Treatment Of Hyperthyroidism Research Articles

Endocrinology: what's new in 2023

This overview provides a selection of studies published in 2023 with an impact on clinical practice. In reproductive endocrinology, important studies have addressed fertility preservation in men with Klinefelter's syndrome, the cardiovascular safety of testosterone replacement therapy, and a novel therapy, fezolinetant, for vasomotor symptoms of menopause. The updated European recommendations concerning adrenal incidentalomas will considerably modify current clinical practice. Based on a solid epidemiological work, the prevalence of pituitary adenomas has been confirmed to affect about 1 per 1000 individuals. Finally, a large British study allows to refine the benefit-risk profile of the three options available for the treatment of hyperthyroidism.

Preoperative Preparation in Hyperthyroidism and Surgery in the Hyperthyroid State.

Hyperthyroidism is a clinical condition that develops due to the excessive production and secretion of thyroid hormones by the thyroid gland, leading to an elevated concentration of thyroid hormones in tissues. Hyperthyroidism is characterized by low TSH and elevated T3 and/or T4, with the most common causes being Graves' disease, toxic multinodular goiter, and solitary toxic adenoma. T3 is the peripherally active form of thyroid hormone, affecting nearly each tissue and system. The most prominent aspects of hyperthyroidism are related to the cardiovascular system. The treatment of hyperthyroidism includes three options: antithyroid drugs (ATDs), radioactive iodine therapy (RAI), and surgery. Among these treatment modalities, surgery is considered as the most effective one. For patients who are candidates for surgery, preoperative preparation is required to ensure that the thyroidectomy can be performed under optimal conditions. Preoperative preparation should be a combination therapy aimed at preventing the synthesis, secretion, and peripheral effects of thyroid hormones from the thyroid gland. Medications that can be used in this treatment include thionamides, beta-blockers, iodine, corticosteroids, cholestyramine, perchlorate, lithium, and therapeutic plasma exchange. These treatment options can be combined based on the patient's condition. While it is recommended that patients be made euthyroid through preoperative antithyroid treatment to prevent the feared complication, which is the thyroid storm, the supporting evidence is limited. Preoperative treatment does not prevent against thyroid storm whether the patient is euthyroid or hyperthyroid during surgery. Whether surgery should be delayed until biochemical euthyroidism is achieved in hyperthyroid patients remains a topic of debate. Recent studies suggest that thyroidectomy can be safely performed during the hyperthyroid phase by experienced anesthesiologists and surgeons without precipitating thyroid storm or increasing intraoperative and postoperative complications. Although achieving the euthyroid state before surgery is ideal in hyperthyroid patients, it is not always possible. Factors such as allergies to medications, drug side effects, treatment-resistant disease, patient noncompliance, and the urgency of definitive treatment are critical in determining whether hyperthyroidism can be controlled preoperatively. When surgery is necessary in hyperthyroid patients without achieving euthyroidism, the patient's overall condition and comorbidities should be evaluated together by the anesthesiologist, surgeon and endocrinologist, with particular attention to stabilizing the cardiovascular system. We believe that in hyperthyroid patients who are cardiovascularly stable during the hyperthyroid phase, thyroid surgery may not need to be delayed and can be performed safely.

Analysis of the Progress of Chinese Medicine Treatment of Hyperthyroidism

Analysis of the Progress of Chinese Medicine Treatment of Hyperthyroidism

Current status of the thyroid hormone measurement items in patients receiving levothyroxine monotherapy by the management based on the thyroid tissue volume.

We and other investigators reported that mild TSH suppression with levothyroxine (LT4) was needed to achieve normal free triiodothyronine (FT3) levels and metabolic euthyroid state in athyreotic patients. Consequently, management methods based on thyroid tissue volume have been implemented for patients receiving LT4 at the Kuma Hospital. This retrospective study examined the composition of the thyroid hormone measurement items (serum-free thyroxine [FT4], FT3, and FT4 + FT3) in patients receiving LT4 monotherapy. According to the etiology of hypothyroidism, 36% of the 25,523 patients included in this study underwent total thyroidectomy (TT). Thirteen percent and 14% had undergone 131I treatment for hyperthyroidism (RIT) and partial thyroidectomy (PT), respectively. Moreover, 37% of patients had received non-invasive treatment (NIT). The proportion of patients who underwent only FT3 measurements was higher (TT, 93%; RIT, 61%) in the first two groups, whereas the proportion of patients who underwent only FT4 measurements was higher (PT, 50%; NIT, 65%) in the remaining two groups. Only FT3 measurements were performed in 58% of patients. Only FT4 measurements were performed in 34% of patients. The serum TSH levels were suppressed in nearly half of the patients (46%). Thus, FT3 was the major thyroid hormone measured in patients receiving LT4 treatment, and the serum TSH levels were suppressed in nearly half of the patients. This may be attributed to the management guidelines at our hospital, a specialized facility for thyroid disease, wherein half of the patients present are athyreotic or have atrophic thyroid glands after TT or RIT.

