Rapid Preoperative Preparation for Severe Hyperthyroid Graves’ Disease

Abstract

Thyroidectomy (TX) is no longer the preferred choice for the therapy of hyperthyroid Graves' disease but is an alternative in patients who are noncompliant with or have reactions to antithyroid drugs, have moderate to severe ophthalmopathy, have large goiters, or who refuse (131)I therapy and/or long-term antithyroid drug therapy. Seventeen clinically and biochemically severely thyrotoxic patients (16 female, mean age of 35 yr), all but one with large goiters, underwent TX after rapid preparation. The potent inhibitors of the deiodination of T(4) to T(3), iopanoic acid (IOP) (500 mg twice a day) and dexamethasone (DEX) (1 mg twice a day), were given with propylthiouracil or methimazole, when possible, and beta-blockers. Thyroid function tests were obtained before treatment and at TX. All patients were thyrotoxic (mean +/- SE: T(4), 21.6 +/- 1.2 micro g/dl; free T(4) index (FTI), 10.3 +/- 0.8; total T(3), 510 +/- 48 ng/dl). IOP and DEX rapidly lowered T(3) values (P < 0.0001; total T(3), 147 +/- 13 ng/dl) with a smaller but significant (P < 0.05) decrease in T(4)/FTI (T(4), 17.9 +/- 1.3 micro g/dl; FTI, 7.9 +/- 0.6). All patients were clinically euthyroid before surgery. None developed hypoparathyroidism, laryngeal nerve damage, or worsening of ophthalmopathy after surgery. The restoration of hyperthyroid Graves' disease to euthyroidism is rapidly accomplished with IOP and DEX, beta-blockers, and, when possible, antithyroid drugs. This is especially relevant in noncompliant patients with large goiters.

Thyroid “Vise” in an Infant With Neonatal Graves’ Disease

“…Our team ultimately decided to treat with a brief course of dexamethasone because it has been established to decrease airway edema for extubation 13 and has been used in treatment of GD in older patients, with resulting improvement in goiter. 14 Whether the goiter improved more rapidly because of the dexamethasone is unclear.…”

Hyperthyroidism—an unusual feature of thyroid carcinoma

“…Dexamethasone and propranolol suppress the conversion of FT 4 to FT 3 . 9,10 Propranolol has the additional benefit of non-selective betareceptor blockade. 10 Lithium inhibits the release of thyroid hormone from the thyroid gland 11 and cholestyramine interferes with the enterohepatic circulation, of FT 4 and FT 3 .…”

Rapid Preparation of Hyperthyroid Patients for Thyroidectomy

“…3,19 Rapid and sa fer con trol of thyro to xi co sis can be ac hi e ved with oral ad mi nis tra ti on of io di de in combi na ti on with thi o na mi des or with io di de alo ne, if thi o na mi des are con tra in di ca ted. [8][9][10][11][12] In phar ma colo gi cal do ses, the ma jor ac ti on of io di des is to in hibit hor mo ne re le a se, pos sibly thro ugh in hi bi ti on of thyrog lo bu lin pro te oly sis. 10 Ra pid im pro ve ment occucs in thyro to xic symptoms wit hin 2-7 days with io di de the rapy.…”

“…6 Phar ma co lo gic amo unts of io di ne ame li o ra te hyperth yro i dism by bloc king thyro id hor mo ne re le ase and tem po ra rily in hi bi ting io di ne or ga ni fi ca ti on in the thyro id gland. [7][8][9][10] Pub lis hed re gi mens for rapid pre pa ra ti on for sur gery include io di ne-rich oral ra di og rap hic con trast agents (IR CAs) such as so dium ipo da te, which are no lon ger ava i lab le in most Eu ro pe an co un tri es. 8,9,11,12 Lu gol's so lu ti on (LS) (8 mg io di de/drop) and sa tu ra ted so lu ti on of po tas si um io di de (SSKI) (40 mg io di de/drop) are the ot her opti ons ava i lab le for use as an io di de do nor.…”

“…[7][8][9][10] Pub lis hed re gi mens for rapid pre pa ra ti on for sur gery include io di ne-rich oral ra di og rap hic con trast agents (IR CAs) such as so dium ipo da te, which are no lon ger ava i lab le in most Eu ro pe an co un tri es. 8,9,11,12 Lu gol's so lu ti on (LS) (8 mg io di de/drop) and sa tu ra ted so lu ti on of po tas si um io di de (SSKI) (40 mg io di de/drop) are the ot her opti ons ava i lab le for use as an io di de do nor. [13][14][15][16] In the pre sent study, we ai med to in ves ti ga te the ef fects of LS used alo ne or to get her with thi o na mi des for the ra pid pre pa ra ti on of hyperth yro id pa ti ents for thyro id sur gery.…”