Toxic multinodular goiter medical therapy

Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Sunny Kumar MD [2],Furqan M M. M.B.B.S[3]

The mainstay of treatment for Toxic multinodular goiter is Surgery. Patients with symptomatic hyperthyroidism, sub-clinical hyperthyroid patients with expected compilations and patients refusing surgical therapy are treated with beta blockers and anti-thyroid pharmacological groups.

Symptomatic therapy for toxic multinodular goiter (TMG) is recommended for the patients with the following:^[1][2][3]

• Thyroid storm
• Overt hyperthyroidism
• Hyperthyroidism with cardiovascular complications
• Hyperthyroidism with central nervous system complications
• Elderly patients
• Patient with coexisting cardiac condition

Following are drugs used in the symptomatic management of toxic multinodular goiter:

• Propanolol
• Atenolol
• Metoprolol
• Nadolol
• Esmolol

Following are antithyroid medicines used in the management of TMG:

• Propylthiouracil
• Methimazole

Anti-thyroid therapy for toxic multinodular goiter (TMG) is recommended for the patients with the following:

• Patients refusing radiation therapy
• Patients refusing surgery
• Patients on peri-operative preparation
• Pregnancy with caution as anti-thyroid medication is teratogenic
• Recently gone through surgery or radiation
• Unfit for radiation of surgery
• Lack of professional expertise or medical facilities.
• Limited life expectancy

Treatment of TMG should be decided on:

• Severity of disease
• Biochemical evaluation of thyroid profile level of TSH, T3, and T4
• Cardiac evaluation“`(echo-cardiogram, electrocardiogram, Holter monitor, or myocardial perfusion studies)
• Neuromuscular complications
• Age
• Goiter size
• Physical examination including vitals as pulse rate and respiratory rate

Pharmacological medical therapy for toxic multinodular goiter is primarily based on beta blockers and anti-thyroid drugs.^[4]

1. Toxic Multinodular Goiter
   • Thyroid storm^[1]
     • Preferred regimen (1): Propylthiouracil 500–1000 mg load, then 250 mg PO / IV 4 hourly PLUS Propranolol 60–80 mg PO 4 hourly(Consider invasive monitoring in congestive heart failure patients) PLUS Hydrocortisone 300 mg intravenous load, then 100 mg 8 hourly PLUS Cholestyramine 4 g PO 6 hourly PLUS Iodine (saturated solution of potassium iodide 5 drops (0.25 mL or 250 mg) orally 6 hourly(start Iodine after 1 hour of administration of Thalidomide to so that iodine may not be used as substrate)
     • Alternative regimen (1): Methimazole 60–80 mg PO in 24 hours PLUS Propranolol 60–80 mg PO 4 hourly(Consider invasive monitoring in congestive heart failure patients) PLUS Hydrocortisone 300 mg intravenous load, then 100 mg 8 hourly PLUS Cholestyramine 4 g PO 6 hourly PLUS Iodine (saturated solution of potassium iodide 5 drops (0.25 mL or 250 mg) orally 6 hourly (start Iodine after 1 hour of administration of Thalidomide to so that iodine may not be used as substrate)

1. • Hyperthyroidism^[5]
     • Preferred regimen (1): Propylthiouracil 500–1000 mg load, then 250 mg PO / IV 4 hourly PLUS Propranolol 60–80 mg PO 4 hourly(Consider invasive monitoring in congestive heart failure patients) PLUS Iodine (saturated solution of potassium iodide 5 drops (0.25 mL or 250 mg) orally 6 hourly(start Iodine after 1 hour of administration of Thalidomide to so that iodine may not be used as substrate)
     • Alternative regimen (1): Methimazole 60–80 mg PO in 24 hours PLUS Propranolol 60–80 mg PO 4 hourly(Consider invasive monitoring in congestive heart failure patients) PLUS Iodine (saturated solution of potassium iodide 5 drops (0.25 mL or 250 mg) orally 6 hourly (start Iodine after 1 hour of administration of Thalidomide to so that iodine may not be used as substrate)
   • Subclinical hyperthyroidism with comorbid conditions such as diabetes mellitus, heart failure or CNS abnormality^[3]
     • Preferred regimen (1): Propylthiouracil 5-10 mg q24h PO for long term to avoid remission with 3 month review of TSH
     • Alternative regimen (1): Methimazole 5-10 mg q24h PO for long term to avoid remission with 3 month review of TSH
   • Subclinical hyperthyroidism without comorbid conditions
     • Preferred: Monitoring/Review of TSH every 3 month
     • Alternative regimen (1):Propylthiouracil 5-10 mg q24h PO for long term to avoid remission with review of TSH every 3 month

Ultrasound-Guided percutaneous ethanol injection (PEI):^[6]

• Patients Toxic Multinodular Goiter differing treatment with surgery, antithyroid medication and radiation therapy can benefit from injection of ethanol to destroy autonomous functioning thyroid nodules to decrease production of thyroid and also considerable reduction in thyroid gland size.
• It is a safe procedure without serious complications
• Some of complications are
  • ethanol leakage into the surrounding tissues
  • local pain
  • dysphonia
  • flushing
  • dizziness
  • recurrent nerve palsy
  • Horner’s syndrome
  • necrosis of the larynx and skin
  • local fibrosis

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