New Guidelines for the Management of Graves Hyperthyroidism

Transcription

1 New Guidelines for the Management of Graves Hyperthyroidism International Guidelines in Thyroid Disease in Daily Practice Vienna, Austria June 8-9, 2012 Rebecca Bahn Mayo Clinic Rochester, MN USA

2 ATA/AACE Guidelines for the Treatment of Patients with Hyperthyroidism International working group of physicians with endocrine, surgical, pediatric, and nuclear medicine expertise Goal: To develop a document containing useful advice for endocrinologists, internists, and primary care practitioners Provide evidence-based recommendations (as much as possible) using a transparent, formal method to rate quality of evidence and strength of recommendations

3 Thyrotoxicosis Guidelines Task Force Rebecca Bahn, Chair Mayo Clinic Henry Burch Walter Reed Army Medical Center David Cooper The Johns Hopkins University School of Medicine Jeffrey Garber Harvard Vanguard Medical Associates Carol Greenlee Western Slope Endocrinology Grand Junction, CO Irwin Klein North Shore University Hospital Peter Laurberg Aarhus University Hospital, Aalborg, Denmark Ross McDougall Stanford University School of Medicine Scott Rivkees Yale University School of Medicine Douglas Ross Massachusetts General Hospital Julie Ann Sosa Yale University School of Medicine Marius Stan Mayo Clinic Consultant and co-author: Victor Montori, Mayo Clinic

4 Endorsements American Academy of Otolaryngology- Head and Neck Surgery Associazione Medici Endocrinologi (AME) British Association of Endocrine and Thyroid Surgeons (BAETS) Canadian Paediatric Endocrine Group (CPEG)-Groupe Canadien d Endocrinologie Pédiatrique (GCEP) (pediatric section only) European Association of Nuclear Medicine (EANM) The Endocrine Society European Society of Endocrinology (ESE) European Society of Endocrine Surgeons (ESES) European Thyroid Association (ETA) International Association of Endocrine Surgeons (IAES) Latin American Thyroid Society (LATS) Pediatric Endocrine Society (PES) Italian Endocrine Society (SIE) Society of Nuclear Medicine (SNM)

5 Grading of Recommendations, Assessment, Development and Evaluation (GRADE) System Quality of the evidence: +++ High quality; evidence at low risk of bias, such as high quality randomized trials showing consistent results directly applicable to the recommendation ++ Moderate quality; studies with methodological flaws, showing inconsistent or indirect evidence + Low quality; case series or unsystematic clinical observations

6 Grading of Recommendations, Assessment, Development and Evaluation (GRADE) System Strength of the recommendation: 1 = strong recommendation (for or against) Applies to most patients in most circumstances Benefits clearly outweigh the risk (or vice versa) 2 = weak recommendation (for or against) Best action may differ depending on circumstances or patient values Benefits and risks or burdens are closely balanced, or uncertain

7 Recommendation 4: Patients with overt Graves hyperthyroidism should be treated with any of the following modalities: radioactive iodine, antithyroid medication, or thyroidectomy. 1/++0

8 Technical remarks: Once the diagnosis has been made, the treating physician and patient should have a comprehensive discussion of each of the treatment options, including the logistics, benefits, expected speed of recovery, drawbacks, potential side effects and cost. This sets the stage for the physician to make recommendations based on best clinical judgment and allows the final decision to reflect the personal values and preferences of the patient.

9 PTU-associated acute hepatic failure Occurs in approximately 1 in 10,000 adults on PTU Prevalence in children is higher; 1 in 2,000 Can occur at any time over the course of treatment Onset is sudden and course is rapidly progressive Routine monitoring of LFTS is not useful

10 Recommendation 13: MMI should be used in virtually every patient who chooses antithyroid drug therapy for Graves disease, except during first trimester of pregnancy when propylthiouracil is preferred, in the treatment of thyroid storm, and in patients with minor reactions to MMI who refuse radioactive iodine therapy or surgery. 1/++0

11 Recommendation 71: We suggest that patients taking MMI who decide to become pregnant obtain pregnancy testing at the earliest suggestion of pregnancy and be switched to PTU as soon as possible in the first trimester and changed back to MMI at the beginning of the second trimester. Similarly, we suggest that patients started on PTU during the first trimester be switched to MMI at the beginning of the second trimester. 2/+00

12 Recommendation 21: If a patient with GD becomes hyperthyroid after completing a course of methimazole,consideration should be given to treatment with radioactive iodine or thyroidectomy. Low-dose methimazole treatment for longer than months may be considered in patients not in remission who prefer this approach. 2/+00