[Momof5]

#1059954

Controversies in the management of Graves’ disease

http://onlinelibrary…98.00558.x/full

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The evidence therefore remains incomplete but at present, treatment for 18 months can be recommended for titration therapy in adults. With this approach, 2 year post treatment remission rates of around 60% should be achievable in adults in iodine sufficient areas.

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The remission rate in patients with a large goitre (> 40 mls) and high pretreatment titre of TRAb was as low as 9% in contrast to a rate of 80% with a small goitre and a low titre of antibodies. Nonetheless, reliable prediction of outcome was still not possible for the majority of patients indicating that the measurement of these parameters has a limited role in guiding the choice of therapy.

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Many patients receive thionamides prior to radioiodine (RAI), either to control thyrotoxicosis before primary therapy with radioiodine or because they have relapsed following a trial of drug therapy. Retrospective studies suggest that the failure rate of RAI therapy is increased 2.5–3 fold if thionamide therapy is not withdrawn 7 days before treatment ( Koroscil, 1995; Lloyd et al., 1997 ). Lloyd et al. (1997 ) also noted a trend towards an increased failure rate even if thionamides were withdrawn a week or more before RAI dosing (9% failure rate − no thionamide; 17% − withdrawn > 7 days before; 29% − withdrawn 4–7 days before). However, if thionamides have only been given in a brief course to achieve euthyroidism, thyroid function may already be returning to thyrotoxic levels 7 days after stopping therapy ( Burch et al., 1994 ). Interestingly, a prospective study of thionamide therapy begun 4 days after RAI indicates little effect on radioidine efficacy at this time ( Kung et al., 1995 ), and some authors recommend routine block-replace therapy for 6 months post RAI to avoid sudden onset hypothyroidism.

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According to these data, patients are at risk of changing thyroid function at anytime after treatment with all three modalities unless they have become permanently hypothyroid and are maintained on a full dose of thyroxine replacement. Nonetheless, more than 90% of patients who have become euthyroid within 1 year of surgery or radioiodine are unlikely to have a recurrence of hyperthyroidism and the same is true for 80–90% of patients 5 years after thionamide therapy.

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In a 15 year follow-up study by Hedley of 434 patients, 40% relapsed during the first year following medical therapy, this figure rising to 58% at 5 years and 61% at 10 years. In this series, 95% of all relapses occurred within 5 years with negligible increase in relapses after 10–15 years ( Hedley et al., 1989 )

[Kimberly]

#1179025

Interesting article – and a nice section on advantages/disadvantages of each of the three treatment options.

[Momof5]

#1179026

Lots of things stuck out for me, but the use of ATD’s prior to RAI reducing the effectiveness of RAI was something I hadn’t stumbled upon before.

Also, that after 5 years of remission the chances of having it again or negligible. I wonder why.

[Kimberly]

#1179027

Yes, it would be interesting to know if there is anything other than the currently documented criteria we know about (gender, antibody levels, goiter presence, smoking status) that makes patients with lasting remissions stand out from those who relapse more quickly.

[gerical]

#1179028

Thanks for all this information. for someone just starting out with all of this it is very useful.

[Author]

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