Evaluation of the triiodothyronine suppression test in the treatment of Graves' disease

Abstract A triiodothyronine (T₃) suppression test was performed on 36 patients with Graves' disease during treatment with antithyroid drugs. The patients were divided into two groups according to the thyroid size before treatment. — It was found that in 10 out of 15 patients without a visibly enlarged thyroid gland thyroid function became suppressive during treatment. Out of 21 patients with a visibly enlarged gland, thyroid function in only 1 patient was suppressed at the end of drug treatment. These findings are in accordance with our earlier findings that the incidence of remission after treatment with antithyroid drugs in Graves' disease is high (72%) in patients without a visibly enlarged gland and low (15%) in patients with a visibly enlarged thyroid gland before treatment.     

Diagnosis and treatment of Graves disease

OBJECTIVE: To review the etiology, diagnosis, and clinical presentation of Graves disease and provide an overview of the standard and adjunctive treatments. Specifically, antithyroid drugs, beta-blockers, inorganic iodide, lithium, and radioactive iodine are discussed, focusing on current controversies. DATA SOURCES: Primary articles were identified through a MEDLINE search (1966-July 2000). Key word searches included beta-blockers, Graves disease, inorganic iodide, lithium, methimazole, and propylthiouracil. Additional articles from these sources and endocrinology textbooks were also identified. We agreed to include articles that would highlight the most relevant points, as well as current areas of controversy. DATA SYNTHESIS: Graves disease is the most common cause of hyperthyroidism. The 3 main treatment options for patients with Graves hyperthyroidism include antithyroid drugs, radioactive iodine, and surgery. Although the antithyroid drugs propylthiouracil (PTU) and methimazole (MMI) have similar efficacy, there are situations when 1 agent is preferred. MMI has a longer half-life than PTU, allowing once-daily dosing that can improve patient adherence to treatment. PTU has historically been the drug of choice for treating pregnant and breast-feeding women because of its limited transfer into the placenta and breast milk. Adjuvant therapies for Graves disease include beta-blockers, inorganic iodide, and lithium. beta-Blockers are used to decrease the symptoms of hyperthyroidism. Inorganic iodide is primarily used to prepare patients for thyroid surgery because of its ability to decrease the vascularity of the thyroid gland. Lithium, which acts in a manner similar to iodine, is not routinely used due to its transient effect and the risk of potentially serious adverse effects. In the US, radioiodine therapy has become the preferred treatment for adults with Graves disease. It is easy to administer, safe, effective, and more affordable than long-term treatment with antithyroid drugs. Hypothyroidism is an inevitable consequence of radioiodine therapy. Radioiodine is contraindicated in pregnant women because it can damage the fetal thyroid gland, resulting in fetal hypothyroidism. Bilateral subtotal thyroidectomy, which was once the only treatment available, is now performed only in special circumstances. In addition to the normal risks associated with surgery, laryngeal nerve damage, hypoparathyroidism, and hypothyroidism can occur following that procedure. CONCLUSIONS: Despite extensive experience with medical management, controversy prevails regarding choosing among the various drugs for treatment of Graves disease. None of the treatment options, including antithyroid drugs, radioiodine, and surgery, is ideal. Each has risks and benefits, and selection should be tailored to the individual patient.     

Treatment of Graves' disease--antithyroid drug therapy]

Graves' hyperthyroidism is thought to be caused by thyroid-stimulating antibodies, which interact with the thyrotropin receptors in the thyroid. In this sense there is no ideal treatment for Graves' hyperthyroidism, yet, according to the pathogenesis of the disease. Therefore, drugs of thionamide which inhibit thyroid hormone synthesis have still been used as the antithyroid drugs widely. However, there are many problems left for antithyroid drug therapy. The author described update considerations to solve these problems faced during the therapy of Grave's hyperthyroidism. Major issues discussed are as follows; 1) Thionamide therapy depending on the severity of Graves' hyperthyroidism. 2) Evaluation of drug effectiveness. 3) Possibility and choice of therapy. 4) Change of therapy from antithyroid drugs. 5) Explanation of antithyroid drug to patients. 6) Side effects. 7) When antithyroid drug should be stopped?     

