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Rapid Preoperative Preparation for Severe Hyperthyroid Graves’ Disease

Department of Surgery and Section of Endocrinology, Diabetes, and Nutrition, Boston Medical Center, Boston, Massachusetts 02118

Address all correspondence and requests for reprints to: Dr. Lewis Braverman, Department of Endocrinology, Diabetes, and Metabolism, 88 East Newton Street, Boston, Massachusetts 02118. E-mail: lewis.braverman{at}bmc.org.

Thyroidectomy (TX) is no longer the preferred choice for the therapy of hyperthyroid Graves’ disease but is an alternative in patients who are noncompliant with or have reactions to antithyroid drugs, have moderate to severe ophthalmopathy, have large goiters, or who refuse ¹³¹I therapy and/or long-term antithyroid drug therapy. Seventeen clinically and biochemically severely thyrotoxic patients (16 female, mean age of 35 yr), all but one with large goiters, underwent TX after rapid preparation. The potent inhibitors of the deiodination of T₄ to T₃, iopanoic acid (IOP) (500 mg twice a day) and dexamethasone (DEX) (1 mg twice a day), were given with propylthiouracil or methimazole, when possible, and ß-blockers. Thyroid function tests were obtained before treatment and at TX. All patients were thyrotoxic (mean ± SE: T₄, 21.6 ± 1.2 µg/dl; free T₄ index (FTI), 10.3 ± 0.8; total T₃, 510 ± 48 ng/dl). IOP and DEX rapidly lowered T₃ values (P < 0.0001; total T₃, 147 ± 13 ng/dl) with a smaller but significant (P < 0.05) decrease in T₄/FTI (T₄, 17.9 ± 1.3 µg/dl; FTI, 7.9 ± 0.6). All patients were clinically euthyroid before surgery. None developed hypoparathyroidism, laryngeal nerve damage, or worsening of ophthalmopathy after surgery. The restoration of hyperthyroid Graves’ disease to euthyroidism is rapidly accomplished with IOP and DEX, ß-blockers, and, when possible, antithyroid drugs. This is especially relevant in noncompliant patients with large goiters.

Abbreviations: DEX, Dexamethasone; FTI, free T₄ index; IOP, iopanoic acid; IRCA, iodinated radiographic contrast agent; MMI, methimazole; PTU, propylthiouracil; TX, thyroidectomy.

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