Ablative radioiodine therapy for hyperthyroidism: long term follow up study

A total of 225 patients were treated for hyperthyroidism with 555 MBq (15 mCi) radioiodine to ablate the thyroid and induce early hypothyroidism. The efficacy of this treatment in eradicating hyperthyroidism and problems of follow up were assessed one to six years later from case records and questionnaires. Information was received from 197 out of 219 live patients (90%) and from 160 doctors concerning 207 patients (92%). Only three patients were not traced and six had died since treatment. The modal time to hypothyroidism was three months, and 64% of patients were hypothyroid at one year; 5.6% had failed to become euthyroid within one year. Ninety five per cent of patients had been seen by the doctor and 82% had had a thyroid test done within the past two years. Most doctors preferred patients to be returned to their care once thyroxine treatment was stabilised. An ablative dose of 131I is recommended as an effective means of treatment which has clear advantages over conventional methods. Good communications and effective follow up should ensure success.     

Outcome of 131I therapy in hyperthyroidism using a 550MBq fixed dose regimen

Background

Radioiodine is the treatment of choice for relapsed hyperthyroidism although the optimum protocol is uncertain. Fixed dose radioiodine is increasingly popular but responses may vary.

Aim

To assess the outcome of 131I therapy in hyperthyroidism using a standard dose regimen in a regional referral centre and to explore factors influencing outcome.

Methods

We studied 449 patients (M:F 82:367; age range 13-89y, median 42y) with hyperthyroidism treated between 2003 and 2007 with a standard dose of 550MBq 131I. Patients were classified as either Graves’ disease, toxic multinodular goitre or indeterminate aetiology. Antithyroid drugs were routinely stopped at least 1 week before radioiodine.

Results

One year after radioiodine 334 (74%) were hypothyroid, 85 (19%) were euthyroid and 30 (7%) had required a further dose of 131I. Patients with Graves’ disease were more likely to become hypothyroid than those with toxic multinodular goitre (78% v 37%, p<0.001) and less likely to become euthyroid (11% v 55%, p<0.001). Free T4 >80pmol/L (normal range 9.0 – 19.0 pmol/L) at presentation was associated with an increased failure rate (17% compared with 5% and 3% for 40-79pmol/L and <40pmol/L respectively; p=0.01). Patients with either a small or no goitre were more likely to be successfully treated by a single dose (96%) than those with a medium/large goitre (85%, p<0.001). Anti-thyroid medication was taken by 345 (77%) (carbimazole n=319) patients up to 1 week prior to 131I and was associated with an increased failure rate (8% v 2%, p=0.027) compared to those who had not had antithyroid medication. Logistic regression showed free T4 at presentation to be the only independent risk factor for failure of the first dose of radioiodine (OR 2.5; 95% CI, 1.2–5.1, p=0.012).

Conclusion

A single standard dose of 550MBq 131I is highly effective in treating hyperthyroidism. The aetiology, severity of hyperthyroidism at diagnosis, goitre size and prior antithyroid medication all had a significant effect on outcome.     

Zinc metabolism in thyroid disease.

This study was designed to evaluate the zinc metabolism in adults of both sexes with thyroid disease. Plasma and erythrocyte zinc concentration and urinary zinc excretion were investigated. The mean concentration of plasma zinc in hypothyroid patients and in euthyroid patients, previously either hyperthyroid or hypothyroid, was lower than that of control subjects, whereas no statistically significant differences were observed in plasma zinc values between hyperthyroid patients and control subjects. The average erythrocyte zinc level in patients with thyroid disease was significantly lower than that in control subjects. Erythrocyte zinc concentration was significantly decreased in hyperthyroidism compared with hypothyroidism, or patients previously either hyperthyroid or hypothyroid but now euthyroid. Increased urinary zinc excretion in hyperthyroidism was noticed compared to euthyroid and hypothyroid patients and to control subjects. Increased urinary zinc concentrations may result from increased tissue catabolism such as muscle. The results of this study suggest that abnormal zinc metabolism occurs commonly in patients with thyroid disease.     