Thyroid disease and pregnancy

Thyroid disease is common in younger women and may be a factor in reproductive dysfunction. This probably only applies to severe cases of hyper- or hypothyroidism. Once adequately treated, neither of these disorders significantly impacts on fertility. The key is to recognize and to treat thyroid disorders in the reproductive-age woman before conception. Thyroxine therapy and even antithyroid drug therapy should be continued during pregnancy as necessary. Pregnancy is a euthyroid state that is normally maintained by complex changes in thyroid physiology. The fetal and neonatal hypothalamic-pituitary-thyroid system develops independently, but it may be influenced by thyroid disease in the mother. Early pregnancy is characterized by an increase in maternal T4 secretion stimulated by hCG and an increase in TBG, resulting in the elevated total serum T4 in pregnancy. The debate continues as to whether maternal T4 is important in early or late fetal brain development. If so, the physiologic changes in thyroid hormone secretion and transport in early pregnancy would help to ensure that a sufficient amount of thyroid hormone was available. There is new evidence in human subjects that substantial maternal T4 can cross the placenta during pregnancy, and this may be particularly important when fetal thyroid function is compromised as a result of congenital hypothyroidism. Maternal and fetal/neonatal outcomes in pregnancy are adversely affected if severe hypothyroidism is undiagnosed or inadequately treated. Thyroid function tests should be obtained during gestation in women taking T4 and appropriate dose adjustments should be made for TSH levels outside a normal range. The TSH-receptor blocking antibodies from the mother are a recognized cause of congenital hypothyroidism in the fetus and neonate that can be permanent or transient. If neonatal hypothyroidism is detected through neonatal screening programs, and prompt and adequate T4 replacement therapy is instituted as soon as possible following delivery, subsequent growth and development are usually normal. Paradoxically, pregnancy often has a favorable effect on the course of maternal Hashimoto's disease, although there is the risk of relapse postpartum. Pathophysiologic conditions of hCG secretion such as gestational trophoblastic disease and hyperemesis gravidarum may present as thyrotoxicosis in pregnancy, but the main cause of this syndrome is Graves' disease. The mainstay of treatment is antithyroid drugs and either propylthiouracil or methimazole may be used safely. Subtotal thyroidectomy, after medical control, is the alternative treatment, but radioiodine ablation is contraindicated.(ABSTRACT TRUNCATED AT 400 WORDS)     

Prise en charge en réanimation du coma myxoedémateux et des formes graves de thyrotoxicose

Hypothyroidism and hyperthyroidism, generally benign conditions, may result in severe features leading to patient admission to the intensive care unit (ICU). Myxedema coma, generally related to the non-compliance with replacement therapy in a patient with chronic hypothyroidism, is characterized by coma associated with hypothermia, bradycardia, and respiratory failure. Thyroid hormone measurement allows the diagnosis. Protocols with rapid intravenous administration of high doses of thyroid hormones, together with warming and mechanical ventilation, have improved the prognosis which remains severe with 50% mortality rate. Nowadays, severe forms of thyrotoxicosis admitted to the ICU are more frequently amiodaroneassociated thyrotoxicosis (whose severity is related to the presence of underlying cardiac diseases) than classic thyroid storms. Treatment of thyroid storm with antithyroid drugs, corticoids, and beta-blockers is generally effective and allows avoiding the need for plasma exchange or emergency thyroidectomy. Prognosis of thyroid storm has improved but remains severe with 20% mortality rate. Diagnosis of the mechanism of amiodarone-induced thyrotoxicosis (type 1 versus type 2) is crucial for treatment. In type 1 (latent preexisting hyperthyroidism worsened by iodine excess), treatment is similar to the one proposed for thyroid storm; in type 2 (thyrotoxicosis related to amiodarone-induced destructive thyroditis), antithyroid drugs are ineffective and treatment relies on corticoids at high doses. However, in these cases, interruption of amiodarone may not be mandatory.     

Hemodynamic variation is a dominant contributing factor of Graves' hyperthyroidism complication: Heart failure and fatal liver dysfunction,a case report and analysis

Tachycardia and atrial fibrillation, early symptoms of hyperthyroidism indicate significant hemodynamic variation in cardiovascular system, if left untreated and further deterioration in hemodynamics can result in chronic heart failure and liver dysfunction even a fatal event. We describe a female patient of Graves'' hyperthyroidism to present the continuum of the pathophysiology development of the disease, to highlight the hemodynamic variation is a dominant contributing factor of Graves'' hyperthyroidism complication, we wish to emphasize cardiac manifestations in the setting of thyrotoxicosis should be treated promptly and aggressively.     