Estimation of Thiocyanate Content from Selected Cruciferous Vegetables

ABSTRACT: As per the studies conducted by the Indian Thyroid Society, it is suggested that one out of ten people in India suffer from hypothyroidism and these figures are likely to increase in the near future. According to the survey, women in the post-menopausal age group are more affected in comparison to men. Globally, the prevalence of hypothyroidism is 4-5%. Taking the same into consideration, a comparative study was undertaken to estimate the thiocyanate content in cruciferous vegetables such as Raphanus sativus (radish), Brassica rapa (turnip), Brassica okracea var. botrytis (cauliflower) Brassica oleracea (broccoli), Brassica clearccea var. botrytis (cabbage). Increased levels of thiocyanate often cause imbalance of the thyroid hormones by inhibiting iodine uptake thereby leading to hypothyroidism. Thiocyanate is therefore also employed in the treatment of hyperthyroidism. This study used 10 gram of sample extract in triplicates that were obtained from different markets, treated with ferric chloride leading to the formation of a colored complex and the amounts of thiocyanate was evaluated colorimetrically. It was observed that the thiocyanate content in cabbage was the highest followed by radish, turnip, broccoli and cauliflower. High thiocyanate content coupled with low iodine content go a long way in leading to goiter which is a clinical manifestation of any abnormality associated with thyroid gland. This leads us to very important conclusion that while ascertaining causes of any abnormalities of the thyroid gland that a person’s diet needs to be taken into consideration.

The Presence of Anti-TPO Antibodies Increase the Likelihood of Post-I131 Hypothyroidism.

The use of radioactive iodine in the treatment of hyperthyroidism is common practice. However, a standardized treatment protocol with regard to radioactive iodine treatment (RAI) remains subject to discussion. We retrospectively analyzed 100 patient records. Patient diagnosis, age, gender, body mass index (BMI), dose of radioactive iodine, thyroid size, the 24 h radioiodine uptake (24 h RAIU) and protein bound iodine (PBI) were deducted, as well as the use of antithyroid drugs prior to RAI. Biochemical parameters were obtained, such as TSH, fT4, fT3, Anti-TPO, Anti-TG antibodies and thyroid stimulating antibodies. After 5 years of follow-up, 46% of the patients proved to be hypothyroid, whereas 8% of the patients were not cured after one dose of RAI. One year after RAI, a larger proportion of patients with a toxic nodule developed hypothyroidism compared to patients with a multinodular goiter (MNG) (44.2% vs. 21.2%). Radioactive iodine dose, PBI, RAIU, BMI, size of the thyroid gland, diagnosis, age and TPO-antibodies showed statistically significant differences in the development of hypothyroidism. Furthermore, thiamazole pretherapy was shown to be a predictor of hypothyroidism, as well as a high PBI value, exhibiting a positive predictive value of 85.2% when the PBI exceeded 0.16. We suggest a standardized measurement of TPO-Ab's to further determine their role in the development of hypothyroidism after RAI. The empirical dosing regimen was very effective, illustrating a 92% cure rate after 1 dose.

The Rare Sore Throat: A Case of Thyroid Storm and Agranulocytosis.

Thyroid storm is a rare but potentially life-threatening metabolic disorder that presents unique management challenges in the emergency department. Thionamides are commonly used as monotherapy for first-line treatment of hyperthyroidism. In this case, a 26-year-old male presented to the emergency department with sore throat, fever, and diarrhea. He was found to have thyrotoxicosis as well as methimazole-induced bone marrow suppression resulting in agranulocytosis. Thyroid storm is a rare condition that carries a high risk of mortality and can further compromise a patient's immune system due to complications of common treatment modalities. It can potentially be misdiagnosed as sepsis due to tachycardia, febrile state, and tachypnea. This case report includes a discussion of diagnostic studies, as well as medical and surgical treatment modalities that led to the patient's recovery.

