskog pristupa kod pacijenata obolelih od hipertireoze

Introduction: Hyperthyroidism represents a condition that occurs due to increased synthesis of thyroid hormones (T3, T4). In 90% of all cases it is caused by: Graves' disease, toxic multinodular goiter and toxic adenoma. Therapy of hyperthyroidism includes medication, radioiodine treatment and surgery. The most prescribed antithyroid drugs belong to the thioamide group (thiamazole and propylthiouracil). Aim: The aim of this study was to analyze the preoperative pharmacotherapeutic approach with the use of 3 drugs from the thioamide group (PTU® (propylthiouracil), Thyrozol® (thiamazole) and Tiastat® (thiamazole) in relation to the demographic and clinical characteristics of patients with hyperthyroidism. Material and methods: The study was conducted as a retrospective study among 62 patients aged 18 to 84 years, who reported to the Center for Endocrine Surgery KCS for the operative treatment of hyperthyroidism in period 2014-2019. Results: Diagnosis of Graves' disease was detected in 35.48% of patients, where 32.26% had toxic multinodular goiter, and 32.26% toxic adenoma. The most patients were prescribed Tiastat® (45.16%), 29.03% of them were prescribed PTU®, and 25.8% of them Thyrozol®. The most of patients suffering from Graves' disease were treated with Tiastat®, those suffering from toxic adenoma with PTU® and toxic multinodular goiter with Tiastat®. The most commonly used doses were 100 mg/day for PTU®, 20 mg/day for Tiastat® and 20 and 30 mg/ day for Thyrozol®. Total thyroidectomy is most commonly performed in patients treated with Tiastat® and hemithyroidectomy in those treated with PTU®. It was observed that there was a statistically significant difference (p &lt; 0.05) in the use of individual drugs regarding to diagnosis, total daily dose of drug, body mass index and type of surgical procedure. Conclusion: The most of patients were prescribed Tiastat®. Pharmacotherapeutic approach in paients with hyperthyroidism is in accordance with the national guidelines.

THE OCCURRENCE OF ACUTE PANCREATITIS AFTER IODINE 131 TREATMENT OF HYPERTHYROIDISM.

Acute pancreatitis is a common and potentially fatal gastrointestinal disease. We report a case of acute pancreatitis induced by iodine-131 therapy for hyperthyroidism. Iodine 131 is distributed through the blood, so it can accumulate and damage normal tissues in other parts of the body that are involved in thyroid hormone metabolis.

The use of combined therapy with CFPE and IVIG in a patient with refractory standard therapy for stiff person syndrome

Patient, female 56 years old. The disease debuted in 2015, 1 month after radioiodine therapy for thyrotoxicosis, episodes of stiffness and pain in the muscles of the back. Since March 2018, the patient noted an increase in the stiffness of the axial muscles, fear of walking, and began to use a cane. In May 2018, constant muscular activity in EMG in paraspinal muscles, proximal muscles of the thighs, an increase of anti-GAD antibodies to 46 U/ml, diagnosed Stiff-person syndrome.Image 1Image 2.

Does Radioactive Iodine Therapy for Hyperthyroidism Cause Cancer?

Radioactive iodine has been considered a safe and effective therapeutic option for hyperthyroidism secondary to Graves disease and autonomously functioning thyroid nodules since the mid-20th century. The question of whether I-131 at the doses used for hyperthyroidism might increase the risk of cancer has been investigated in a number of observational cohort studies over the years, with the preponderance of evidence being reassuring as to its safety. In particular, the 1998 Cooperative Thyrotoxicosis Therapy Follow-up Study (CTTFUS) has been widely cited as compelling evidence that I-131 is safe in hyperthyroidism therapy with respect to carcinogenesis. However, in 2019, a study by Kitahara and colleagues re-analyzed the CTTFUS cohort, extending the follow-up time and applying a novel dosimetric model for estimating tissue absorbed doses of radiation. This new analysis concluded that radioactive iodine was associated with an increased risk for mortality from overall cancer, breast cancer, and non-breast solid cancers. Reaction to this study was vociferous and particularly negative in the nuclear medicine literature. This mini-review was inspired by the 2019 CTTFUS controversy, and it is intended to provide the necessary context for clinicians to provide nuanced advice to their patients on the subject. To that end, the pre-2019 literature is surveyed, the 2019 CTTFUS study and a 2020 follow-up are discussed, and lessons from the literature and critical commentaries are considered.

