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Hyperthyroidism caused by a single hyperfunctioning thyroid nodule may be treated symptomatically with propranolol as in Graves disease Definitive treatment is with surgery or RAI For patients under age 40 years, surgery is usually recommended; patients are made euthyroid with a thiourea preoperatively and given several days of iodine, ipodate sodium, or iopanoic acid before surgery as in Graves disease (see above) Transient postoperative hypothyroidism resolves spontaneously Permanent hypothyroidism occurs in about 14% of patients by 6 years after surgery Patients over age 40 years with a toxic solitary nodule are offered RAI Permanent hypothyroidism occurs in about one-third of patients by 8 years after RAI The nodule remains palpable in 50% and may grow in 10% of patients after RAI



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Hyperthyroidism caused by a toxic multinodular goiter may also be treated symptomatically with propranolol as in Graves disease This disorder usually affects older individuals, so RAI is ordinarily selected over surgery as the definitive treatment Thioureas do reverse hyperthyroidism, but there is a 95% recurrence rate after they are stopped Older patients who are quite thyrotoxic are rendered nearly euthyroid with methimazole, which is stopped at least 3 days before RAI treatment Meanwhile, the patient follows a low-iodine diet; this is done to enhance the thyroid gland s uptake of RAI, which may be relatively low in this condition (compared to Graves disease) Relatively high doses of RAI are usually required; recurrent thyrotoxicosis and hypothyroidism are common, so patients must be monitored closely Surgery is generally reserved for pressure symptoms or cosmetic indications Patients are prepared for surgery as in Graves disease (see above)





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Patients with hyperthyroidism due to subacute thyroiditis are treated symptomatically with propranolol Ipodate sodium or

thyrotoxicosis usually requires a prolonged course of methimazole After two doses of methimazole, iopanoic acid or sodium ipodate may be added to the regimen to further block conversion of T4 to T3; the recommended dosage for each is 500 mg orally twice daily for 3 days, followed by 500 mg once daily until thyrotoxicosis is resolved -Blockers may be required Withdrawal of amiodarone does not have a significant therapeutic effect for several months Therapy with 131I may be successful in some patients with adequate RAI uptake Thyroidectomy is reserved for resistant cases Treatment of type II amiodarone-induced thyrotoxicosis consists of prednisone plus either iopanoic acid or ipodate sodium (see above) -Blockers may be required Withdrawal of amiodarone is not usually necessary Because the condition is transient, thyroidectomy is rarely required

The resulting plot is shown below:

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iopanoic acid, 500 mg orally daily, promptly corrects elevated T3 levels and is continued for 15 60 days until the serum FT4 level normalizes The condition subsides spontaneously within weeks to months Thioureas are ineffective, since thyroid hormone production is actually low in this condition RAI is ineffective, since the thyroid s iodine uptake is low Since periods of hypothyroidism may occur following the initial inflammatory episode, patients should have close clinical follow-up, with serum FT4 measurement when necessary Prompt treatment of the transient hypothyroidism may reduce the incidence of recurrent thyroiditis Pain can usually be managed with aspirin or other nonsteroidal anti-inflammatory drugs

Rarely, hyperthyroidism develops as a result of release of stored thyroid hormone during severe Hashimoto s thyroiditis The thyroperoxidase or thyroglobulin antibodies are usually high, but RAI uptake is low, thus distinguishing it from Graves disease This is especially common in postpartum women, in whom it may be transient Treatment is with propranolol Patients are monitored carefully for the development of hypothyroidism and treated

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