Graves’ disease – management of Graves’ orbitopathy and thyrotoxicosis, including new therapies

Graves' disease (GD) is the most common cause of hyperthyroidism in countries with adequate iodine supply, and its main extrathyroid manifestation is thyroid orbitopathy. For many years, thyrotoxicosis has been treated with antithyroid drugs, radioactive iodine therapy and thyroidectomy, and glucocorticoids have remained the standard treatment of thyroid eye disease (TED). Currently, there is a growing trend of using targeted therapies in the treatment of thyroid orbitopathy (TO). The significant development of immunobiology, a better understanding of the pathophysiology of the disease and a multitude of studies on new therapies give hope for better treatment results and an improvement in the quality of life of patients. The aim of the paper is to discuss the current principles of management of Graves' disease, including thyroid orbitopathy, with particular emphasis on new therapeutic methods. The potent role of K1-70TM and small molecule thyroid stimulating hormone (TSH) receptor antagonists in the treatment of hyperthyroidism is indicated. Not only do we point out the promising outcomes of combining glucocorticoids with mycophenolates, but also highlight the use of teprotumumab, rituximab, cyclosporin A, azathioprine, methotrexate, tocilizumab and sirolimus in the therapy of active moderate to severe form of orbitopathy. The protective and supportive effect of statins in the treatment of TED is noted. The limitations of the research results mentioned in the paper are remarked and the need for further randomized studies of long-term safety and efficacy in a larger group of patients is underlined.

Radioactive iodine treatment for Graves' hyperthyroidism: incidence of Graves orbitopathy.

There are limited recent data on the effect of radioactive iodine (RAI) for Graves' disease on Graves' orbitopathy (GO) development or reactivation. This audit investigates the GO incidence in patients with Graves' disease after RAI treatment, and explores risk factors present, and steroid prophylaxis use. A retrospective audit of Graves' disease patients treated with RAI over a 5-year period. Data collected: smoking status, thyroid-stimulating hormone receptor antibody (TRAb) status, GO history, Graves' disease duration, eye features pre- and post-treatment, prophylactic corticosteroids, RAI dose given, post-RAI thyroid status, duration until hypothyroid. One hundred one patients were included, with a median Graves' disease duration 36 months. 34/101 (33.7%) were active/ex-smokers, 86/101 (85.1%) were TRAb-positive, 11/101 (10.9%) had a GO history; 32 (31.7%) had eye features present. Median RAI dose given was 596MBq. 8/101 (7.9%) patients received prophylactic corticosteroid; 89/101 (88.1%) achieved hypothyroid state in the year after RAI. GO developed in 5/101 (5.0%), of which 4/5 (80%) were de novo in high-risk individuals who did not receive steroids. One was a GO reactivation despite steroids. Two required intravenous steroids with/without orbital radiotherapy, one completed oral steroid taper; the remainder were treated conservatively. Our cohort had a lower GO incidence in patients with Graves' disease receiving RAI, with majority arising de novo . It is essential that all patients are assessed for Graves orbitopathy risk factors and counselled adequately prior to RAI. The decision to initiate steroids should be undertaken in a multi-disciplinary setting involving endocrinologists and ophthalmologists.

Hyperthyroidism therapy: What can decision support systems already achieve?

AbstractCurrently, only a few theoretical support systems exist for the treatment of hyperthyroidism. They are typically not practically applicable and solely focus on Graves’ disease. The recently developed DigiThy software framework can be used to assist physicians for methimazole dose titration during the treatment of Graves’ disease. In this study, a pool of 60 virtual patients was created to compare physicians’ individual treatment approaches by 8 different physicians and students (including three colleagues, unexperienced with care of Graves’ disease) with the decision support system DigiThy in terms of already defined performance indices. These indices are used to assess the deviation of FT4 from the reference range throughout the treatment. The computer aided treatment algorithms outperformed the usual care approach according to different prespecified criteria for treatment success. Two out of the three unexperienced colleagues improved their treatment success over time, i.e. with more patients treated. In conclusion, our findings suggest that the DigiThy software may be a useful tool for use as a decision support system in routine care of patients with Graves’ disease, while also serving as an effective training tool for the education of physicians. Randomized controlled studies are required before implementation of DigiThy in daily clinical practice.