Thirty-five cases of transient hyperthyroidism

Over a 7-year period transient hyperthyroidism was diagnosed in 35 patients seen in a consulting practice in a community hospital. The patients were followed up for an average of 15 months. Initially all of them had biochemical evidence of hyperthyroidism but a very low 24-hour uptake of radioiodine. The hyperthyroid phase was short, and there were no relapses. Seventeen patients subsequently became hypothyroid; this phase, too, was almost always transient. The clinical course of the disease in the 11 women who became hyperthyroid within 6 months after giving birth was similar to that experienced by the other patients, but of the 11 who had increased titres of antimicrosomal antibodies a significantly greater proportion (73%) showed at least transient evidence of hypothyroidism; 1 patient remained frankly hypothyroid for a year. Transient hyperthyroidism can be distinguished from Graves' disease only if the uptake of radioiodine is measured. It is important to make this distinction, as transient hyperthyroidism can be managed safely and symptomatically with beta-blockers alone. The propensity of this disease for the postpartum period and the high proportion of patients with antithyroid antibodies suggest an autoimmune cause.     

The early development of transient and permanent hypothyroidism following radioiodine therapy for hyperthyroid Graves'' disease.

The outcome in 110 patients first treated with radioiodine (mean dose 6.56 mCi) for hyperthyroid Graves' disease in 1980 was reviewed. In 23% of the patients the disease had not been controlled by the initial dose after 3 months, and 17% were given one or two more doses. Within 2 years 65% of the patients required replacement thyroxine therapy. Although about half of the patients were biochemically hypothyroid 3 months after the last dose of iodine 131, this condition was transient in a third of them; five of these patients even became hyperthyroid again. Patients with transient, as opposed to permanent, hypothyroidism at 3 months tended to be clinically euthyroid but to have residual palpable thyroid tissue and only a modest reduction in the serum thyroxine level. It is therefore recommended that patients not overtly hypothyroid 3 months after treatment with 131I be observed still longer before thyroxine replacement therapy is instituted.     

Serum angiotensin-converting enzyme. Alterations in hyperthyroidism, hypothyroidism, and subacute thyroiditis

Angiotensin-converting enzyme (ACE) activity was measured in the serum samples of 247 patients with varying thyroid states. In 60 hyperthyroid patients, the mean (+/- SD) ACE level of 29.5 +/- 9.7 units/mL was higher than in all other groups. The serum ACE level was 17.0 +/- 5.1 units/mL in 129 euthyroid subjects and differed from the level of 13.9 +/- 5.1 units/mL observed in 34 hypothyroid patients. Twenty-four patients receiving exogenous thyroid hormone had elevated serum thyroxine values. Their mean serum triiodothyronine level was in the normal range, and the mean ACE level did not differ from the euthyroid mean. The mean serum ACE level fell from 30.8 to 17.4 units/mL in 35 hyperthyroid patients studied before and after therapy. In 12 hypothyroid subjects, the mean serum ACE level rose from 11.6 to 15.8 units/mL after thyroid hormone replacement. In eight of ten patients with transient hyperthyroidism (subacute thyroiditis or painless thyrotoxic thyroiditis), their highest ACE levels were observed in the hyperthyroid or transition phase and fell progressively with the lowest values being recorded during the hypothyroid or early recovery phases. Thus, ACE activity may respond to thyroid hormone, and interpretation of serum ACE levels may require knowledge of the patient's thyroid status. Serum ACE may be useful as a probe for exploring peripheral thyroid hormone action.     

~(131)I治疗老年人甲亢97例分析

目的探讨老年人甲状腺机能亢进症 (以下简称老年人甲亢 )的临床特征及13 1I治疗的疗效。方法对 97例资料齐全诊断明确的老年人甲亢患者进行13 1I治疗 ,追踪观察治疗后 1- 2年甲亢的治愈率及其合并症的转归。结果 (1)老年人甲亢患者症状、体征多不典型 ;(2 ) 97例患者中 ,治愈 6 8例 (70 1% ,其中早发甲低 6例 ) ,好转 2 2例 (2 2 .7% ) ,无效 7例 (7 2 % )。有合并症的 5 3例患者中 ,临床治愈 4 5例 (84 9% ) ,好转 5例 (9 4 % ) ,无效 3例 (5 7% )。结论 13 1I治疗对老年人甲亢的疗效非常理想 ,应作为老年人甲亢的首选治疗方法。     