Cancer Risk After Radioactive Iodine Treatment for Hyperthyroidism

Whether radioactive iodine (RAI) therapy for hyperthyroidism can increase cancer risk remains a controversial issue in medicine and public health. To examine site-specific cancer incidence and mortality and to evaluate the radiation dose-response association after RAI treatment for hyperthyroidism. The Medline and Cochrane Library electronic databases, using the Medical Subject Headings terms and text keywords, and Embase, using Emtree, were screened up to October 2020. Study inclusion criteria were as follows: (1) inclusion of patients treated for hyperthyroidism with RAI and followed up until cancer diagnosis or death, (2) inclusion of at least 1 comparison group composed of individuals unexposed to RAI treatment (eg, the general population or patients treated for hyperthyroidism with thyroidectomy or antithyroid drugs) or those exposed to different administered doses of RAI, and (3) inclusion of effect size measures (ie, standardized incidence ratio [SIR], standardized mortality ratio [SMR], hazard ratio [HR], or risk ratio [RR]). Two independent investigators extracted data according to the Meta-analysis of Observational Studies in Epidemiology (MOOSE) guidelines. Overall quality assessment followed the recommendations of United Nations Scientific Committee on the Effects of Atomic Radiation. The SIR and SMRs and the RRs and HRs were pooled using random-effects meta-analysis. Cancer incidence and mortality for exposure vs nonexposure to RAI therapy and by level of RAI administered activity. Based on data from 12 studies including 479 452 participants, the overall pooled cancer incidence ratio was 1.02 (95% CI, 0.95-1.09) and the pooled cancer mortality ratio was 0.98 (95% CI, 0.92-1.04) for exposure vs nonexposure to RAI therapy. No statistically significant elevations in risk were observed for specific cancers except thyroid cancer incidence (SIR, 1.86; 95% CI, 1.19-2.92) and mortality (SMR, 2.22; 95% CI, 1.37-3.59). However, inability to control for confounding by indication and other sources of bias were important limitations of studies comparing RAI exposure with nonexposure. In dose-response analysis, RAI was significantly associated with breast and solid cancer mortality (breast cancer mortality, per 370 MBq: 1.35; P = .03; solid cancer mortality, per 370 MBq: 1.14; P = .01), based on 2 studies. In this meta-analysis, the overall pooled cancer risk after exposure to RAI therapy vs nonexposure was not significant, whereas a linear dose-response association between RAI therapy and solid cancer mortality was observed. These findings suggest that radiation-induced cancer risks following RAI therapy for hyperthyroidism are small and, in observational studies, may only be detectable at higher levels of administered dose.

Серцеві наслідки тяжкого тиреотоксикозу та їх зміни у віддаленому періоді після хірургічного лікування

