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1 Graves ophthalmopathy The risk of having a flare of ophthalmopathy following 131I treatment for hyperthyroidism is about 6% for nonsmokers and 23% for smokers Graves ophthalmopathy can also be aggravated by thiazolidinediones (eg, pioglitazone, rosiglitazone); these oral diabetic agents are best avoided or withdrawn in patients with Graves disease For acute, progressive exophthalmos, intravenous methylprednisolone, begun promptly, is superior to oral prednisone, possibly due to improved compliance Methylprednisolone is given intravenously, 500 mg weekly for 6 weeks, then 250 mg weekly for 6 weeks If oral prednisone is chosen for treatment, it must be given promptly in daily doses of 40 60 mg/d orally, with dosage reduction over several weeks Higher initial prednisone doses of 80 120 mg/d are used when there is optic nerve compression Prednisone alleviates eye symptoms in 64% of nonsmokers, but only 14% of smokers respond well Progressive active exophthalmos may be treated with retrobulbar radiation therapy using a supervoltage linear accelerator (4 6 MeV) to deliver 20 Gy over 2 weeks to the extraocular muscles, avoiding the cornea and lens Prednisone in high doses is given concurrently Patients who respond well to orbital radiation include those with signs of acute inflammation, recent exophthalmos (< 6 months), or optic nerve compression Patients with chronic proptosis and orbital muscle restriction respond less well Retrobulbar radiation does not cause cataracts or tumors; however, it can cause radiation-induced retinopathy (usually subclinical) in about 5% of patients overall, mostly in diabetics For severe cases, orbital decompression surgery may save vision, though diplopia often persists postoperatively General eye protective measures include wearing glasses to protect the protruding eye and taping the lids shut during sleep if corneal drying is a problem Methylcellulose drops and gels ( artificial tears ) may also help Tarsorrhaphy or canthoplasty can frequently help protect the cornea and provide improved appearance Hypothyroidism and hyperthyroidism must be treated promptly 2 Cardiac complications a Sinus tachycardia Treatment consists of treating the thyrotoxicosis A -blocker (as described above) such as.
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Pregnant women with hyperthyroidism are treated with methimazole or propylthiouracil in the smallest dose possible, permitting mild hyperthyroidism to occur since it is usually well tolerated These drugs do cross the placenta and rarely may induce TSH hypersecretion and fetal goiter Thyroid hormone administration to the mother does not prevent hypothyroidism in the fetus, since T4 and T3 do not freely cross the placenta Fetal hypothyroidism is rare if the mother s hyperthyroidism is controlled with small daily doses of propylthiouracil (50 150 mg/d orally) or methimazole (5 15 mg/d orally) Thyroidectomy is reserved for women who are allergic or resistant to antithyroid drugs (usually due to noncompliance) or who have very large goiters Fetal ultrasond at 32 weeks gestation can visualize any fetal goiter, so fetal thyroid dysfunction can be diagnosed and treated During lactation, women treated with propylthiouracil secrete very little of it into breast milk Methimazole is secreted in somewhat higher concentrations in breast milk However, the use of either propylthiouracil or methimazole during breast-feeding does not significantly affect the infant s thyroid hormone levels, and both drugs are approved for nursing mothers by the American Academy of Pediatrics No adverse reactions to these drugs (eg, rash, hepatic dysfunction, leukopenia) have been reported in breast-fed infants Recommended doses are 20 mg daily or less for methimazole and 450 mg daily or less for propylthiouracil It is recommended that the medication be taken just after breast-feeding
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Hyperthyroid symptoms from pituitary hyperplasia are treated with propranolol Definitive treatment is with RAI or thyroid surgery Treatment of type I amiodarone-induced
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