Graves' disease and atrial fibrillation: the case for even higher doses of therapeutic iodine-131

Seventy five consecutive patients with Graves' disease complicated by atrial fibrillation were given a large single therapeutic dose of 600 MBq (16.2 mCi) iodine-131 in an effort to control their hyperthyroidism rapidly and thus restore sinus rhythm. Patients were initially followed up every three months after treatment and then at yearly intervals. The mean period of follow up was 3.1 years. A total of 44 of the patients became hypothyroid and 31 euthyroid, and 33 (75%) and 14 (45%) of these patients, respectively, reverted to sinus rhythm (p less than 0.01). Of the 33 who became hypothyroid and reverted to sinus rhythm, 30 had developed the hypothyroidism within six months after treatment. These results are a strong case for increasing the dose of radioiodine in patients with Graves' disease complicated by atrial fibrillation in an effort to speed the onset of thyroid failure and thus maximise the rate of reversion to sinus rhythm.     

碳酸锂与丙基硫氧嘧啶对Graves病重型甲亢131碘疗效影响的比较

目的 比较碳酸锂与丙基硫氧嘧啶对Graves病重型甲亢的131碘（^131I）治疗效果的影响.方法 Graves病重型甲亢患者^131I治疗前为防止甲亢危象,一组采用碳酸锂联合治疗,每次口服量250mg,1日3次,持续5周,于开始服用碳酸锂2周后给予治疗量的^131I;一组使用丙基硫氧嘧啶联合治疗,每次口服量100mg,1日3次,余同前组,并于给^131I前后停药7 d.结果 碳酸锂组一次性治愈率明显高于丙基硫氧嘧啶组（P＜0.05）,而两组早发甲状腺功能减退发生率差异无显著性（P〉0.05）.结论Graves病重型甲亢患者^131I治疗前联合使用不同药物对^131I一次性治愈率有不同影响,^131I治疗前联合碳酸锂治疗的效果明显好于丙基硫氧嘧啶.     

用收缩时间间期评价甲状腺机能亢进及减退患者的左心室功能

本文对129例甲状腺机能亢进、正常或低下的患者作了 STI 测定。甲亢者表现 PEPI 缩短,PEP/LVET 变小,经适当治疗后可恢复正常。甲低者则有PEPI 延长,PEP/LVET 增大。一些心功能参数与血清 TT_3或 TT_4之间有线性相关。本文表明,甲亢或甲减时可引起左室功能改变,STI 测定对评价心脏对甲状腺激素水平变化的反应是一种有价值的方法。     

The diagnostic dilemma of isolated hyperthyroxinemia in acute illness.

Eighteen patients with a variety of illnesses but no history of thyroid disease were shown to have elevated serum total and free thyroxine (T4) concentrations but low serum total triiodothyronine (T3) levels. Thyroid function tests were requested initially to excluded the possibility of hyperthyroidism in a setting of hypermetabolism. Clinical and laboratory follow-up investigations demonstrated that 15 patients were euthyroid and that hormonal alterations were transient features of the intercurrent illnesses. Three patients did, in fact, have hyperthyroidism. Retrospective analysis of diagnostic data demonstrated that of the initial thyroid function screening tests, serum total T3 concentration, the T3/TF4 ratio, and the indirectly measured free T3 (FT3) index were the most useful parameters in excluding hyperthyroidism. The FT3 index was the most helpful, being normal or low in all the euthyroid and high in each of the hyperthyroid patients.     

Thyroid hormone profile in obese subjects--a clinical study.

Fifty obese subjects with body weight above 120% of the ideal weight for that height or body mass index greater than 27.8 kg/m2 in men or 27.3 kg/m2 in women were studied for thyroid hormone profile. Nearly three-fourths obese subjects had body mass index of 30-40 kg/m2. Eighty-six per cent subjects were clinically and biochemically euthyroid. Fourteen per cent of the subjects had hypothyroidism; out of them, 8% were clinically and biochemically hypothyroid while 6% were only biochemically hypothyroid. None of the hypothyroid subjects had morbid obesity (greater than 40 kg/m2 body mass index). Duration of obesity in hypothyroid subjects was less than 10 years in nearly three-fourths of cases.     