Актуальність. Результатом хірургічного лікування зоба з тяжким тиреотоксикозом може бути поліпшення загального стану і фізичної активності, зменшення та/або ліквідація клінічних проявів тиреотоксичної кардіоміопатії (ефективне лікування) або ж погіршення загального стану (неефективне лікування). З позицій такого підходу віддалені результати хірургічного лікування токсичного зоба з тяжким тиреотоксикозом вивчені недостатньо. Мета. Вивчити віддалені результати хірургічного лікування хворих на токсичний зоб з тяжким тиреотоксикозом із пріоритетним дослідженням змін серцевої діяльності і фізичної активності. Матеріали та методи. Дослідження проведено у 123 лікованих хірургічним методом хворих на тяжку форму токсичного зоба. Вік пацієнтів становив від 21 до 74 років. Тривалість тиреотоксикозу перебувала в межах від 18 до 74 місяців. Показаннями до хірургічного лікування були часті рецидиви тиреотоксикозу, прогресування тиреотоксичної кардіоміопатії на тлі тиреостатичної терапії з розвитком розладів ритму серцевої діяльності й серцевої недостатності. Вивчали структурні й функціональні зміни в серці за даними ехокардіографії в режимі В, розлади серцевої діяльності за результатами добового холтерівського моніторингу ЕКГ, фізичну активність за даними тесту шестихвилинної ходьби. Віддалені наслідки лікування оцінювали за розробленими градаціями: добрий, задовільний, незадовільний результат і неефективне лікування. Результати. Встановлено, що хірургічне лікування хворих на токсичний зоб з тяжким тиреотоксикозом дозволяє ліквідувати тиреотоксикоз, а в частини пацієнтів — розлади ритму серцевої діяльності, зменшити інтенсивність клінічних проявів тиреотоксичної кардіоміопатії, поліпшити фізичну активність і загальний стан хворих. Проведені дослідження показали, що результати хірургічного лікування залежать від тяжкості розладів ритму серцевої діяльності й серцевої недостатності, тобто наслідків тиреотоксикозу, що розвиваються на основі тиреотоксичної кардіоміопатії. Добрий і задовільний результати хірургічного лікування отримано в 55 (44,7 %) випадках, незадовільний результат — у 40 (32,5 %) хворих, і неефективним лікування було у 28 (22,8 %) пацієнтів. Висновки. Хірургічне лікування хворих на токсичний зоб з тяжким тиреотоксикозом дозволяє досягнути позитивних результатів: ліквідувати тиреотоксикоз, зменшити інтенсивність клінічних проявів тиреотоксичної кардіоміопатії, поліпшити серцеву діяльність, фізичну активність і загальний стан пацієнтів. Віддалені результати хірургічного лікування хворих на тяжкий тиреотоксикоз залежать від тривалості захворювання, медикаментозної терапії тиреотоксикозу і віку пацієнтів. Зі збільшенням значень цих показників результати лікування погіршуються. Серед існуючих показань до хірургічного лікування хворих на токсичний зоб з проявами тяжкого тиреотоксикозу першим і основним є наявність тиреотоксичної кардіоміопатії з розладами ритму серцевої діяльності. Універсальним показником для прогнозування віддалених результатів хірургічного лікування хворих на токсичний зоб є довжина пройденої відстані тесту шестихвилинної ходьби.

Lithium as an adjuvant to 131I therapy for hyperthyroidism complicated by severe jaundice in 4 cases

Lithium as an adjuvant to 131I therapy for hyperthyroidism complicated by severe jaundice in 4 cases

Plasmapheresis as First Line Therapy for Thyrotoxicosis in a Critically Ill Patient

Introduction: The role of plasmapheresis (TPE) in thyrotoxicosis management is not well established. Its use may be determined on an individualized basis (1). We report a case of a critically ill patient where TPE was utilized as first-line therapy for refractory thyrotoxicosis. Clinical Case: A 33-year-old woman with Graves’ disease complicated by medication non-adherence presented with rapidly ascending paralysis and bulbar weakness. Primary work up was consistent with acute inflammatory demyelinating polyneuropathy (AIDP) based on EMG findings of motor fiber polyneuropathy with demyelinating features. Laboratory evaluation revealed uncontrolled hyperthyroidism (TSH <0.05 uU/mL, N 0.3-4.2 uU/mL; fT4 3.9 ng/dL, N 0.6-1.5 ng/dL; tT3 318, N 60-160 ng/dL). Initially, there was low concern for thyrotoxicosis based on a Burch-Wartofsky score of 15 (2). Standard dose methimazole and aggressive beta-blockade were initiated. Hospital course was complicated by hypoxic respiratory failure due to progressive paralysis requiring intubation and septic shock from Klebsiella pneumonia requiring initiation of pressors and broad-spectrum antibiotics. Biochemical evaluation showed increasing fT4 (3.8 ng/dL) and tT3 (419 ng/dL) levels. Burch-Wartofsky score increased to 55, consistent with a thyrotoxic crisis. Due to the patient’s critical condition, TPE was rapidly initiated along with standard therapy for thyrotoxic crisis (high dose methimazole, esmolol drip, stress dose corticosteroids, cholestyramine, and potassium iodide) as a bridge to definitive management with thyroidectomy. Rapid clinical improvement with a decline in fT4 levels (3.8 to 2.1 ng/dL) was noted after initiation of TPE with normalization in fT4 (1.5 ng/dL) and tT3 (54 ng/dL) after three sessions. Thyroidectomy was pursued after clinical stabilization. Surgical pathology showed diffuse papillary hyperplasia consistent with Graves’ disease. Due to persistent respiratory failure, the patient underwent tracheostomy placement. Repeat EMG revealed severe myopathic dysfunction without demyelinating features favoring a diagnosis of acute thyrotoxic myopathy over AIDP. Patient was ultimately discharged to a long term acute care facility due to slow neurological recovery. Conclusion: TPE should be considered as first line management in conjunction with conventional medical therapy in critically ill patients with thyrotoxicosis as a bridge to thyroidectomy due to rapid time to effect and patient stabilization.

