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New guidelines outline diagnosis, management of hyperthyroidism
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The American Association of Clinical Endocrinologists and the American Thyroid Association have collaborated to release new guidelines outlining the appropriate management of patients with hyperthyroidism and other causes of thyrotoxicosis.
“Our goal with these new guidelines is to provide every doctor treating thyroid patients the tools they need to provide the most effective care,” AACE president Yehuda Handelsman, MD, said in a press release. “Today, we have access to more clinical research data than ever before, and these guidelines help put that knowledge in the physicians’ hands.”
Key updates to optimize care
Important updates address the treatment of Graves’ disease, specifically regarding various therapeutic options, according to Rebecca S. Bahn, MD, chairwoman of the joint task force charged with developing the guidelines.
“The new guidelines review well-established treatment options for Graves’ disease while emphasizing how and when physicians should take their patients’ preference into consideration,” Jeffrey R. Garber, MD, president-elect of the American College of Endocrinology and an Endocrine Today Editorial Board member, said in a press release.
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According to Bahn, another major update is the task force’s decision to not endorse specific therapies for Graves’ disease over others.
“The guidelines state that [radioactive iodine therapy, antithyroid medication and thyroidectomy] are all acceptable treatment options,” Bahn, professor of medicine and consultant in endocrinology, metabolism and nutrition at the Mayo Clinic, Rochester, Minn., told Endocrine Today. “This is a significant change because past guidelines in the United States have been more in favor of radioactive iodine as the first-line treatment for every patient. We’re taking a bit of a different tack.”
The task force takes a stronger stance on recommended antithyroid medications. If medication is a patient’s therapy of choice, the guidelines strongly suggest that physicians prescribe methimazole or carbimazole outside of the United States instead of propylthiouracil (PTU) because previous research has linked PTU to severe liver failure. This recommendation, however, does not hold in every instance, Bahn said. Methimazole has been associated with birth defects; therefore, the task force recommends that pregnant women use PTU during the first trimester and then switch to methimazole during the second and third trimesters and postpartum if hyperthyroidism persists. Further, because severe liver failure related to PTU use is more common in children, the guidelines strongly recommend that methimazole, instead of PTU, be used in the pediatric population with Graves’ disease.
Other updates address treating hyperthyroidism related to nodular thyroid disease, including multinodular, goiter or toxic adenoma. Currently, radioactive iodine and thyroidectomy are the most popular treatment options, but the guidelines also suggest that long-term, low-dose methimazole may be appropriate in some instances. Generally, this suggestion is limited to elderly patients or those with shorter life expectancies.
The task force also provided recommendations that patients with active moderate to severe Graves’ ophthalmopathy be treated with methimazole or surgery, and not radioactive iodine. The guidelines note, however, that those with mild disease who smoke and choose radioactive iodine treatment should take concurrent corticosteroids or consider surgery or antithyroid medication instead.
New directions
The new guidelines are patient-centric and emphasize that decisions regarding treatment of hyperthyroidism should be made jointly by the patient and the physician with consideration of both the specific clinical setting and the patient’s preference, Bahn said. She suggested providing a copy of the guidelines to interested patients in appropriate situations.
“Although these guidelines offer recommendations and educated information for clinical practice, they are just guidelines,” Bahn said. “The final decision for all of these things depends on a conversation between the patient and the physician, which requires informed decision-making on both sides.” – by Melissa Foster
For more information:
Disclosure: Dr. Bahn reports no relevant financial disclosures.
These guidelines are much needed. They update previous guidelines from the ATA and AACE, but go much further, including other aspects of thyrotoxicosis, diagnosis and treatment that were previously not addressed with evidenced-based recommendations. Eighty percent of the rated recommendations are strong, but more than two-thirds of the recommendations are based on low-quality evidence, simply emphasizing the fact that much of what we do is based on expert opinion.
The guidelines cover the spectrum of Graves’ disease management quite well. The experts outline strategies based on clinical facts and patient expectations that provide a useful structure within which to interpret our discussions with patients about choosing an acceptable clinical approach. A section on the management of subclinical hyperthyroidism is also included, which lays out useful scenarios of management strategy. As this guideline is the most comprehensive to date, it is perhaps not surprising that a unique section on the inducement of hyperthyroidism with iodine is included, and the work also contains information on the therapeutic use of iodine in the patient with thyrotoxicosis. This discussion of iodine is quite comprehensive and interesting.
Overall, this is a large step forward in providing those who manage patients with thyrotoxicosis with a logical, precise and well-written reference to optimize patient outcomes. As the evidence for the majority of what we say is revealed to be of low quality, these guidelines also identify gaps in our knowledge that should be the focus of investigation for years to come.
– James V. Hennessey, MD
Director, Clinical Endocrinology
Division of Endocrinology
Beth Israel Deaconess Medical Center
Disclosure: Dr. Hennessey reports no relevant disclosures.
Note: Read an editorial about the guidelines written by Dr. Hennessey and colleagues in the June 2011 issue of Thyroid.
Pearce EN. Thyroid. 2011;21:573-576.
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