The impact of hyperthyroidism on sexual functions in men and women: a systematic review and meta-analysis.

This study aimed to review the current knowledge on sexual dysfunction in men and women with hyperthyroidism through a systematic review and meta-analysis. Available clinical trials from the MEDLINE database were searched using a prerecorded protocol (Protocol Prospero ID: CRD42022340587), and obtained data were analyzed and reported according to the PRISMA guidelines. Pooled effect estimates were computed using a random-effects model. Twenty eligible studies were identified, of which 15 were included in this meta-analysis. The prevalence of erectile dysfunction was significantly higher in participants with hyperthyroidism than that in controls [odds ratio = 9.16 (95% confidence interval [CI], 5.0-16.5)]. Treatment of hyperthyroidism alone improved erectile functions [effect size, ES = 0.36 (95% CI, -0.01-72)] and mean intra-vaginal ejaculation latency time [ES = 0.63 (95% CI, 0.27-98)] among men with erectile dysfunction and/or premature ejaculation. The prevalence of premature ejaculation also decreased with treatment of hyperthyroidism [odds ratio = 0.11 (95% CI, 0.04-28). Women with hyperthyroidism demonstrated higher odds in female sexual dysfunction than controls [odds ratio = 4.34 (95% CI, 2.63-7.18)]. Female sexual function index scores in women with hyperthyroidism were also significantly lower than those in the controls with moderate effect sizes. An evident and reversible disruption of sexual functions under hyperthyroidism conditions was observed in both sexes.

Hyperthyroidism: A Review.

Overt hyperthyroidism, defined as suppressed thyrotropin (previously thyroid-stimulating hormone) and high concentration of triiodothyronine (T3) and/or free thyroxine (FT4), affects approximately 0.2% to 1.4% of people worldwide. Subclinical hyperthyroidism, defined as low concentrations of thyrotropin and normal concentrations of T3 and FT4, affects approximately 0.7% to 1.4% of people worldwide. Untreated hyperthyroidism can cause cardiac arrhythmias, heart failure, osteoporosis, and adverse pregnancy outcomes. It may lead to unintentional weight loss and is associated with increased mortality. The most common cause of hyperthyroidism is Graves disease, with a global prevalence of 2% in women and 0.5% in men. Other causes of hyperthyroidism and thyrotoxicosis include toxic nodules and the thyrotoxic phase of thyroiditis. Common symptoms of thyrotoxicosis include anxiety, insomnia, palpitations, unintentional weight loss, diarrhea, and heat intolerance. Patients with Graves disease may have a diffusely enlarged thyroid gland, stare, or exophthalmos on examination. Patients with toxic nodules (ie, in which thyroid nodules develop autonomous function) may have symptoms from local compression of structures in the neck by the thyroid gland, such as dysphagia, orthopnea, or voice changes. Etiology can typically be established based on clinical presentation, thyroid function tests, and thyrotropin-receptor antibody status. Thyroid scintigraphy is recommended if thyroid nodules are present or the etiology is unclear. Thyrotoxicosis from thyroiditis may be observed if symptomatic or treated with supportive care. Treatment options for overt hyperthyroidism from autonomous thyroid nodules or Graves disease include antithyroid drugs, radioactive iodine ablation, and surgery. Treatment for subclinical hyperthyroidism is recommended for patients at highest risk of osteoporosis and cardiovascular disease, such as those older than 65 years or with persistent serum thyrotropin level less than 0.1 mIU/L. Hyperthyroidism affects 2.5% of adults worldwide and is associated with osteoporosis, heart disease, and increased mortality. First-line treatments are antithyroid drugs, thyroid surgery, and radioactive iodine treatment. Treatment choices should be individualized and patient centered.

Therapeutic Management and Long-Term Outcome of Hyperthyroidism in Patients with Antithyroid-Induced Agranulocytosis: A Retrospective, Multicenter Study.

