The effect of combination therapy with propylthiouracil and cholestyramine in the treatment of Graves’ hyperthyroidism

Tsai, Wen-Chin; Pei, Dee; Wang, Tso‐Fu; Wu, Du-An; Li, Jer-Chuan; Wei, Cheng Lian; Lee, Chien-Hsing; Chen, Sheng-Pyng; Kuo, Shi‐Wen

doi:10.1111/j.1365-2265.2005.02249.x

Cited by 74 publications

(48 citation statements)

References 18 publications

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“…The conventional preoperative preparation for surgery includes antithyroid drugs, b blockers, steroids, and iodine administration [4].…”

Section: Discussionmentioning

confidence: 99%

“…A combination of antithyroid drugs, cholestyramine, and b blocker drugs is usually enough to achieve euthyroid status in thyrotoxic patients [4]. However, in patients with iatrogenic thyrotoxicosis or for whom antithyroid drugs are contraindicated or who are resistant to antithyroid drugs, further therapies are needed to restore euthyroid hormone status.…”

Section: Introductionmentioning

confidence: 97%

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Preoperative therapeutic plasma exchange in patients with thyrotoxicosis

Ezer

Çalışkan

Parlakgümüş

et al. 2009

J of Clinical Apheresis

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The purpose of this report was to determine the effectiveness of therapeutic plasma exchange (TPE) in preoperative preparation of patients with thyrotoxicosis scheduled for either thyroid or nonthyroid surgery. We retrospectively reviewed 11 patients with thyrotoxicosis and those who prepared surgery with plasmapheresis between 1999 and 2008 at our institution. Ten patients underwent thyroid surgery and one patient was operated for femur fracture during antithyroid drug treatment. The indications for plasmapheresis in all patients with severe thyrotoxicosis were poor response to medical treatment (seven patients), agronulocytosis due to antithyroid drugs (three patients), iodine-induced thyrotoxicosis (Jodd Basedow effect in one patient), and rapid preparation for urgent orthopedic operation (one patient). After TPE, we observed a marked decrease in free thyroxin (FT3) and free triiodothyronin (FT4) levels; however, the decline in the biochemical values were not statically significant (P > 0.62, P > 0.15). Although both FT3 and FT4 levels remained above the normal limits in two of 11 patients, the signs and symptoms of thyrotoxicosis improved in all patients and no thyroid storm observed during the perioperative period. TPE can be considered a safe and effective alternative to prepare patients with thyrotoxicosis for surgery when drug treatment fails or is contraindicated and when emergency surgery is required.

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“…The conventional preoperative preparation for surgery includes antithyroid drugs, b blockers, steroids, and iodine administration [4].…”

Section: Discussionmentioning

confidence: 99%

Section: Introductionmentioning

confidence: 97%

Preoperative therapeutic plasma exchange in patients with thyrotoxicosis

Ezer

Çalışkan

Parlakgümüş

et al. 2009

J of Clinical Apheresis

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“…Cholestyramine has been used to treat intrahepatic cholestasis in pregnancy (81,82). It is not absorbed from the gut, but it binds thyroid hormones during their enterohepatic circulation and thereby decreases circulating T 4 and T 3 in hyperthyroidism (83,84,85,86,87). Common side effects are nausea and other types of gastrointestinal discomfort, and there has been concern about binding of fat-soluble vitamins (especially vitamin K) during prolonged use.…”

Section: Alternative Therapies For Graves' Hyperthyroidism In Early Pmentioning

confidence: 99%

ENDOCRINOLOGY IN PREGNANCY: Pregnancy and the incidence, diagnosing and therapy of Graves’ disease

Laurberg

Andersen

2016

European Journal of Endocrinology

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Thyroid hormones are essential developmental factors, and Graves' disease (GD) may severely complicate a pregnancy. This review describes how pregnancy changes the risk of developing GD, how early pregnancy by several mechanisms leads to considerable changes in the results of the thyroid function tests used to diagnose hyperthyroidism, and how these changes may complicate the diagnosing of GD. Standard therapy of GD in pregnancy is anti-thyroid drugs. However, new studies have shown considerable risk of birth defects if these drugs are used in specific weeks of early pregnancy, and this should be taken into consideration when planning therapy and control of women who may in the future become pregnant. Early pregnancy is a period of major focus in GD, where pregnancy should be diagnosed as soon as possible, and where important and instant change in therapy may be warranted. Such change may be an immediate stop of anti-thyroid drug therapy in patients with a low risk of rapid relapse of hyperthyroidism, or it may be an immediate shift from methimazole/carbimazole (with risk of severe birth defects) to propylthiouracil (with less risk), or maybe to other types of therapy where no risk of birth defects have been observed. In the second half of pregnancy, an important concern is that not only the mother with GD but also her foetus should have normal thyroid function.Thyroid hormones are essential developmental factors as first shown by Gudernatsch when he, in 1912, fed tadpoles thyroid tissue and observed metamorphosis (1). In mammals, thyroid hormones are especially of importance for brain development (2, 3), and even a few months with lack of thyroid hormones in infant life may lead to irreversible brain damage. This is the background for the universal screening for congenital hypothyroidism performed in many countries. However, thyroid hormones are also important for normal pregnancy, and maternal thyroid disease may severely increase the risk of pregnancy complications, including Invited author's profile Peter Laurberg was Clinical Professor of Internal Medicine and Endocrinology, Department of Endocrinology, Aalborg University Hospital, Aalborg, Denmark. His research mainly focused on thyroid disease prevention, epidemiology, diagnosing and therapy, including studies on iodine and thyroid, and pregnancy and thyroid. He had special research interest on the risk from and optimal management of autoimmune hypo-and hyperthyroidism in pregnancy and post-partum, management of Graves' disease in general, and how the burden of thyroid disease can be minimized by adjusting the population's iodine intake. He has coauthored several international guidelines on thyroid disease management, including management of thyrotoxicosis, and thyroid disease in pregnancy. Peter Laurberg died June 20, 2016.

