Clinical Thyroidology® for the Public

Summaries for the Public from recent articles in Clinical Thyroidology
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GRAVES’ DISEASE
Long-term benefits of thyroid surgery for Graves’ disease

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BACKGROUND
Graves’ disease is the most common cause of hyperthyroidism in the United States. There are 3 options for treatment of Graves’ disease: 1) antithyroid medications, 2) radioactive iodine therapy and 3) surgery. Radioactive iodine therapy and surgery are considered “definitive” therapy as they usually result in destroying the thyroid and causing hypothyroidism. In general, radioactive iodine therapy has been the most common treatment in the United States, followed by antithyroid medications. Surgery is often reserved for patients with bad eye disease or the need to control their hyperthyroidism immediately. However, surgery is utilized more frequently in other parts of the world with good outcomes.

The current study compared the outcomes head to head of the 3 possible treatments: antithyroid medications, radioactive iodine therapy and surgery. They looked at death, related health problems, health care cost, and the risk of relapse of the Graves’ disease.

THE FULL ARTICLE TITLE
 Liu X et al. Outcomes of Graves’ disease patients following antithyroid drugs, radioactive iodine, or thyroidectomy as the first-line treatment. Ann Surg 273:1197–1206. PMID: 33914484.

SUMMARY OF THE STUDY
The authors enrolled more than 6000 patients with Graves’ disease at a large medical center. Overall, 75% initially were treated with antithyroid medications, 20% with radioactive iodine therapy and 5% with surgery. Patients that had surgery had a significant and remarkably lower all-cause risk of dying as well as lower rates of cardiovascular disease, neuropsychiatric symptoms, diabetes, and high blood pressure. They also had the lowest rate of disease relapse (return of Graves’ disease) at 2.4% and the lowest direct health care costs at 10 years. Radioactive iodine therapy also had better outcomes that medication, but to a much lesser extent. Patients treated with radioactive iodine therapy also had a 20% relapse rate compared to 75% of those treated initially with medication.

WHAT ARE THE IMPLICATIONS OF THIS STUDY?
Surgery is an excellent, and seemingly superior treatment for Graves’ disease, resulting in lower all-cause death rate, less medical and psychological complications, minimal relapse risk, and lower overall health care costs long-term. The only downside is the expected permanent hypothyroidism. This is important information to be relayed to patients who are deciding on the best course of treatment for their Graves disease. Another important factor to consider is the experience of the surgeon, as the best outcomes come from high volume thyroid surgeons.

— Melanie Goldfarb, MD

ABBREVIATIONS & DEFINITIONS

Hyperthyroidism: a condition where the thyroid gland is overactive and produces too much thyroid hormone. Hyperthyroidism may be treated with antithyroid meds (Methimazole, Propylthiouracil), radioactive iodine or surgery.

Graves’ disease: the most common cause of hyperthyroidism in the United States. It is caused by antibodies that attack the thyroid and turn it on.

Thyroid eye disease (TED): also known as Graves ophthalmopathy. TED is most often seen in patients with Graves’ disease but also can be seen with Hashimoto’s thyroiditis. TED includes inflammation of the eyes, eye muscles and the surrounding tissues. Symptoms include dry eyes, red eyes, bulging of the eyes and double vision.

Methimazole: an antithyroid medication that blocks the thyroid from making thyroid hormone. Methimazole is used to treat hyperthyroidism, especially when it is caused by Graves’ disease.

Propylthiouracil (PTU): an antithyroid medication that blocks the thyroid from making thyroid hormone. Propylthiouracil is used to treat hyperthyroidism, especially in women during pregnancy.

Thyroidectomy: surgery to remove the entire thyroid gland. When the entire thyroid is removed it is termed a total thyroidectomy. When less is removed, such as in removal of a lobe, it is termed a partial thyroidectomy.

Radioactive iodine (RAI): this plays a valuable role in diagnosing and treating thyroid problems since it is taken up only by the thyroid gland. I-131 is the destructive form used to destroy thyroid tissue in the treatment of thyroid cancer and with an overactive thyroid. I-123 is the nondestructive form that does not damage the thyroid and is used in scans to take pictures of the thyroid (Thyroid Scan) or to take pictures of the whole body to look for thyroid cancer (Whole Body Scan).

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