Antithyroid Drug Therapy for Graves’ Disease and Implications for Recurrence

Abstract

Graves' disease (GD) is the most common cause of hyperthyroidism worldwide. Current therapeutic options for GD include antithyroid drugs (ATD), radioactive iodine, and thyroidectomy. ATD treatment is generally well accepted by patients and clinicians due to some advantages including normalizing thyroid function in a short time, hardly causing hypothyroidism, and ameliorating immune disorder while avoiding radiation exposure and invasive procedures. However, the relatively high recurrence rate is a major concern for ATD treatment, which is associated with multiple influencing factors like clinical characteristics, treatment strategies, and genetic and environmental factors. Of these influencing factors, some are modifiable but some are nonmodifiable. The recurrence risk can be reduced by adjusting the modifiable factors as much as possible. The titration regimen for 12–18 months is the optimal strategy of ATD. Levothyroxine administration after successful ATD treatment was not recommended. The addition of immunosuppressive drugs might be helpful to decrease the recurrence rate of GD patients after ATD withdrawal, whereas further studies are needed to address the safety and efficacy. This paper reviewed the current knowledge of ATD treatment and mainly focused on influencing factors for recurrence in GD patients with ATD treatment.

Post-partum and non-post-partum relapsing Graves’ hyperthyroidism display different response to anti-thyroid drugs

“…Our hypothesis is supported by the different behavior of circulating TRAb, which, after 12 months of MMI treatment, were found to be significantly lower in the PP as compared with the NPP group of relapsing GD patients. Because negative tests for TRAb at the time of ATD withdrawal can predict a sustained remission of Graves' hyperthyroidism (7,24), it is not surprising that medical treatment was much more successful in the PP as compared with the NPP group of hyperthyroid patients.…”

“…Relapsing hyperthyroidism being diagnosed within 12 months after delivery was considered to be a PP-related recurrence. The median (range) time after delivery when hyperthyroidism relapsed was 5 months (2,3,4,5,6,7,8,9,10). Relapsing hyperthyroidism occurring later than 12 months after delivery or in women with no history of pregnancy was considered as a non-PP-related recurrence.…”

“…Apart from the rare side effects of thionamides, the major problem with medical treatment of Graves' hyperthyroidism is the high relapse rate after ATD withdrawal (2,4,5). Besides the genetic background, several factors including male gender, younger age, large goiter, smoking habit, presence of active/severe orbitopathy and elevated serum TSH-receptor antibodies (TRAb) at presentation were identified as predictors of relapsing hyperthyroidism after ATD withdrawal (6,7,8). Although two recent reports, as well as an extensive literature review suggest that relapsing Graves' hyperthyroidism can be successfully treated with a second course of ATD (7,9,10), it is commonly believed that, once hyperthyroidism recurs after ATD withdrawal, there is little chance of inducing a permanent remission with thionamide therapy.…”

Nuclear Medicine in the Assessment of Thyrotoxicosis Associated with Increased Thyroid Function and Radioiodine 131 Ablative Therapies

“…Current therapeutic options for these pathologies include antithyroid drugs (ATD), radioactive iodine and thyroidectomy. The choice of treatment depends on the type of pathology (Graves' disease, toxic multinodular goiter, pretoxic or toxic adenoma), physiological characteristics of the patient (age, pregnancy, breastfeeding), co-morbidities (advanced age, heart failure, large compressive intrathoracic goiters, thyroid ophthalmopathy), as well as refractoriness to the treatment administered [8,14].…”

“…The medication is prescribed for 12-18 months normally, with the aim of achieving remission of the disease. However, the frequency of recurrences (more frequently in young males) and severe side effects like cytopenias, vasculitis, liver failure or agranulocytosis (higher in pediatric patients than adults) are a main limitation of ATD treatment [8,14,16].…”