Radioiodine treatment in autoimmune hyperthyroidism: analysis of outcomes in relation to dosage

BACKGROUND: Controversy exists regarding the optimal dose of radioiodine ((131)I) therapy in autoimmune hyperthyroidism (i.e., Graves' Disease). METHODS: In order to evaluate the efficacy and safety of high dose (131)I therapy in autoimmune hyperthyroidism, a retrospective review of patients who received (131)I therapy for Graves' disease from 1980 to 2000 in the Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán, Mexico City was carried out. RESULTS: The study population consisted of 596 autoimmune hyperthyroid patients with a mean age of 35 years. The mean follow-up period was 10.31 +/- 2.37 years. Remission of hyperthyroidism occurred in 81.9%, persistent hyperthyroidism was recorded in 14.4% and recurrence in 3.7%. (131)I doses of 5-9 mCi (185-333 MBq) and > or =20 mCi (> or =740 MBq) were associated with remission rates of 65.5% and 87.7% respectively. Remission occurred earlier and more often with high doses of (131)I. The high-dose group (20-30 mCi [740-1110 MBq]) had the lowest rate of persistence (9.7, 27.5 and 34.3%, for 20-30 [740-1110 MBq], 10-14 [370-518 MBq] and 5-9 [185-333 MBq] mCi, respectively p <0.05) and hypothyroidism occurred earlier in this group (p = 0.05). CONCLUSIONS: Remission of autoimmune hyperthyroidism is more likely with doses of 20-30 mCi (740-1110 MBq).     

桥本氏病诊断与治疗中甲状腺激素及自身抗体的变化规律

本文对115例桥本氏病作了分析,其中甲状腺功能亢进者30例,功能正常者52例,功能减低33例,TG-Ab和TM-Ab阳性率分别为87.5％和81.3％。本文对23例患者进行了2～24个月动态观察,无论是甲亢或是甲低者,在抗甲状腺药物或替代治疗中,甲状腺激素浓度变化对治疗较敏感,短期内可恢复正常,自身抗体转阴则较缓慢。     

Treatment of thyrotoxicosis resistant to carbimazole with corticosteroids.

We report two patients whose thyrotoxicosis failed to respond to conventional treatment with carbimazole. The patients remained persistently hyperthyroid, both clinically and biochemically, despite several months of carbimazole therapy at the maximum recommended doses. Prednisolone 20 mg per day was then given in addition to the antithyroid drug and a dramatic response observed in both cases. They were then successfully treated with radioiodine. Prednisolone has not been previously used to treat patients with hyperthyroidism who have not responded to thionamide drugs. Our experience suggests that corticosteroids may be potentially useful for controlling thyrotoxicosis in combination with carbimazole before definite treatment can be instituted.     

孕期不同甲状腺功能状态血清高密度脂蛋白胆固醇和载脂蛋白A-Ⅰ的变化趋势

目的:研究不同甲状腺功能状态对孕妇血清高密度脂蛋白胆固醇( high density cholesterol, HDL-C)和载脂蛋白A-Ⅰ( apolipoprotein A-Ⅰ, ApoA-Ⅰ)代谢的影响. 方法:采集30名甲状腺功能正常(正常组)、19名亚临床甲状腺功能减退(亚甲减组)及8名亚临床甲状腺功能亢进(亚甲亢组)孕妇孕9~12、14~17、23~26和37~40周的空腹血清标本,测其血清HDL-C和ApoA-Ⅰ含量. 采用重复测量数据方差分析的秩和检验分析4个妊娠时段孕妇血清HDL-C、ApoA-Ⅰ含量的变化;采用一般线性模型( general linear model, GLM )分析3 组孕妇孕期血清HDL-C、ApoA-Ⅰ含量的差异. 结果:孕期各组孕妇血清HDL-C含量的变化差异均无统计学意义(χ2 =5. 428,P=0. 143;χ2 =2. 027,P=0. 567;χ2 =2. 885,P=0. 410),正常孕妇和亚甲减孕妇血清ApoA-Ⅰ的含量增高,差异均有统计学意义(χ2 =46. 343,P<0. 001;χ2 =35. 984,P<0. 001),亚甲亢孕妇血清ApoA-Ⅰ含量的变化差异无统计学意义(χ2 =6. 750,P=0. 080). 亚甲亢孕妇孕期血清HDL-C和ApoA-Ⅰ的含量均低于正常孕妇,差异均有统计学意义(P=0.025,P=0.027),正常孕妇与亚甲减孕妇孕期血清 HDL-C和 ApoA-Ⅰ含量的差异均无统计学意义(P =0. 378,P =0. 549). 结论:妊娠期亚甲亢影响孕妇血清HDL-C和ApoA-Ⅰ代谢,进而影响胎儿的生长发育;妊娠期亚甲减(经优甲乐治疗后)未发现影响孕妇血清HDL-C和ApoA-Ⅰ代谢.     