Survey of Practice: The Current Extent of Adjunctive Use of Lithium in the UK During Radioactive Iodine Therapy for Hyperthyroidism

Abstract Background: The latest United Kingdom National Institute for Health and Care Excellence (NICE) guideline recommends 131I as first-line definitive treatment for Graves’ disease in patients who are unlikely to achieve remission with antithyroid medication. A small but significant proportion of patients have recurrence of hyperthyroidism after 131I therapy. Lithium enhances thyroidal iodine retention and thus increases radiation dose delivered to the thyroid gland during 131I therapy. While clinical trial findings with adjuvant Lithium have not been universally positive, several studies have demonstrated a favorable effect on cure rate, speed of cure and stabilization of thyroid hormone status during131I therapy. Aim: To determine the extent to which Lithium is used as an adjunct to 131I therapy for hyperthyroidism in the UK. Methods: We conducted a survey of 82 nuclear medicine departments and 236 consultant endocrinologists in National Health Service (NHS) hospitals across the UK. Results: Responses were received from 43 departments and 64 endocrinologists. Ten nuclear medicine departments reported that they do not perform therapeutic procedures. Amongst the remainder, only one department stated that Lithium is considered routinely as an adjunct to 131I for selected patients. Amongst consultant endocrinologists, only two indicated that they use Lithium as an adjunct to 131I therapy. Conclusions: Owing to mixed trial evidence and a lack of guideline support for adjunctive Lithium with 131I, its use is not widespread the UK at present. However, some researchers report that it might offer faster control of hyperthyroidism and reduce the amplitude of post-therapy thyroid function fluctuations. As these could be important determinants not only of quality of life but also of safety of treatment, our findings may be valuable to those planning randomized controlled trials of adjunctive Lithium with 131I therapy for Graves’ disease.

A Higher Cutoff for TSI Would Better Predict Recurrence in Patients With Graves’ Disease?

