Treatment of hyperthyroidism

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Radioiodine (iodine131) is the treatment of choice in patients over 40 years of age, but in younger patients most centres adopt the empirical approach of prescribing a 12-18 month course of carbimazole and recommending surgery if relapse occurs. There should be a noticeable clinical improvement within 10-14 days, and most patients will be biochemically euthyroid within 4-6 weeks of starting carbimazole 40 mg daily. Patients with Graves' disease are likely to become hypothyroid within a year of treatment with radioiodine, but this is an unusual occurrence in patients with nodular goitre. There may be an exacerbation of hyperthyroidism a few days after treatment with radioiodine, owing to a transient increase in serum thyroid hormone concentrations; in patients with atrial fibrillation and cardiac failure it is therefore good practice to render the patient euthyroid with an antithyroid drug before giving radioiodine.

Hyperthyroidism is associated with an increase in cardiovascular and cerebrovascular mortality, which is most evident in the first year following treatment with radioiodine. For example, a large series from a single centre, based on more than 100 000 patient years of follow up, showed that the standardised mortality ratio, in the year after ablative radioiodine, was 1.8:1 (95% confidence interval (CI) 1.6 to 2:1).9 At least some of this excess mortality could probably be avoided by earlier diagnosis and more aggressive treatment of the hyperthy-roidism and its cardiovascular complications.

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