Antithyroid drug-induced agranulocytosis (AIA) (neutrophils <500/µL) is a rare but serious complication in the treatment of hyperthyroidism. Adult patients with AIA who were followed up at 12 hospitals in Spain were retrospectively studied. A total of 29 patients were studied. The etiology of hyperthyroidism was distributed as follows: Graves' disease (n = 21), amiodarone-induced thyrotoxicosis (n = 7), and hyperfunctioning multinodular goiter (n = 1). Twenty-one patients were treated with methimazole, as well as six patients with carbimazole and two patients with propylthiouracil. The median (IQR) time to development of agranulocytosis was 6.0 (4.0-11.5) weeks. The most common presenting sign was fever accompanied by odynophagia. All of the patients required admission, reverse isolation, and broad-spectrum antibiotics; moreover, G-CSF was administered to 26 patients (89.7%). Twenty-one patients received definitive treatment, thirteen patients received surgery, nine patients received radioiodine, and one of the patients required both treatments. Spontaneous normalization of thyroid hormone values occurred in six patients (four patients with amiodarone-induced thyrotoxicosis and two patients with Graves' disease), and two patients died of septic shock secondary to AIA. AIA is a potentially lethal complication that usually appears around 6 weeks after the initiation of antithyroid therapy. Multiple drugs are required to control hyperthyroidism before definitive treatment; additionally, in a significant percentage of patients (mainly in those treated with amiodarone), hyperthyroidism resolved spontaneously.

Large method differences for free thyroid hormone assays in the hyperthyroid range can affect assessment of hyperthyroid status: Comparison of Abbott Alinity to Roche Cobas, Siemens Centaur and equilibrium dialysis LC-MS/MS

BackgroundFree T4 (FT4) determination is one of the most commonly performed biochemical tests in endocrinology. Treatment of thyroid dysfunctions is adjusted based on the severity of symptoms and biochemical test results. For Graves’ hyperthyroidism, clinical guidelines recommend using FT4 as a (rough) guide to dose antithyroid drugs, together with other clinical information. It is well known that different platforms and methods give different FT4 results; however, large non-linear method differences at high FT4 concentrations are less well recognized. Current clinical guidelines do not make it clear that method differences in the hyperthyroid range can affect recommendations. MethodSerum samples from patients with very low (biochemically hypothyroid) to very high (hyperthyroid) concentrations of FT4 and/or free T3 (FT3) were analyzed using Abbott Alinity and compared to concentrations measured using Roche Cobas, Siemens ADVIA Centaur (FT4 only) and an in-house equilibrium dialysis liquid chromatography tandem mass spectrometry (LC-MS/MS) method. ResultsAlinity measured markedly lower FT4 and FT3 concentrations compared to the other methods, particularly at high FT4 concentrations. Regression analysis indicated that Alinity FT4 had a non-linear (curved) relationship to FT4 measured by the other methods. The method differences affected guideline-recommended treatments for hyperthyroidism. ConclusionMeasured free thyroid hormone concentrations are highly method-dependent, especially at high FT4 concentrations. Clinicians treating hyperthyroid patients should be aware that patients appear much less hyperthyroid from FT4-measurements performed using Alinity compared to Cobas or Centaur. Guideline-recommended antithyroid drug dosages based on FT4 (including multiples of the upper reference range) have to be adjusted to the FT4 method used. FT4 results from different methods should be clearly distinguished (e.g. separate lines) in medical records.

A comparison between the anti-thyroid properties of methimazole and its derivatives with two S donor atoms endorsed by iodine adsorption capacity, docking and DFT calculations

Charge transfer adducts formed between iodine and several chemical families, such as thiourea and its derivatives, thiocyanates, and isothiocyanates have been studied for their pharmaceutical importance in hyperthyroidism treatment. The anti-thyroid activity of a sulfur-containing compound in vivo is directly related to the ease of charge transfer from sulfur to iodine [S(n.b) → σ*(I2)]. In the current work, for the first time six methimazole-based bidentate ligands (L0–L6) have been selected to investigate their anti-thyroid activity by in silico studies using docking and root mean square deviations (RMSD) calculations. Furthermore, their iodine adsorption ability has been studied experimentally and theoretically using DFT. The geometrical and electronic properties of these compounds were examined and compared with each other, and the nature of the SII bond has also been discussed. These compounds can adsorb iodine 3 to 9 times more than their weight in solution and vapor phase, which is an incredible record considering their simple structure. A comparison of the obtained result with methimazole as a known anti-thyroid drug indicates that, these compounds can be nominated as new anti-thyroid drugs. Regarding the extraordinary capacities of iodine adsorption, these linkers are strongly suggested for designing novel CPs/MOFs and COFs with iodine uptake purpose.

