Hyperthyroidism: Follow-up Management

University of the East
Ramon Magsaysay Memorial Medical Center, Inc.
GRADUATE SCHOOL
Aurora Boulevard, Quezon City

Hyperthyroidism:Follow-up Management


Patients, even after the actual treatment and regardless of type of treatment, should see their doctor regularly.

The following are recommended follow-up care (Lee, 2009):

• Antithyroid medications users:
Medications are usually tapered after 4-6 weeks to prevent hypothyroidism. Thyroid function tests are done every 4-6 weeks until the thyroid hormones levels are stable. For the first year, follow-up tests are done every 3 months. After that, medications are either stop entirely or tapered for those with Graves’ hyperthyroidism to determine if the patient has undergone remission.

• RAI patients:
Thyroid function tests are done every 4-6 weeks until the thyroid hormones levels are stable. It is acceptable for the patient to take low doses of thyroid hormone replacement (25-50 mcg/d and adjusted every 6-8 wk to normalize the TSH level) to prevent hypothyroidism if the thyroid hormone levels are dropping to the low-normal range. According to Pradeep et al. (2007), with this method, hypothyroidism is rather unpredictable so patients have to go to referral centers for thyroid function tests.

• Thyroid surgery patients:
Thyroid function tests are done 3-4 weeks after the surgery to check if thyroid hormones levels are stable and in normal range. Partial replacement of thyroid hormones is started after surgery. Then, thyroid function tests are done 4-8 weeks after surgery and thyroid hormone replacement are regulated to keep TSH on a normal range. L-thyroxine supplementation gives satisfactory results for long-term euthyroidism (Efremidou, Papageorgiou, Liratzopoulos, & Manolas, 2009).


Galofr´e, Lomvardias, and Davies’ (2008) follow-up management concur with that of Lee’s (2009) and add that use of thyroxine replacement therapy involves annual follow-up and long-term follow-up is done yearly as well.

Lacey, Jones, & Clarke (2001) recommend follow-ups for those with multinodular goitre with superimposed Graves’ disease because such condition entails cancer risk. Follow-up, TSH determination and thyroid palpation included, every year is done for small goiters when in euthyroid state.

Canbaz et al. (2008) followed-up patients at the end of the first week and month and then every three months during the first year. Follow-ups include physical examination and, if necessary, free T3, free T4 and TSH levels, serum levels of calcium and laryngoscopy. The patients are then followed-up at least one year after the surgery.
In another study (Moreno et al., 2006), patients are followed-up “once per month during the first year after operation and then at 18 months, 24 months, and yearly until the patient became hypothyroid.”

Rivkees’ (2001) recommendations regarding follow-ups are pretty much the same as the other authors. “Long-term follow-up should include regular examination of the thyroid gland and measurement of circulating levels of thyroid hormones once or twice a year. All newly appearing thyroid nodules should be biopsied or excised.”

Hyperthyroidism relapse is common after ATD treatment cessation (Kaguelidou et al., 2008). After completing 1 course of ATD and atleast 2 years follow-up, relapse rate for hyperthyroidism is 59% at 1 year and 68% at 2 years. Thus, prolonged use of ATD can be linked to a better prognosis. It can be suggested that treatment compliance must be emphasized to patients and health care providers must be vigilant in doing so. Nakagawa et al. (2002) also suggest that ATD should be continued during pregnancy and after delivery as this is beneficial in preventing postpartum recurrence of Graves’ hyperthyroidism and does not result in neonatal hypothyroidism or malformations.

Dale, Daykin, Holder, Sheppard, and Franklyn (2001) give focus on the weight change recognized on hyperthyroid patients after treatment. The average increase in weight with ATD users ranges from 1´55 to 16´4 kg over 6 months to 5 years. Weight stabilizes after 2 or 5 years according to longer-term studies. This suggests that weight loss or gain should be monitored as well.

As seen on the studies of the above authors, they are practically in unison on the time and methods of follow-up management. There may be some variation but it is understandable since physicians may pattern their approach depending on the situation and the condition of the patient. The important thing with follow-ups is the compliance of the patient with the regimen. A trusting relationship between the health care provider and patient is then very important.