Introduction: GD is an autoimmune disease mediated by immunoglobulins (Igs) that activate TSH receptor (rTSH). Relapse after withdrawal of antithyroid drugs (ATD) can reach 60%. Measurement of TSH receptor antibodies (TRAb) and thyroid stimulating immunoglobulin (TSI) could be an indirect indicator of GD activity. TRAb assays measures thyroid-stimulating, thyroid-blocking and neutral Igs; TSI assays measures only stimulating Igs. Objetive: Evaluate, prospectively, autoimmunity before and after ATD therapy for thyrotoxicosis through TSI measurement. Methods: Patients were evaluated at the first visit and at the time of ATD withdrawal. TSH, thyroid hormones, TPO antibody, thyroglobulin antibody, and TRAb were measured using eletrochemiluminescent assays Roche Diagnostics; TSI was determined by chemiluminescent assay Siemens Diagnostics. According to manufacturers, TRAb < 1.75 IU/L and TSI < 0.55 IU/L were negative. Results: Sixty-seven patients mean age 45,7±2,45 years, 65 women, were evaluated: 50 at the first visit, 40 (80%) with GD, and 10 (20%) with toxic multinodular goiter (TMNG). TSI diagnostic sensitivity (Sen%) and specificity (Spe%) to diagnose GD were 90% and 100% respectively, similar to that of TRAb, of 89% and 100%. Thirty-six patients were evaluated for recurrence after suspension of ATD (19 of them also had the initial assessment): 21 (58.3%) did not present recurrence in an mean period of 9.5±2.1 months (3-18); and 15 (41.7%) relapsed in 4.4±2.6 months (2-12). In 10/21 patients who did not relapse, and whose TRAb was negative, TSI was positive at low levels, which was responsible for the low Spe% of this test. Assessing possible other cutoff points for the TSI in the recurrence assessment, an adjustment to 1.4 (TSI <1.4 IU/L = negative) raised the Spe% to 86%. Conclusions: In this group, TSI and TRAb were equivalent for GD diagnosis. Many clinical factors have been suggested and TRAb measurement is known to be useful for predicting GD relapse because of the active pathogenic role of TRAb. For predicting recurrence, with the proposed cutoff point proposed by the kit manufacturer for TSI, a better sensitivity was obtained when compared with TRAb (93% versus 67%), despite very low specificity (38%); by raising the cutting point to 1.4 specificity could be increased to 86% without reduced sensitivity. A larger sample in needed to support a higher TSI cutoff point in the clinical routine for the assessment of GD recurrence after ATD.

A Case for Lithium Pretreatment Prior to Radioactive Iodine Ablation in Grave’s Disease

Radioactive iodine ablation (RAIA) therapy with Iodine-131 (I-131) is an established treatment for grave’s thyrotoxicosis. However, there is 10 to 20% chance of treatment failure. Lithium, a drug used to treat bipolar disorder, has significant effects on thyroid function. The most clinically relevant is the inhibition of thyroid hormone release. It is also known to inhibit colloid formation, and is involved in blocking organic iodine as well as thyroid hormone release from the thyroid gland without an effect on radioiodine uptake. This leads to increased radioiodine retention in the thyroid gland. Here, we present a case which exemplifies this action of lithium. A 46 year old male with a history of atrial fibrillation and grave’s disease presented to the endocrine clinic. TSH was <0.01 and FT4 was 36. RAI uptake (RAIU) scan showed diffusely increased uptakes with 4 and 24 hour values of 61.2 and 54.6 %. He subsequently underwent RAI ablation with 18 mCi of I 131. He then presented three years later with persistent hyperthyroid symptoms. TSH <0.01 and FT4 4.3. RAIU showed 24-h thyroid uptake of 41%. Patient opted for a second treatment with RAIA and was treated with 30 millicuries of I 131. He however continued to have clinical and biochemical evidence of thyrotoxicosis and was started on methimazole (MMI). Although he was biochemically euthyroid on MMI, he continued to complain of hyperthyroid symptoms such as palpitations, tremors and weight loss. When methimazole was briefly held six months after initiation, TSH was undetectable and FT4 had increased from 0.83 to 1.42. He subsequently underwent a third RAIU off MMI which showed normal 4 and 24 hour uptake, measuring 15.7% and 28% respectively. Patient subsequently opted for third trial of RAI ablation with lithium pretreatment. He declined surgery. He was started on lithium 900mg/day for 6 days, starting on the day of RAI ablation. He underwent RAI ablation with 45 mCi I-131. Patient tolerated the procedure well with subsequent tests indicating hypothyroidism requiring levothyroxine supplementation. Patient’s hyperthyroid symptoms resolved. Several factors affect the efficacy of radioiodide therapy for hyperthyroidism including the short persistence of radioiodide in the thyroid gland. In hyperthyroid Graves’ patients, radioactive iodide uptake is enhanced due to presence of TSH receptor antibody, however, radioiodide is also rapidly discharged because of its increased turnover. Lithium can significantly reduce the release of iodine from the thyroid gland and thus increase iodine retention. There is evidence to suggest that adjuvant lithium can increase thyroidal radioiodine uptake in patients with a low baseline RAIU (< 30%). This case demonstrate that lithium can be used safely prior to RAI therapy in cases of RAI ablation failure even with low baseline RAIU.

