Total thyroidectomy safe for most older adults with Graves’ disease
Click Here to Manage Email Alerts
Few older adults who undergo total thyroidectomy for treatment of Graves’ disease developed hypoparathyroidism requiring calcitriol therapy, according to data published in Thyroid.
“Operative management with total thyroidectomy will not be the best option for all older adults with Graves’ disease, some of whom may have increased surgical risk due to other medical problems,” Carolyn Dacey Seib, MD, MAS, assistant professor in the department of surgery at Stanford University, told Healio. “However, surgery will be a good option for some older patients, including those with large or symptomatic goiters, thyroid eye disease, concurrent primary hyperparathyroidism or those who want expedient and definitive management of their hyperthyroidism. These patients should feel reassured that the incidence of hypoparathyroidism, in addition to neck hematoma or recurrent laryngeal nerve injury, in this study was low and feel comfortable asking for a referral to discuss thyroidectomy with a surgeon.”
Seib and colleagues conducted a population-based cohort study of 4,650 Medicare beneficiaries diagnosed with Graves’ disease who underwent a total thyroidectomy from 2007 to 2017 (mean age, 72.8 years; 85.6% women; 78.8% white). Age, sex, race and ethnicity, comorbidities and ZIP code of residence were collected. A claims-based frailty index was used to categorize patients as robust, prefrail, mildly frail or moderately to severely frail. Permanent hypoparathyroidism was identified through one or more Part D pharmacy claims for calcitriol 6 to 12 months after a total thyroidectomy. The percentage of participants with a concurrent diagnosis for hypoparathyroidism 1 year after thyroidectomy was determined. Researchers also collected incidences of neck hematoma and recurrent laryngeal nerve injury within 14 days of a thyroidectomy.
Of the cohort, 2.2% developed permanent hypoparathyroidism and were treated with calcitriol after thyroidectomy. Of those with a calcitriol prescription, 29.8% had a diagnosis code for hypoparathyroidism.
Adults with permanent hypoparathyroidism were older than those who did not develop the condition (mean age, 74.2 years vs. 72.8 years; P = .04). In multivariable analysis, adults aged 76 years or older had a higher likelihood for permanent hypoparathyroidism after a total thyroidectomy for the treatment of Graves’ disease compared with adults aged 66 to 75 years (adjusted OR = 1.68; 95% CI, 1.13-2.51). No other patient characteristics were associated with permanent hypoparathyroidism.
Few adults had other perioperative complications from total thyroidectomy, with 2.1% diagnosed with neck hematoma and 0.9% needing a hematoma evacuation within 14 days of a thyroidectomy. Of the cohort, 3.9% having a temporary or permanent recurrent laryngeal nerve injury, with 1.6% having a recurrent laryngeal nerve injury 6 to 12 months after their thyroidectomy.
Seib noted that researchers didn’t analyze surgeon operative experience as part of the study. She recommended older adults interested in operative management for Graves’ disease reach out to an experienced thyroid surgeon to reduce their risk of complications.
“We are doing further research to document the long-term benefits and risks of thyroidectomy for Graves’ disease in older adults, such as the incidence of cardiovascular disease and adverse events in this population,” Seib said. “This will help our older patients make more informed treatment decisions.”
For more information:
Carolyn Dacey Seib, MD, MAS, can be reached at cseib@stanford.edu.
Perspective
Back to Top
Rachel Pessah-Pollack, MD, FACE
Many patients in the U.S. with Graves’ disease are treated with antithyroid drugs and radioactive iodine ablation. The use of thyroidectomy in older adults with Graves’ disease remains rare due to concern for perioperative complications, including permanent hypoparathyroidism, which can be associated with a reduced quality of life. There are numerous benefits of thyroidectomy in carefully selected patients with Graves’ disease, including rapid resolution of hyperthyroidism and effective lowering of thyroid stimulation hormone receptor antibodies, and it is the preferred use in the presence of moderate to severe thyroid eye disease, which can be exacerbated by radioiodine therapy.
Seib and colleagues’ objective of this population-based longitudinal study of older adults with Graves’ disease in the U.S. was to determine the incidence of permanent hypoparathyroidism after thyroidectomy. The authors noted of the cohort, 2.2% developed permanent hypoparathyroidism requiring calcitriol and a low incidence of neck hematoma and recurrent laryngeal nerve injury after surgery. Prior international population-based studies have shown significantly higher rates of permanent hypoparathyroidism after thyroid surgery for benign disease.
On multivariable analysis in this study, the only factor associated with permanent hypoparathyroidism was patient age with adults older than 75 years having a higher likelihood compared with adults 66 to 75 years of age. Interestingly, concurrent parathyroidectomy and parathyroid auto-transplantation were not independently associated with permanent hypoparathyroidism.
There were a few limitations in this study, including no assessment of the experience of the surgeon, complexity of the surgical case and preoperative thyroid status. Surgical complications are demonstrated to be lower when performed by surgeons with thyroid surgery expertise. Additionally, the study population was primarily female and approximately 80% white. The authors were unable to document calcium and parathyroid hormone levels confirming permanent hypoparathyroidism as some patients may have recovery of parathyroid function 1-year post-thyroidectomy.
Future research is needed to focus on which older adults with Graves’ disease will benefit from operative management, including looking at data in men and other racial groups to help informed decision-making. It would be helpful to document biochemical parameters in future studies, including preoperative calcium and 25-hydroxyvitamin D levels.
The authors’ findings help document the low number of postoperative cases of permanent hypoparathyroidism in the U.S. 1 year after thyroidectomy in older adults and should be reassuring to clinicians to consider thyroidectomy as an option for older adults with Graves’ disease, particularly in geographic locations with access to a high-volume thyroid surgeon.
Collapse
Read more about
Click Here to Manage Email Alerts