Subsequent management of primary hyperthyroidism

Once the patient is euthryoid on antithyroid therapy, the options for subsequent management depend on the cause and severity of the disease, and patient preference. See Options for subsequent management of primary hyperthyroidism for management options—specialist guidance is recommended for the selection of subsequent treatment.

Note: Refer the patient to a specialist for selection of subsequent management.

For long-term follow-up of hyperthyroidism, see here.

Table 1. Options for subsequent management of primary hyperthyroidism
[NB1]
a course of antithyroid drug therapy, followed by drug withdrawal long-term antithyroid drug therapy radioiodine thyroidectomy
a course of antithyroid drug therapy, followed by drug withdrawal
usual patient groups who use this option	young patient with first episode of mild Graves disease and a small goitre
contraindications and precautions	previous severe adverse reaction to antithyroid drug therapy liver disease
treatment information	titrate the maintenance dose to achieve euthyroidism (see Dose titration) in adults, continue antithyroid therapy for 12 to 18 months—this improves the chance of sustained remission compared with a shorter course in children, antithyroid therapy is usually continued for at least 2 years the chance of sustained remission is also improved if the patient’s TSH-receptor antibody concentration is normalised before stopping treatment. If the TSH-receptor antibody remains elevated, the antithyroid drug can be continued until the antibody concentration returns to the normal range
long-term antithyroid drug therapy
usual patient groups who use this option	persistent or recurrent Graves disease that is easily controlled with low-dose antithyroid therapy
contraindications and precautions	previous severe adverse reaction to antithyroid drug therapy liver disease
treatment information	titrate the maintenance dose to achieve continued euthyroidism (see Dose titration) ongoing dose titration and monitoring requires specialist guidance
radioiodine
usual patient groups who use this option	severe Graves disease with large goitre (eg causing tracheal obstruction or narrowing) recurrent severe Graves disease severe hyperthyroidism in an older patient subclinical or mild hyperthyroidism in an older patient (usually associated with nodular thyroid disease) [NB2] hyperthyroidism due to a toxic adenoma or multinodular goitre young patient with mild Graves disease whose TSH-receptor antibody remains elevated despite antithyroid drug therapy
contraindications and precautions	active Graves-related eye disease current or imminently planned pregnancy
treatment information	high-dose radioiodine can achieve shrinkage and relief of obstructive symptoms antithyroid drug therapy usually used to achieve euthyroidism before radioiodine [NB2] the antithyroid drug should be stopped for 3 to 7 days before radioiodine treatment—it can be restarted approximately 1 week after the dose, and then gradually decreased over 2 to 4 months as the radioiodine becomes effective radioiodine likely to be followed eventually by hypothyroidism, usually requiring thyroxine replacement therapy
thyroidectomy
usual patient groups who use this option	severe Graves disease with large goitre (eg causing tracheal obstruction or narrowing) recurrent severe Graves disease hyperthyroidism due to a toxic adenoma or multinodular goitre [NB3] young patient with mild Graves disease whose TSH-receptor antibody remains elevated despite antithyroid drug therapy thyroid cancer
contraindications and precautions	high surgical risk previously operated or externally irradiated neck lack of access to high-volume surgeon
treatment information	antithyroid drug therapy is used to achieve euthyroidism before surgery thyroidectomy followed by permanent hypothyroidism, usually requiring thyroxine replacement therapy
Note: TSH = thyroid stimulating hormone NB1: This table outlines the typical treatments used for different patient groups; however, the choice should be individualised with specialist advice, and consideration of patient preference. NB2: Preparation with an antithyroid drug is not required in older patients with mild or subclinical hyperthyroidism. Hyperthyroidism in these patients is usually due to toxic adenoma or multinodular goitre, and early treatment with radioiodine is safe and effective and has a lower risk of subsequent hypothyroidism than in patients with Graves disease. NB3: For toxic adenoma or unilateral multinodular goitre, lobectomy is preferred over thyroidectomy.