IPERTIROIDISMO: TERAPIA DEFINITIVA.

COME E QUANDO

Michele Zini 

Servizio di Endocrinologia - Arcispedale S. Maria Nuova, IRCCS Reggio Emilia 

michele.zini@asmn.re.it

Definitive treatment

A definitive treatment of GD is recommended in case of:

• Occurrence of a major adverse reaction to ATDs or persistence of unpleasant minor side effects

• Unsatisfactory response to ATDs or poor compliance of the patient

• Coexisting morbidities that suggest a definitive control of thyroid hyperfunction

• Relapse of hyperthyroidism after withdrawal of medical treatment

• Pregnancy planning

Radioiodine therapy (RAI)

RAI is the most cost-effective treatment for GD and is followed in nearly all patients by a definitive cure of hyperthyroidism. Patients should be informed that in most cases this target is reached at the expense of hypothyroidism induction

Indications for 131I treatment are:• ATDs use contraindications• Presence of comorbidities that cause a high surgical risk• Previous thyroid surgery or external beam irradiation• Lack of an experienced thyroid surgeon

Radioiodine therapy (RAI)

Contraindications for RAI treatment are:

• Pregnancy and breast feeding• Very young age (< 5 years)• Presence of suspicious or malignant thyroid nodules• Severe active Graves orbitopathy (GO) 

Surgical treatment

• When surgery is needed, total thyroidectomy should be performed as the procedure of choice

• Hyperthyroidism should be carefully controlled with MMI before thyroidectomy

Thyroidectomy should be considered in presence of:• Large goiter not suitable for RAI treatment • Diagnosis or suspect of thyroid malignancy• Need of hyperthyroidism resolution in the short-term

(pregnancy planned within 6 months)• Severe active GO

Surgical treatment

Surgery is contraindicated in:• First and third trimester of pregnancy• Patients at surgical risk due to relevant

comorbidities or previous thyroid surgery surgery

Fattori di rischio per ipoparatiroidismo postchirurgico Thomusch O. et al., Surgery 133: 180-185, 2003

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CONCLUSIONS: Extent of resection and surgical technique had a greater impact on permanent postoperative hypoparathyroidism than thyroid pathologic condition.

CHIRURGIA RADIOIODIO

ETA’ RIDOTTA

NODULARITA’ AVANZATA

ETA’ AVANZATA

NODULARITA’ RIDOTTA

CONCLUSIONI (1)

• Pazienti stabilmente eutiroidei con basse dosi di metimazolo possono proseguire in sicurezza la terapia per un tempo indefinito

• Per molti pazienti potrebbe essere preferibile mantenere uno steady state con i farmaci rispetto al cambio di strategia che comportano i trattamenti definitivi

CONCLUSIONI (2)

• Prima di passare ad un trattamento definitivo:• il corso di terapia con metimazolo deve

essere di durata sufficientemente lunga per rendere ragionevolmente improbabile che il m. di Basedow vada in remissione

• ogni volta che è possibile, si deve tentare la sospensione della terapia

CONCLUSIONI (3)

Se si decide per un trattamento definitivo:• informare il paziente sul carattere

irreversibile del trattamento ablativo

• informare il paziente sul probabile sviluppo di ipotiroidismo

CONCLUSIONI (4)

Nel decidere sul tipo di trattamento definitivo:• valutare il rischio anestesiologico• valutare l’aspetto ecografico della

tiroide• tenere nella dovuta considerazione i

values del paziente