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“…We would recommend considering corticosteroids in the setting of a massive levothyroxine overdose (>10,000 mcg), especially if the initial FT 4 level is above the limit of quantification of the assay or in any patient with associated adrenal insufficiency. Bile acid sequestrants, such as cholestyramine, reduce enterohepatic recycling of thyroxine and have been demonstrated to lower thyroid hormone levels in thyrotoxicosis, 23,24 including levothyroxine overdose. 25 Use of these agents in thyrotoxicosis is usually well tolerated and of low toxicity, 24 so they could be considered in patients who have taken a large overdose, to increase fecal thyroid hormone clearance.…”

Section: Symptomatic Treatmentmentioning

confidence: 99%

Case report: clues to the diagnosis of an unsuspected massive levothyroxine overdose

Allen

Crawford

Conaglen

et al. 2015

CJEM

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There is currently little literature pertaining to levothyroxine overdose apart from minor or accidental overdoses in the pediatric population. In particular, there is little information available on how to confidently differentiate levothyroxine overdose from endogenous causes of thyrotoxicosis when there is no history available at the time of assessment.We report a levothyroxine (15,800 mcg) and citalopram (2,460 mg) overdose in a 55-year-old woman presenting with seizure and tachycardia in which the diagnosis was not initially suspected. Clinical data, including a long history of treated hypothyroidism and lack of a goiter; and biochemical findings, such as an incompletely suppressed thyroid-stimulating hormone (TSH) level, despite a markedly elevated free thyroxine level (FT 4 ), a normal sex hormone-binding globulin level at baseline, and an undetectable thyroglobulin, supported the diagnosis of thyrotoxicosis due to a massive exogenous thyroid hormone overdose. Treatment was given to decrease free triiodothyronine (FT 3 ) conversion and increase thyroid hormone clearance with dexamethasone and cholestyramine. The patient made a full recovery.Levothyroxine overdose can result in subtle symptoms and signs clinically, even when in massive quantities. This can make diagnosis challenging. Biochemical features, such as the pattern of thyroid hormone elevation and thyroglobulin levels, help differentiate exogenous thyroid hormone overdose from endogenous causes of thyrotoxicosis. RÉSUMÉLa documentation sur le surdosage de lévothyroxine est peu abondante, exception faite des surdosages mineurs ou accidentels chez les enfants; plus particulièrement, il manque d'information sur la manière de faire la distinction, en toute confiance, entre le surdosage de lévothyroxine et la thyrotoxicose d'origine endogène, dans les cas d'absence d'antécédents évocateurs au moment de l'évaluation.Sera exposé ici un cas de surdosage de lévothyroxine (15 800 μg) et de citalopram (2460 mg) chez une femme de 55 ans, prise de convulsions et de tachycardie, chez qui rien, au point de départ, ne laissait soupçonner le diagnostic. Toutefois, des données d'ordre clinique, notamment des antécédents d'hypothyroïdie traitée de longue date et l'absence de goitre; des résultats d'analyses biochimiques, par exemple la présence de thyréostimuline (TSH) partiellement supprimée malgré un taux nettement élevé de thyroxine libre (T 4 libre); un taux normal, au départ, de globuline de liaison aux hormones sexuelles et un taux indétectable de thyroglobuline, ont étayé le diagnostic de thyrotoxicose attribuable à un surdosage massif d'hormone thyroïdienne d'origine exogène. Le traitement, par la dexaméthasone et la cholestyramine, visait à abaisser la conversion de la triiodothyronine libre (T 3 libre) et à accroître la clairance de l'hormone thyroïdienne. La patiente s'est complètement rétablie.Le surdosage de lévothyroxine, même massif, peut se manifester par des signes et des symptômes cliniques peu prononcés, d'où la difficulté de poser le dia...

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The effect of combination therapy with propylthiouracil and cholestyramine in the treatment of Graves’ hyperthyroidism

Abstract: Cholestyramine contributed to a more rapid and complete decline in thyroid hormone levels in patients with Graves' hyperthyroidism. It was thus proved to be an effective and well-tolerated adjunctive therapy.

Cited by 74 publications

References 18 publications

Preoperative therapeutic plasma exchange in patients with thyrotoxicosis

Preoperative therapeutic plasma exchange in patients with thyrotoxicosis

ENDOCRINOLOGY IN PREGNANCY: Pregnancy and the incidence, diagnosing and therapy of Graves’ disease

Case report: clues to the diagnosis of an unsuspected massive levothyroxine overdose

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