Response to thyrotrophin-releasing hormone in atrial dysrhythmias.

Seventy-eight clinically euthyroid patients with atrial dysrhythmias, either established or paroxysmal, and sixty-three patients in sinus rhythm with coronary disease were screened for hyperthyroidism using thyroid function tests including the thyroid-stimulating hormone (TSH) response to thyrotrophin-releasing hormone (TRH). All had normal levels of serum thyroxine (T4) apart from three with dysrhythmias who were found to have hyperthyroidism. Twenty per cent of patients with atrial dysrhythmias and 10% of those in sinus rhythm had exaggerated TSH response to TRH. Thirty-six per cent of patients with an exaggerated response of TSH to TRH had significant titres of thyroid auto-antibodies compared with 15% with positive antibodies in those with normal TSH response to TRH. Auto-immune thyroid disease may be more closely related to heart disease than has previously been recognized. Rapid atrial dysrhythmias may occur in the presence of a normal serum thyroxine, high levels of TSH and positive thyroid antibodies.     

甲状腺机能亢进性肌病24例临床分析

目的通过分析甲状腺机能亢进性肌病的临床表现,予以减少及减轻其发病率。方法 24例甲状腺机能亢进症的患者,经行甲状腺功能,肌电图等检查确诊为甲状腺机能亢进性肌病,予改善循环,营养神经,抑制免疫等治疗后观察其临床症状缓解情况。结果所有患者临床症状均明显缓解。结论甲状腺机能亢进症患者在合并明显甲状腺机能亢进性肌病时,可适当加用糖皮质激素抑制免疫反应,缓解临床症状。     

2种剂量131I治疗Graves病的前瞻性随机对照研究

目的观察2种剂量131I治疗Graves病的临床疗效、影响因素及并发症发生情况。方法将652例符合入选标准的Graves病患者随机分为2组,分别按照甲状腺放射性活度60～100μCi(2.22～3.70 MBq)/g(小剂量组)、80～120μCi(2.96～4.44 MBq)/g(常规剂量组)计算给予131I治疗剂量。随访12个月,观察2组一次性有效率及治疗后甲减发生率。8例浸润性突眼患者131I治疗后给予强的松0.5 mg/kg治疗1个月。结果治疗有效率:小剂量组为80.0%,常规剂量组为82%,2组比较差异无统计学意义(P>0.05)。小剂量组甲状腺功能减退发生率显著低于常规剂量组(12.1%vs 16.8%,P<0.05)。治疗结局与患者临床特征、甲状腺摄碘率、抗体水平、血浆激素水平之间均无显著相关性(P>0.05)。所有无浸润性突眼患者未发生新发眼病,8例患浸润性突眼患者眼部症状无加重。结论小剂量与常规剂量131I治疗甲亢一次性有效率无差别,而甲减发生率明显降低。适当调低常规治疗剂量治疗甲状腺功能亢进可能更加合理。     

Rapid Estimation of Thyroid Function by Photomotography

The usefulness of photomotographic determination of the duration of the ankle reflex in the diagnosis of thyroid dysfunction was studied. Diagnoses by photomotography and I¹³¹ uptake were in accord in 28 normals (260-380 milliseconds), 14 hypothyroid (390-600) and 21 hyperthyroid patients (160-250). Euthyroid reflex duration did not vary in 141 healthy persons when considered in terms of race, sex, age and pregnancy. In 172 patients, psychiatric or neuromuscular illness, heart failure, fever or several drugs had no effect. Hyperthyroidism was erroneously diagnosed in seven euthyroid subjects; there were no false hypothyroid values. Photomotography is helpful in the diagnosis of thyroid dysfunction, especially hypothyroidism.