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Home | Articles | Diabetes and Endocrinology | Hyperthyroidism

Hyperthyroidism

Last updated 3rd December 2020

Last Updated on 29th November 2018 by Chris Isles.  Due for Review 29th November 2019.

Antithyroid Drug Therapy

  1. There are two main drugs for hyperthyroidism – Carbimazole and Propythiouracil. Carbimazole is used much more commonly except in early pregnancy and is tolerated well.
  2. The main side effects to be concerned about are agranulocytosis and liver dysfunction both of which are rare but can have significant morbidity.
  3. Hyperthyroidism (and hypothyroidism) can cause liver dysfunction so when LFTs are deranged, it is worth reviewing whether they are improving or not.
  4. If a patient has a sore throat or fever they should attend for an urgent (same day) full blood count. If neutrophils are <1000, then consideration should be given to ceasing anti-thyroid drug therapy.
  5. Agranulocytosis can occur at any time, on any dose and can also be delayed but tends to occur within 2-3 weeks of taking Carbimazole.
  6. In general, Propythiouracil is less well tolerated than Carbimazole and if Carbimazole is definitely contraindicated then it is unlikely that Propythiouracil will be used (except in pregnancy).

Radioactive Iodine

  1. Radioactive iodine (RAI) is considered definitive therapy for hyperthyroidism as 93% of patients never become hyperthyroid again after a single dose of RAI.
  2. Radioactive iodine is given as a single dose (~500 MBq).
  3. In the immediate time after the dose is given 50% of the dose is taken up by the thyroid gland and over the next 4 days (approx) the other 50% is excreted through bodily fluids and so patients are advised to wash their clothes and crockery separately, to avoid cooking especially when it involves manual handling such as kneading dough. Men are advised to pass urine sitting down. Patients are also advised to avoid close, prolonged contact with people for up to 25 days depending on who the other people are. Children and pregnant women are at highest risk.
  4. This means there is a risk if patients are admitted to a hospital especially if there is vomiting or incontinence. Patients should carry an information card and radiation protection should be informed. They should be managed in a side room and if a patient needs admission in the very early days post RAI dose may need to be managed in a hospital which has a radioiodine room (there is no such room in DGRI).
  5. Staff also need to be aware of the risks to themselves, other patients and visitors. Advice should be sought from radiation protection immediately/next morning even at weekends. The information card also has contact details of the Nuclear Medicine Department in Crosshouse Hospital who administer the RAI in DGRI.
  6. Please note that emergency management of the patient should take priority over radiation protection but it is important to consider who has contact with the patient.

Thyroidectomy

  1. Thyroidectomy is also considered to be a definitive therapy for hyperthyroidism.
  2. Total thyroidectomy is the operation of choice and will leave the patient hypothyroid and so they will need Levothyroxine therapy (usually 100-150 micrograms daily) from the 1st post-operative day.
  3. There is a small risk of hypoparathyroidism which may be transient so measure serum calcium and replace if required (follow hypocalcaemia guideline in Clinical handbook).
  4. Also measure vitamin D and replace with alfacalcidol (follow hypocalcaemia guideline) if indicated.