A prospective study of the effects of radioiodine therapy for hyperthyroidism in patients with minimally active Graves’ ophthalmopathy

A prospective study of the effects of radioiodine therapy for hyperthyroidism in patients with minimally active Graves’ ophthalmopathy

A comparative study of melasma severity after hyperthyroid therapy in hyperthyroid subjects with melasma

Melasma, and its variant chloasma, is an acquired and chronic disorder of hyperpigmentation, characterized by symmetrical hypermelanoses of the face. The exact pathogenesis of melasma remains unclear. Several hormones are thought to play a role, including thyroid hormones. The study's objectives are to determine the proportion of melasma cases in hyperthyroid patients and to compare the severity of melasma before and after medications of hyperthyroid therapy. A quasi-experimental (pre-post intervention) study was conducted in Jakarta from August 2019 to February 2020. Twenty-three patients either newly diagnosed with hyperthyroidism or that had undergone hyperthyroid therapy for a maximum of 3 months and also had melasma were recruited. The severity of melasma was scored with the modified Melasma Area and Severity Index (mMASI), and dermoscopy of the lesions was performed. The evaluation was performed after 3 months of hyperthyroid therapy. Among the 69 hyperthyroid patients, 45 (65%) had melasma. The mean difference in the mMASI score was 0.49 (p > 0.05). Dermoscopy features did not show any differences between the start and end of the study. There is no significant improvement of melasma severity in hyperthyroid patients after 3 months of hyperthyroid therapy.

Svim sporednim putevima do izlečenja hipertireoze - zamke i mogućnosti

There are three basic modalities for the treatment of thyrotoxicosis: thyrosuppresive drug therapy, ablation with radioactive iodine and surgical treatment. Patients who do not achieve adequate thyrotoxicosis control, as was the case of described patient, have a high mortality rate due to the possibility of developing a thyroid storm. The use of drug therapy for hyperthyroidism, as the first line of treatment, is associated with the appearance of various side effects, as was the case in our patient. Side effects of Methimazole are dose-dependent, while in the case of Propylthiouracil, the occurrence of side effects is not clearly dose-dependent. In the case of the described patient, all alternative, lesser known modalities for the treatment of hyperthyroidism were applied, after the occurrence of adverse reactions to thyrosuppressive therapy. Sodium perchlorate, ie. Sodium with perchloric acid is rarely used in the treatment of hyperthyroidism, as in cases of severe idiosyncratic reactions to thionamides, agranulocytosis or hepatitis, if the eumetabolic state is not achieved and the application of a therapeutic dose of radioiodine is not possible. It is applied in the form of a solution, usually 8%; In more severe forms of the disease, when hyperthyroidism is very pronounced, 10 to 15 drops a day are given 4 to 6 times and the dose is sometimes reduced to the minimum maintenance dose. After the adverse reaction even to sodium perchlorate therapy we were left with one more, last option-Plasma Therapy exchange. Plasma Therapy Exchange (TPE) is an out-of-body blood purification technique designed to remove high-molecular-weight substances bound to plasma proteins (autoantibody pathogens, immunocomplexes, cryoglobulins, myeloma light chains, endotoxins, lipoprotein-containing cholesterol, and thyroid). The effectiveness of treatment depends on the volume of blood being processed, the volume of plasma exchanged in each process, the number of procedures performed, the frequency of exchange and the rate of mobilization, stabilization and re-synthesis of cells or plasma components. TPE is an effective alternative treatment that provides an opportunity to prepare patients for definitive treatment: ablative therapy such as RAI ablation or thyroidectomy. Therapeutic plasmapheresis, if performed in specialist centers, is a safe, fast and effective method.