Upcoming New Guidelines on Hyperthyroidism Discussed at AACE

The new clinical practice guidelines on the management of hyperthyroidism that are soon to be released jointly by the American Thyroid Association (ATA) and the American Association of Clinical Endocrinologists (AACE) are a work in progress and not yet carved in stone, said David S. Cooper, MD, Professor of Medicine at The Johns Hopkins University School of Medicine, Baltimore, Maryland.

The guidelines have updated or new recommendations for the management of hyperthyroidism in the following conditions and patients: Graves’ disease, nodular thyroid disease, in childhood, in pregnancy, in patients with subclinical hyperthyroidism, in patients with Graves’ ophthalmopathy, and in patients with drug-induced disease, thyroiditis, thyroid storm and other miscellaneous forms.

In the treatment of Graves’ disease, the guidelines now emphasize that there are three different treatments, and that each one is reasonable.

“In the United States, radioiodine has long been preferred for the treatment for Graves’ disease. However, we acknowledge in these guidelines that we may not be exactly right on this, and that the other treatments, surgery and anti-thyroid drugs, may be also be OK,” Cooper said. “People routinely are rejecting radioiodine off the bat, and also after failing an anti-thyroid drug. We used to give them one try on an anti-thyroid drug and if they failed, well that was that. But patients do want to be on anti-thyroid therapy and I think that’s probably fine.”

The new guidelines also say that radioiodine should be avoided in very young children less than five years of age.

Another major change is the new emphasis being placed on methimizole. “Methimizole is now the player, in terms of anti-thyroid therapy. PTU is now to be relegated as a “second class citizen” except in specific circumstances,” he said.

The treatment of Graves’ disease in people who have eye problems or are at risk for developing ophthalmopathy is another focus. “This is a new area as well,” Cooper said.

Although the use of radioiodine has been somewhat de-emphasized, the guidelines cite certain factors that favor its use. These include women planning a pregnancy in the near future — within six months – the elderly, people with comorbidities that increase surgical risk, and patients with previously operated or externally irradiated necks.

Patients who are considering having thyroidectomy for Graves’ disease should have the procedure done in a high volume center. Surgeons who perform less than 30 thyroidectomies a year have higher complication rates, Cooper noted.

The guidelines are currently in draft form and include 108 recommendations. The process of formally grading the quality of the evidence and the strength of the recommendations is ongoing, and they will be submitted for simultaneous publication in Thyroid and Endocrine Practice in mid 2010, Cooper said.