Hyperthyroidism Management

Aka: Hyperthyroidism Management, Grave Disease Management

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II. Precautions

  1. Thyroid Storm is a medical emergency and requires specific and ordered management
    1. See Thyroid Storm
    2. ICU management is indicated in Burch Wartofsky Score >45
  2. Thyroiditis is managed symptomatically (see antiandrenergic medications below)
    1. Anticipate resolution spontaneously by 6 months
    2. Drug-Induced Thyroiditis should also prompt removal of offending agent
    3. Antithyroid medications and Thyroid ablation are NOT indicated in Thyroiditis
  3. Antithyroid medications and Thyroid ablation are primarily for Grave Disease and toxic Goiters

III. Medications: Antiadrenergic Medications

  1. Indications
    1. Thyroiditis
    2. Concurrent initially with ablation, PTU/MTZ, surgery
    3. Symptomatic control
      1. Controls Tremor, Palpitations, nervousness
  2. Beta Blockers (non-selective are preferred)
    1. Propranolol (preferred)
      1. Also blocks peripheral T4 to T3 conversion (by inhibiting 5'-monodeiodinase)
      2. Start: 10-20 mg orally every 6 hours
      3. Advance to 20 to 80 mg every 6 hours
    2. Selective Beta Blockers may be used as an alternative (consider in COPD, Asthma)
      1. Metoprolol Tartrate 25-50 mg every 6 to 8 hours
      2. Metoprolol Succinate (XL) 100 mg orally daily (up to 200 mg/day)
      3. Atenolol 25 to 100 mg orally daily
  3. Diltiazem (Cardizem)
    1. Alternative if Beta Blockers not tolerated or contraindicated

IV. Medications: Antithyroid Medications

  1. Indications
    1. Hyperthyroidism in children and adolescents
    2. Pregnancy
      1. Propylthiouracil in first trimester, Methimazole in second trimester
    3. Grave's Disease without Goiter
      1. Thionamides are first-line treatment
      2. Result in euthyroid state within 18 months in up to 50%
  2. Antithyroid Medications (Thionamides)
    1. Methimazole 15-30 mg per day (up to 120 mg)
    2. Propylthiouracil (PTU) 100-200 mg orally every 8 hours
      1. Indicated in pregnancy first trimester
  3. Monitoring
    1. See Antithyroid Medications
    2. Monitoring Thyroid function (T4 Free, Total T3) every 4-6 weeks until euthyroid, then TSH, T4 Free every 3-6 months
    3. Monitoring for Agranulocytosis (CBC) and hepatotoxicity (LFT)

V. Management: Ablation

  1. Radioactive Iodine (I-131)
    1. Management of choice for Grave's Disease of all ages (not in pregnancy or moderate Graves Orbitopathy)
    2. Recurrent Hyperthyroidism after Antithyroid Drugs
    3. Toxic Multinodular Goiter
    4. Toxic Nodule in patient over age 40 years old
  2. Subtotal Thyroidectomy
    1. Pregnancy
    2. Children intollerant to antithyroid medications
    3. Toxic Nodule under age 40 years old
    4. Large Thyroid Goiter causing local compression
  3. Monitoring after ablation
    1. Thyroid Stimulating Hormone (TSH) may not be initially accurate
    2. Follow Free T4, Free T3 to base Thyroid Replacement

VI. References

  1. Ginsberg (2003) CMAJ 168:575-85 [PubMed]
  2. Kravets (2016) Am Fam Physician 93(5): 363-70 [PubMed]
  3. Mounsey (2025) Am Fam Physician 112(2): 146-52 [PubMed]
  4. Reid (2005) Am Fam Physician 72:623-36 [PubMed]

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