Thyroid function during pregnancy

BACKGROUND: This Case Conference reviews the normal changes in thyroid activity that occur during pregnancy and the proper use of laboratory tests for the diagnosis of thyroid dysfunction in the pregnant patient. CASE: A woman in the 18th week of pregnancy presented with tachycardia, increased blood pressure, severe vomiting, increased total and free thyroid hormone concentrations, a thyroid-stimulating hormone (TSH) concentration within the reference interval, and an increased human chorionic gonadotropin (hCG) beta-subunit concentration. ISSUES: During pregnancy, normal thyroid activity undergoes significant changes, including a two- to threefold increase in thyroxine-binding globulin concentrations, a 30-100% increase in total triiodothyronine and thyroxine concentrations, increased serum thyroglobulin, and increased renal iodide clearance. Furthermore, hCG has mild thyroid stimulating activity. Pregnancy produces an overall increase in thyroid activity, which allows the healthy individual to remain in a net euthyroid state. However, both hyper- and hypothyroidism can occur in pregnant patients. In addition, two pregnancy-specific conditions, hyperemesis gravidarum and gestational trophoblastic disease, can lead to clinical hyperthyroidism. The normal changes in thyroid activity and the association of pregnancy with conditions that can cause hyperthyroidism necessitates careful interpretation of thyroid function tests during pregnancy. CONCLUSION: Assessment of thyroid function during pregnancy should be done with a careful clinical evaluation of the patient's symptoms as well as measurement of TSH and free, not total, thyroid hormones. Measurement of thyroid autoantibodies may also be useful in selected cases to detect maternal Graves disease or Hashimoto thyroiditis and to assess risk of fetal or neonatal consequences of maternal thyroid dysfunction.     

Acute coronary syndrome with severe atherosclerotic and hyperthyroidism: A case report

BACKGROUNDAcute coronary syndrome (ACS) encompasses a spectrum of cardiovascular emergencies arising from the obstruction of coronary artery blood flow and acute myocardial ischemia. Recent studies have revealed that thyroid function is closely related to ACS. However, only a few reports of thyrotoxicosis-induced ACS with severe atherosclerosis have been reported.CASE SUMMARYA 33-year-old man, who had a history of hyperthyroidism without taking any antithyroid drugs and no history of coronary heart disease, experienced neck pain with occasional heart palpitations starting 3 mo prior that were aggravated after an activity. As the symptoms worsened at 21 d prior, he went to a hospital for treatment. The electrocardiogram examination showed a multilead ST segment elevation and pathological Q waves. Based on these findings and his symptoms, the patient was diagnosed with a suspected myocardial infarction and transferred to our hospital on July 2, 2020. He was diagnosed with a rare case of ACS due to coronary artery atherosclerosis in the anterior descending artery complicated by hyperthyroidism. A paclitaxel-coated drug balloon was used for treatment to avoid the use of metal stents, thus reducing the time of antiplatelet therapy and facilitating the continued treatment of hyperthyroidism. The 9-mo follow-up showed favorable results.CONCLUSIONThis case highlights that atherosclerosis is a cause of ACS that cannot be ignored even in a patient with hyperthyroidism.     

Central hypothyroidism and hyperthyroidism

Thyroid function is maintained by tonic secretion of TSH by the pituitary. TSH secretion, in turn, is dependent on hypothalamic TRH production. Therefore, diseases of the hypothalamus and pituitary are frequently associated with TSH deficiency, producing central hypothyroidism. All patients with hypothalamic or pituitary disease should have thyroid function tests including a serum TSH by radioimmunoassay (RIA). In central hypothyroidism the TSH RIA is inappropriately low in relationship to the degree of hypothyroxinemia but is not always undetectable. In fact, because of the production of biologically inactive TSH, the TSH RIA may be in the high range of normal. Therapy of central hypothyroidism includes the management of associated pituitary hormone deficiencies, particularly secondary adrenal failure, and neurologic defects. A rare cause of hyperthyroidism is excessive TSH secretion. This may be due to a TSH-secreting pituitary tumor or to a functional disturbance in TSH secretion. TSH-secreting pituitary tumors are often large and locally invasive. Selective pituitary resistance to thyroid hormone is the most common cause of functional TSH-induced hyperthyroidism. It is important to rule out generalized thyroid hormone resistance before use of antithyroid drugs or thyroid surgery in patients suspected of this disorder. This is because antithyroid treatment is contraindicated in generalized thyroid hormone resistance.     