FRI542 Long-term Metabolic Outcomes In Graves’ Disease: Is There A Difference Between Oral Anti-thyroid Medications And Radioactive Iodine Treatment?

Abstract Disclosure: E. Shemesh: None. T. Kolitz: None. A. Nathan: None. K.M. Tordjman: None. Y. Greenman: None. E. Izkhakov: None. Introduction: The treatment of hyperthyroidism in patients with Graves’ disease (GD) is associated with various metabolic comorbidities, including weight gain and an increased risk of cardiovascular and cerebrovascular diseases. Few studies have assessed the potential differences in metabolic outcomes between radioactive iodine (RAI) and oral anti-thyroid drug (ATD) therapies. Aim: We sought to investigate the long-term (&amp;gt;10 years) metabolic effects of RAI versus ATD therapy in GD. We also compared the occurrence rates following long-term use to those with short-term (&amp;lt;5 years) use in order to explore a potential "legacy effect". Hypothesis: RAI and oral ATD treatment will differ in their associated risk of metabolic sequelae, including the occurrence of hypertension, dyslipidemia, obesity, and diabetes. Methods: Patients attending the Institute of Endocrinology at the Tel Aviv Sourasky Medical Center filled in a questionnaire on post-RAI or post-ATD treatment for GD. Results: In total, 143 participants had been followed-up for 5 years, and 87 of them (age range 31-88 years, 65 females [74.7%]) had completed &amp;gt;10 years of follow-up (mean follow-up period 14±1 years). During the initial 5-year follow-up period, RAI treatment was associated with a significantly increased rate of obesity and dyslipidemia in the short-term, but no comparable differences persisted into the &amp;gt;10-year follow-up period. However, mean fasting glucose concentrations were higher among RAI recipients compared to ATD recipients (106 and 91 mg/dL, respectively, p=0.037) even after 10 years, and the mean triglyceride concentration was also higher in the former (127 and 88 mg/dL, respectively, p=0.02). There were no significant group differences in the rates of diabetes mellitus or dyslipidemia in the &amp;gt;10-year follow-up period. Conclusions: RAI therapy is associated with long-term higher glucose and triglyceride levels compered to ATD therapy in patients with GD. Clinical metabolic diagnosis are comparable. The significant group differences in the occurrence of metabolic morbidities that had been observed after the first 5 years of follow-up persisted to a greater or lesser extent into the extended &amp;gt;10-year follow-up period, as evidenced by fasting glucose and triglycerides concentrations Presentation: Friday, June 16, 2023