References:

Canbaz, H., Dirlik, M., Colak, T., Ocali, K., Akca, T., Bilgin, O., Tasdelen, B., and Aydin, S. (2008). Total thyroidectomy is safer with identification of recurrent laryngeal nerve. J Zhejiang Univ Sci B, 9(6):482-488. doi:10.1631/jzus.B0820033

Dale, J., Daykin, J., Holder, R., Sheppard, M.C., and Franklyn, J.A. (2001). Weight gain following treatment of hyperthyroidism. Clinical Endocrinology, 55, 233-239. Retrieved on February 18, 2010 from http://web.ebscohost.com/ehost/pdf?vid=1&hid=106&sid=82ed60d4-38d8-4aa0-a9ae 430cbcac2c56%40sessionmgr110

Efremidou, E., Papageorgiou, M., Liratzopoulos, N., and Manolas, K. (2009). The efficacy and safety of total thyroidectomy in the management of benign thyroid disease: a review of 932 cases. Can J Surg, Vol. 52, No. 1. Retrieved on February 18, 2010 from http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2637645/pdf/20090200s00008p39.pdf/?tool=pmcentrez

Galofr´e, J., Lomvardias, S., and Davies, T. (2008). Evaluation and Treatment of Thyroid Nodules: A Clinical Guide. MOUNT SINAI JOURNAL OF MEDICINE, 75:299–311. DOI:10.1002/msj.20040

Kaguelidou, F., Alberti, C., Castanet, M., Guitteny, M-A., Czernichow, P., and Léger, J. (2008). Predictors of autoimmune hyperthyroidism relapse in children after discontinuation of antithyroid drug treatment. J Clin Endocrinol Metab, 93:3817-3826. Retrieved on February 19, 2010 on http://www.gghjournal.com/volume25/1/pdf/ab23.pdf

Lacey, N.A., Jones, A., and Clarke, E.M. (2001). Role of radionuclide imaging in hyperthyroid patients with no clinical suspicion of nodules. The British Journal of Radiology, 74, 486–489. Retrieved on February 19, 2010 on http://bjr.birjournals.org/cgi/reprint/74/882/486.pdf

Lee, S. (2009).Hyperthyroidism: Follow-up.Retrieved on February 19, 2010 from Medscape website: http://emedicine.medscape.com/article/121865-followup

Moreno, P., Go´mez, J., Go´mez, N., Francos, J., Ramos, E., Rafecas, A., and Jaurrieta, E. (2006). Subtotal Thyroidectomy: A Reliable Method to Achieve Euthyroidism in Graves_ Disease. Prognostic Factors World J Surg, 30: 1950–1956. DOI: 10.1007/s00268-005-0770-x

Nakagawa, Y., Mori, K., Hoshikawa, S., Yamamoto, M., Ito, S., and Yoshida, K. (2002). Postpartum recurrence of Graves’ hyperthyroidism can be prevented by the continuation of antithyroid drugs during pregnancy. Clinical Endocrinology, 57, 467–471. Retrieved on February 18, 2010 from http://web.ebscohost.com/ehost/pdf?vid=1&hid=106&sid=eaf9ce97-4c96-4ae6-9f48 7873df8bebc6%40sessionmgr112

Pradeep, P.V., Agarwal, A., Baxi, M., Agarwal, G., Gupta, S.K., and Mishra, S.K. (2007). Safety and Efficacy of Surgical Management of Hyperthyroidism: 15-year Experience from a Tertiary Care Center in a Developing Country. World J Surg, 31: 306–312. DOI: 10.1007/s00268-006-0572-9

Rivkees, S., (2001). The Use of Radioactive Iodine in the Management of Hyperthyroidism in Children. Current Drug Targets - Immune, Endocrine & Metabolic Disorders, 1, 255-264. Retrieved on February 18, 2010 from http://web.ebscohost.com/ehost/pdf?vid=1&hid=106&sid=c3b87700-0047-465d-afd5-91b27c9aef9f%40sessionmgr112