This document discusses definitive treatment options for Graves' disease. Radioactive iodine therapy is recommended in most cases as it is cost-effective and results in definitive hyperthyroidism cure by inducing hypothyroidism. Surgery is an alternative if the goiter is large or there is suspicion of thyroid cancer. The risks and benefits of radioactive iodine versus surgery should be considered based on each patient's individual circumstances and preferences.

1. IPERTIROIDISMO: TERAPIA DEFINITIVA.
COME E QUANDO
Michele Zini
Servizio di Endocrinologia - Arcispedale S. Maria
Nuova, IRCCS Reggio Emilia
michele.zini@asmn.re.it

5. Definitive treatment
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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

6. 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

7. Radioiodine therapy (RAI)
Contraindications for RAI treatment are:
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Pregnancy and breast feeding
Very young age (< 5 years)
Presence of suspicious or malignant thyroid nodules
Severe active Graves orbitopathy (GO)

8. 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

9. 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

10. Fattori di rischio per ipoparatiroidismo postchirurgico
CONCLUSIONS: Extent of resection and surgical technique had a greater impact
on permanent postoperative hypoparathyroidism than thyroid pathologic condition.
M
Thomusch O. et al., Surgery 133: 180-185, 2003

11. ETA’ RIDOTTA
ETA’ AVANZATA
NODULARITA’
AVANZATA
NODULARITA’
RIDOTTA
CHIRURGIA
RADIOIODIO

12. 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

13. 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

14. 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

15. 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