FRI497 Thyroid Storm And Recurrent Myopericarditis

Abstract Disclosure: D.J. Gomez D' Aza: None. T. Zahedi: None. F. Zhang: None. Introduction: Thyroid storm is an acute life-threatening complication of hyperthyroidism with high mortality rate. Plasmapheresis is often used in patients who are unresponsiveness to conventional treatment for thyroid storm. About 5% of thyroid storm patients present with heart failure while other cardiovascular dysfunctions include tachycardia, arrhythmias, hypertension, and pericardial disease. Myopericarditis is characterized by pericarditis associated with myocardial inflammation evident by elevated cardiac biomarkers. Thyrotoxicosis associated with pericarditis and myocarditis is rare. Here, we report a case of recurrent myopericarditis and thyroid storm in Grave’s disease treated with plasmapheresis. Case Report: A 47 years male with a history of Schizophrenia and Hyperthyroidism due to Grave’s disease was presented with poor oral intake, generalized weakness, and tachycardia with HR 180 bpm. Labs showed elevated troponin 0.505 ng/mL, Free T4 &amp;gt; 6.99 mg/dL, T3 &amp;gt; 651 ng/dL, and low TSH &amp;lt; 0.015 mg/dL. Burch-Warsofsky scale was 50 points which suggested thyroid storm. EKG revealed atrial fibrillation. Patient was managed with propranolol, propylthiouracil (PTU), iodine solution, hydrocortisone, and Diltiazem. However, his mental status deteriorated requiring intubation and patient developed cardiac shock with BP 77/53 mmHg. Troponin I trended up to 23.60 ng/mL and EKG showed ST-segment elevation in the anterior and inferior leads. Echocardiogram revealed severely reduced ejection fraction of 15 % and diffuse hypokinesis. Cardiac catheterization was unremarkable. PTU was discontinued due to liver dysfunction with AST and ALT levels above 1500 U/L and 2500 U/L. A session of plasmapheresis was initiated and the post labs showed an improvement of thyroid and liver function to Free T4 2.46 mg/dL, TSH 0.022 mg/dL, and ALT/AST 641/682 U/L. Patient was hemodynamically stable with normal sinus rhythm. Cardiac magnetic resonance images revealed left ventricular dilation with high T2 signal, late gadolinium enhancement in the pericardial region of basal inferolateral, inferior, and mid segments, consistent with pericarditis. Previous record showed patient had a similar admission 4 months ago with a diagnosis of myopericarditis. Discussion: The association of recurrent myopericarditis and hyperthyroidism may be related with the autoimmune dysfunction and underlying viral infection that precipitated inflammation of the thyroid gland, triggered thyroid storm, and caused cardiac event. Rapid correction of the hyperthyroid state is warranted in thyroid storm in addition to aggressive treatments for heart failure, arrhythmias, and myopericarditis. Our patient’s cardiac function improved rapidly after achieving euthyroidism by plasmapheresis. The treatment of hyperthyroidism is critical in preventing the recurrence of myopericarditis. Presentation: Friday, June 16, 2023

FRI513 Pathological Bone Fracture In An Adolescent With Graves’ Disease

Abstract Disclosure: J. Hayes dorado: None. M. Calla Ayala: None. D. Vargas Sejas: None. E. Coca Tapia: None. G. Justiniano Vargas: None. F. Leon Arze: None. Graves’ disease is the most common pediatric cause of hyperthyroidism. Although hyperthyroidism has been reported to cause a decrease in bone mineral density (BMD), its association with bone fractures is rare. A 12-year-old female patient presented to emergency with left arm pain that started after collision with an electricity pole. Her medical history included fractured right femur one year previously. Her heart rate 128 beats/min, blood pressure 120/70 mm Hg, weight 44 kg, height 156 cm (75th percentile) and BMI 18 kg/m2(50th percentile). Family history was unremarkable. He had prominent thyromegaly with diffuse enlargement and soft consistency on palpation. X-ray revealed a fracture of left humerus. Demineralization of bone was detected. Blood Tests: calcium 8.9 mg/dL (8.5-10.5); phosphate 4.36 mg/dL (3.7-5.6); alkaline phosphatase 239 U/L (42-362); PTH 23 pg/mL (12-88); 25-OHD 22.8 ng/mL (20-80); TSH &amp;lt;0.01 μIU/mL (0.38-5.33); fT3 29 pg/mL (2.6-4.37); and fT4 5.13 ng/dL (0.61-1.2). Auto-antibodies were positive: thyroid peroxidase Abs 42 IU/mL (0-9), thyroglobulin Abs 21 IU/mL (0-4) and TSH Receptor Abs 7.33 IU/L (0-0.1). Complete blood count, liver, kidney function tests were normal. Thyroid ultrasonography showed a significant increase in thyroid gland volume and vascularization. A diagnosis of Graves’ disease was confirmed. Methimazole, propranolol, calcium and vitamin D therapies were started. Pre-treatment bone densitometry showed significantly low BMD: lumbar BMD (L1-L4) was 0.701 g/cm2 (Z-score - 2) and femoral BMD was 0.639 g/cm2 (Z-score -2). Euthyroidism was achieved after ten weeks of treatment and clinical signs of hyperthyroidism had improved. At six months follow up there were no clinical signs of hyperthyroidism and the patient remained euthyroid. Bone densitometry investigation one year after diagnosis showed marked improvement: lumbar BMD (L1-L4) was 0.898 g/cm2 (Z-score -0.5) and femoral BMD was 0.799 g/cm2 (Z-score -0.4). Untreated adolescents with Graves’ disease may present with fractures. It highlights the importance of considering hyperthyroidism as a possible diagnosis among the differential diagnoses of pathological bone fractures. Presentation: Friday, June 16, 2023