妊娠期剧吐与妊娠期高血压、妊娠期糖尿病、妊娠结局的关系研究

目的分析妊娠期剧吐与妊娠期高血压、妊娠期糖尿病、妊娠结局的关系。方法回顾性选取2017年1月至2019年1月我院收治的200例孕产妇,依据妊娠期剧吐发生情况将其分为有妊娠期剧吐组(n=20)和无妊娠期剧吐组(n=180)。比较两组的妊娠期高血压、妊娠期糖尿病发生情况及妊娠结局。结果两组的妊娠期高血压、妊娠期糖尿病发生率无显著差异(P>0.05)。有妊娠期剧吐组的早产儿、小于胎龄儿、低出生体重儿发生率显著高于无妊娠期剧吐组(P<0.05),但两组的新生儿5 min Apgar评分≤7分、死胎发生率比较,差异均不显著(P>0.05)。结论妊娠期剧吐与妊娠期高血压、妊娠期糖尿病、新生儿5 min Apgar评分≤7分、死胎无关,与早产儿、小于胎龄儿、低出生体重儿相关,临床可通过积极干预妊娠期剧吐、强化孕检,有效改善妊娠结局。     

Lithium: Thyroid Effects and Altered Renal Handling

Background: Lithium is frequently used in the treatment of bipolar affective disorder, and is widely known to affect thyroid function, most commonly resulting in hypothyroidism and goiter. Less well-known is the association between lithium therapy and hyperthyroidism and the potential for lithium to moderate the effects of thyroxine at a cellular level. Lithium excretion relates principally to glomerular filtration rate and proximal tubule function. Thyroxine, through its effects on tubular function, alters lithium clearance such that thyroid disease may cause retention of lithium and subsequent toxicity. Case Reports: We report 2 cases with lithium toxicity, both of whom were later found to be hyperthyroid. One patient developed thyroid storm following dialysis to remove lithium. The other received antithyroid medication early. Both suffered a protracted multifactorial delirium requiring intensive inpatient care. Conclusion: In addition to altering thyroid function, lithium therapy may mask the signs of hyperthyroidism by inducing cellular unresponsiveness. In some lithium-treated patients with biochemical hyperthyroidism, early antithyroid treatment may be appropriate. Altered renal tubular function induced by hyperthyroidism may result in retention of lithium and systemic toxicity. We propose induction of the proximal tubule sodium hydrogen antiporter as the relevant mechanism.     

Management of hyperthyroidism in Trinidad and Tobago

A questionnaire study of current practices regarding the investigation and treatment of hyperthyroidism was undertaken in Trinidad and Tobago between December 1999 and March 2000. The study evaluated the choice of laboratory tests requested and the therapeutic choices for a standard patient with hyperthyroidism. In addition, clinical scenarios based upon variations of the standard case (by altering age, gender, goitre size and duration of disease) were also tested. Two hundred and ninety-six questionnaires were sent; 134 (45%) were returned, of which four were excluded for incomplete data. Ninety five per cent of respondents requested biochemical confirmation but the range of tests varied widely. Thyroid scintigraphy was requested by 36% and thyroid ultrasound by 35%. Medical treatment (75%) with antithyroid drugs was the most popular choice for treatment of the standard patient. This did not change significantly if the patient was male. On the other hand, radioiodine (62%) was more popular in the treatment of chronic/relapsing hyperthyroidism (p < 0.005). In the elderly, medical management was still the most popular choice (57%) but the choice of radioiodine therapy was significantly increased compared with that in the standard patient (36% vs 19%) (p<0.005). In a young female with a large goitre and chronic disease, surgical intervention (61%) was the treatment of choice, especially among surgeons and general practitioners; radioiodine was chosen by 28% of respondents (mostly internists). There is need for clear guidelines in investigating thyroid disease but therapeutic choices are well informed and consistent with accepted practice elsewhere. In particular there is a fairly liberal attitude towards radioiodine use in hyperthyroidism.     

