ATA Updates Guidance on Thyrotoxicosis Management

In issuing new evidence-based recommendations, the American Thyroid Association (ATA) provides guidance to clinicians in the management of patients with all forms of thyrotoxicosis, including hyperthyroidism.

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Coauthored by an international task force including experts and researchers from institutions such as Walter Reed National Military Medical Center, the Johns Hopkins University School of Medicine, and Duke University School of Medicine, the guidelines state that appropriate treatment of thyrotoxicosis requires an accurate diagnosis and outline 124 recommendations to help define current best practices for patient evaluation, diagnosis, and treatment, according to the ATA. The task force examined relevant literature using a systematic PubMed search supplemented with additional published materials. The new recommendations include the following:

  • The etiology of thyrotoxicosis should be determined. If the diagnosis is not apparent based on the clinical presentation and initial biochemical evaluation, diagnostic testing is indicated and can include, depending on available expertise and resources, (1) measurement of thyrotropin receptor antibodies (TRAb), (2) determination of the radioactive iodine (RAI) uptake, or (3) measurement of thyroidal blood flow on ultrasonography. A sodium iodide I 123 or technetium Tc 99m pertechnetate scan should be obtained when the clinical presentation suggests a toxic adenoma or toxic multinodular goiter.
  • β-adrenergic blockade is recommended in all patients with symptomatic thyrotoxicosis, especially elderly patients and thyrotoxic patients with resting heart rates in excess of 90 beats/min or coexistent cardiovascular disease.
  • In patients who are at increased risk for complications due to worsening of hyperthyroidism, resuming methimazole 3 to 7 days after RAI administration should be considered.
  • Sufficient activity of RAI should be administered in a single application, typically a mean dose of 10 to 15 mCi (370-555 MBq), to render the patient with Graves disease hypothyroid.
  • A pregnancy test should be obtained within 48 hours prior to treatment in any woman with childbearing potential who is to be treated with RAI. The treating physician should obtain this test and verify a negative result prior to administering RAI.

In to address clinical topics including the initial evaluation and management of thyrotoxicosis, and the management of Graves disease hyperthyroidism, the task force sought to update existing guidelines as a way to “aid in the care of patients with thyrotoxicosis and to share what the task force believes is current, rational, and optimal medical practice,” the authors wrote.

—Mark McGraw

Reference:

Ross DS, Burch HB, Cooper DS, et al. 2016 American Thyroid Association guidelines for diagnosis and management of hyperthyroidism and other causes of thyrotoxicosis [published online August 12, 2016]. Thyroid. doi:10.1089/thy.2016.0229.