THU669 Time To Achieve Euthyroidism In Graves Disease Using Methimazole In An Urban Population

Abstract Disclosure: S.S. Habbsa: None. E. Yunasan: None. A. Krishnan: None. K.M. Munir: None. Context: Previous studies of treatment response in Graves disease have shown that that the mean time to reach euthyroidism with methimazole (MMI) was several weeks to months. In 1987 Okamura et al. concluded that the average period was 6-7 weeks with MMI 30mg daily. Nakamura et al. showed similar data in 2007 (5.8 +/- 4 weeks). These studies were performed in Japanese hospitals over 15 years ago. Limited data exists regarding treatment response times with different doses in a diverse urban population, which may vary with regards to typical dietary patterns, thyroid hormone metabolism and thionamide pharmacokinetics. Objective: The objective of this retrospective chart review was to determine the mean time to achieve euthyroidism with MMI in patients with newly diagnosed Graves disease in Baltimore City. Methods: Patients with Graves hyperthyroidism newly diagnosed in the last 5 years were identified from outpatient endocrine and primary care clinics within the University of Maryland Medical Center healthcare system. Time to achieve euthyroidism (from the start of thionamide therapy to date of euthyroid labs, defined as normal free T4 level) was assessed. Results: 128 patients with recently diagnosed Graves hyperthyroidism were identified (126 patients treated with MMI only and 2 with PTU only). 78% of subjects were female and the mean age at diagnosis was 47 years. The average daily dose of MMI ranged from 2.5mg to 60mg. On average, Free T4 decreased by 0.47 ng/dL per week. The mean time to achieve euthyroidism was 10.1 weeks (8.6, 11.6) overall, similar in males and females. On sub analysis, time to achieve euthyroidism was lower in younger males (age &amp;lt; 40 years) [6.6 weeks (3.9, 9.3)] and older females (age &amp;gt; 40 years) [8.3 (6.9, 9.7)]. Conclusion: The above data may inform expectations for treatment response for newly diagnosed Graves disease, specifically in an urban population on a Westernized diet. Patient forums have shown increasing interest in therapeutic alternatives to thionamides, including specialized diets. This data may help to determine whether other proposed therapies for initial treatment of Graves hyperthyroidism are more or less efficacious. Presentation: Thursday, June 15, 2023

THU662 Poor Response To Medical Treatment In A Patient With Amiodarone-induced Hyperthyroidism: A Therapeutic Dilemma

Abstract Disclosure: A.A. Asiri: None. R. Sulimani: None. W. Alkhidady: None. Introduction: Hyperthyroidism is a well-known complication of amiodarone therapy. An incidence of 3% is reported in North America1, and even higher percentages in amiodarone deplete areas of about 10%.2 Treatment of amiodarone-induced hyperthyroidism (AIH) is challenging, it depends on various factors including the type of AIH, dependence of the patient’s cardiac condition on amiodarone therapy, other complications or comorbidities of the patient such as hepatic injury or dysfunction and the response of the patient to antithyroid therapy. Clinical Case: We present a case of a 32-year-old lady with a therapeutic dilemma in treating type I AIH, resistant to medical therapy. Our patient first had acquired COVID-19-induced myocarditis in 2020 and subsequently developed sustained ventricular tachycardia and was treated with amiodarone and placed on an implantable cardioverter-defibrillators (ICD) device. Two years later in 2022, the patient developed type I amiodarone-induced hyperthyroidism, with a free T4 reaching 100 pmol/L (Reference range 15-22 pmol/L) and complicated with transaminitis. She was unresponsive to medical therapy including: anti-thyroid medications, IV high-dose hydrocortisone, potassium iodide drops, and cholestyramine. She also developed adverse events with two of the antithyroid medications, Carbimazole and PTU; where she had elevated liver enzymes more than five time upper limit of normal and a generalized skin rash with PTU. Plasmapheresis was not an option as some of her cardiac medications drug levels could be affected. She underwent an emergent total thyroidectomy with dual beta blockade (Propranolol and Sotalol) successfully without any post op events. Her T4 level normalized within 8 days of her operation and her liver enzymes normalized within 2 weeks. Conclusion: We report the success and safety of surgical management in a patient with a cardiac arrhythmia and uncontrolled severe amiodarone-induced hyperthyroidism in the setting of adequate beta blockade.