Use of an artificial neural network to predict Graves' disease outcome within 2 years of drug withdrawal

BACKGROUND: Graves' disease (GD) is an autoimmune disorder characterized by hyperthyroidism, which can relapse in many patients after antithyroid drug treatment withdrawal. Several studies have been performed to predict the clinical course of GD in patients treated with antithyroid drugs, without conclusive results. The aim of this study was to define a set of easily achievable variables able to predict, as early as possible, the clinical outcome of GD after antithyroid therapy. METHODS: We studied 71 patients with GD treated with methimazole for 18 months: 27 of them achieved stable remission for at least 2 years after methimazole therapy withdrawal, whereas 44 patients relapsed. We used for the first time a perceptron-like artificial neural network (ANN) approach to predict remission or relapse after methimazole withdrawal. Twenty-seven variables obtained at diagnosis or during treatment were considered. RESULTS: Among different combinations, we identified an optimal set of seven variables available at the time of diagnosis, whose combination was useful to efficiently predict the outcome of the disease following therapy withdrawal in approximately 80% of cases. This set consists of the following variables: heart rate, presence of thyroid bruits, psycological symptoms requiring psychotropic drugs, serum TGAb and fT4 levels at presentation, thyroid-ultrasonography findings and cigarette smoking. CONCLUSIONS: This study reveals that perceptron-like ANN is potentially a useful approach for GD-management in choosing the most appropriate therapy schedule at the time of diagnosis.     

Toxic multinodular goiter

The prevalence of toxic multinodular goiter (TMNG) is very rare in Japan which iodine intake is sufficient or excessive. It accounts for about < 1.0% of hyperthyroidism. The pathogenesis of TMNG is unknown, especially iodine rich area like in Japan although in iodine-deficient arears iodine insufficiency and TSH stimulating is the major promoting factors in its pathogenesis. Unlike Graves' disease, TMNG is more prevalent among aged patients and its symptoms of hyperthyroidism develops insidiously. Radionuclide imaging and ultrasonography provide very important information about the diagnosis of TMNG in addition to thyroid function tests. The treatments for TMNG are surgery after amelioration of thyroid function with antithyroid drugs, radioiodine treatment and PEIT (percutaneous ethanol injection therapy). We always have to pay attention to the existence of thyroid cancer complicated with TMNG.     

妊娠合并甲状腺机能亢进的观察与护理

目的 探讨妊娠合并甲状腺机能亢进（以下简称甲亢）的观察与护理方法。方法 对2001—2005年住院分娩的产妇，选择其中妊娠合并甲亢32例，作回顾性分析。结果 甲亢合并早孕者16例，发生妊娠剧吐10例，先兆流产6例；甲亢合并晚孕者16例，发生早产3例，胎儿窘迫6例，合并妊娠高血压综合征2例；产后出血2例；新生儿窒息3例。结论 对妊娠合并甲亢应引起高度重视，加强围产期护理，降低围产期母婴死亡率。     

Thyroid storm and warm autoimmune hemolytic anemia

Graves’ disease is often associated with other autoimmune disorders, including rare associations with autoimmune hemolytic anemia (AIHA). We describe a unique presentation of thyroid storm and warm AIHA diagnosed concurrently in a young female with hyperthyroidism. The patient presented with nausea, vomiting, diarrhea and altered mental status. Laboratory studies revealed hemoglobin 3.9 g/dL, platelets 171 × 10⁹ L^?1, haptoglobin <5 mg/dL, reticulocytosis, and positive direct antiglobulin test (IgG, C3d, warm). Additional workup revealed serum thyroid stimulating hormone (TSH) <0.01 μIU/mL and serum free-T4 (FT4) level 7.8 ng/dL. Our patient was diagnosed with concurrent thyroid storm and warm AIHA. She was started on glucocorticoids to treat both warm AIHA and thyroid storm, as well as antithyroid medications, propranolol and folic acid. Due to profound anemia and hemodynamic instability, the patient was transfused two units of uncrossmatched packed red blood cells slowly and tolerated this well. She was discharged on methimazole as well as a prolonged prednisone taper, and achieved complete resolution of the thyrotoxicosis and anemia at one month. Hyperthyroidism can affect all three blood cell lineages of the hematopoietic system. Anemia can be seen in 10–20% of patients with thyrotoxicosis. Several autoimmune processes can lead to anemia in Graves’ disease, including pernicious anemia, celiac disease, and warm AIHA. This case illustrates a rarely described presentation of a patient with Graves’ disease presenting with concurrent thyroid storm and warm AIHA.     

Effect of Nei-Guan point (P6) acupressure on ketonuria levels, nausea and vomiting in women with hyperemesis gravidarum

AIM: This paper is a report of a study to examine the effect of Nei-Guan point acupressure on nausea, vomiting and ketonuria levels in women diagnosed with hyperemesis gravidarum. BACKGROUND: Previous studies have shown that acupressure application on the Nei-Guan point is effective in relieving nausea and vomiting associated with pregnancy and surgery. However, no findings have been supported by physiological data. METHOD: A randomized control group pretest-post-test design was implemented from 1 April 2003 to 30 April 2004 using three groups: a Nei-Guan point acupressure group, a placebo group and a control group which received only conventional intravenous treatment. The participants were 66 women admitted to two general hospitals in Korea with hyperemesis gravidarum. RESULTS: The degree of nausea and vomiting was statistically significantly lower in the Nei-Guan point acupressure group in comparison with the placebo and control groups. Ketonuria levels were reduced over time and, on days three and four of hospitalization, levels in the treatment group were statistically significantly lower than in the placebo or control groups (P < 0.05). CONCLUSION: Nei-Guan point acupressure is a useful treatment for relieving symptoms experienced by women with hyperemesis gravidarum.     

妊娠合并甲状腺机能亢进的观察与护理

目的探讨妊娠合并甲状腺机能亢进(以下简称甲亢)的观察与护理方法。方法对2001-2005年住院分娩的产妇,选择其中妊娠合并甲亢32例,作回顾性分析。结果甲亢合并早孕者16例,发生妊娠剧吐10例,先兆流产6例;甲亢合并晚孕者16例,发生早产3例,胎儿窘迫6例,合并妊娠高血压综合征2例;产后出血2例;新生儿窒息3例。结论对妊娠合并甲亢应引起高度重视,加强围产期护理,降低围产期母婴死亡率。     

Therapeutic plasma exchange and continuous renal replacement therapy for severe hyperthyroidism and multi-organ failure:A case report

BACKGROUND Severe hyperthyroidism is a life-threatening exacerbation of thyrotoxicosis,characterized by high fever and multiorgan failure. The most common medical treatments are administration of antithyroid drugs and radioactive iodine, and thyroidectomy. In some patients, antithyroid therapy is limited due to serious adverse effects or failure to control disease progression. In some extreme cases,such as thyroid storm, conventional therapy alone does not yield effective and rapid improvement before the development of multiorgan failure.CASE SUMMARY This report describes a Chinese patient with severe hyperthyroidism accompanied by multiorgan failure, who was transferred to the medical intensive care unit of our hospital. The patient presented with palpitations, vomiting,diarrhea, and shortness of breath for a week. Laboratory tests showed elevation of thyroid hormones. Hepatic failure occurred with high aminotransferase levels and jaundice. Given her abnormal liver function and medication history, we could not exclude diagnosis of propylthiouracil-induced hepatic failure.Moreover, she also suffered from heart failure. Therapeutic plasma exchange(commonly known as TPE) and continuous renal replacement therapy(commonly known as CRRT) were used as life-saving therapy, which resulted in notable improvement of clinical symptoms and laboratory tests.CONCLUSION Combined TPE and CRRT are safe and effective for patients with hyperthyroidism and multiorgan failure.     

Hyperthyroidism: diagnosis and treatment

The proper treatment of hyperthyroidism depends on recognition of the signs and symptoms of the disease and determination of the etiology. The most common cause of hyperthyroidism is Graves' disease. Other common causes include thyroiditis, toxic multinodular goiter, toxic adenomas, and side effects of certain medications. The diagnostic workup begins with a thyroid-stimulating hormone level test. When test results are uncertain, measuring radionuclide uptake helps distinguish among possible causes. When thyroiditis is the cause, symptomatic treatment usually is sufficient because the associated hyperthyroidism is transient. Graves' disease, toxic multinodular goiter, and toxic adenoma can be treated with radioactive iodine, antithyroid drugs, or surgery, but in the United States, radioactive iodine is the treatment of choice in patients without contraindications. Thyroidectomy is an option when other treatments fail or are contraindicated, or when a goiter is causing compressive symptoms. Some new therapies are under investigation. Special treatment consideration must be given to patients who are pregnant or breastfeeding, as well as those with Graves' ophthalmopathy or amiodarone-induced hyperthyroidism. Patients' desires must be considered when deciding on appropriate therapy, and dose monitoring is essential.