No single treatment is best for all patients with hyperthyroidism. The appropriate choice of treatment will be influenced by your age, the type of hyperthyroidism that you have, the severity of your hyperthyroidism, other medical conditions that may be affecting your health, and your own preference. It may be a good idea to consult with an endocrinologist who is experienced in the treatment of hyperthyroid patients. If you are unconvinced or unclear about any thyroid treatment plan, a second opinion is a good idea.
Drugs known as antithyroid agents—methimazole (Tapazole®) or in rare instances propylthiouracil (PTU)—may be prescribed if your doctor chooses to treat the hyperthyroidism by blocking the thyroid gland’s ability to make new thyroid hormone. Methimazole is presently the preferred one due to less severe side-effects. These drugs work well to control the overactive thyroid, bring quick control of hyperthyroidism and do not cause permanent damage to the thyroid gland. In about 20% to 30% of patients with Graves’ disease, treatment with antithyroid drugs for a period of 12 to 18 months will result in prolonged remission of the disease. For patients with toxic nodular or multinodular goiter, antithyroid drugs are sometimes used in preparation for either radioiodine treatment or surgery.
Antithyroid drugs cause allergic reactions in about 5% of patients who take them. Common minor reactions are red skin rashes, hives, and occasionally fever and joint pains. A rarer (occurring in 1 of 500 patients), but more serious side effect is a decrease in the number of white blood cells. Such a decrease can lower your resistance to infection. Very rarely, these white blood cells disappear completely, producing a condition known as agranulocytosis, a potentially fatal problem if a serious infection occurs. If you are taking one of these drugs and get an infection such as a fever or sore throat, you should stop the drug immediately and have a white blood cell count that day. Even if the drug has lowered your white blood cell count, the count will return to normal if the drug is stopped immediately. But if you continue to take one of these drugs in spite of a low white blood cell count, there is a risk of a more serious, even life-threatening infection. Liver damage is another very rare side effect. A very serious liver problem can occur with PTU use which is why this medication should not generally be prescribed. You should stop either methimazole or PTU and call your doctor if you develop yellow eyes, dark urine, severe fatigue, or abdominal pain.
Another way to treat hyperthyroidism is to damage or destroy the thyroid cells that make thyroid hormone. Because these cells need iodine to make thyroid hormone, they will take up any form of iodine in your blood stream, whether it is radioactive or not. The radioactive iodine used in this treatment is administered by mouth, usually in a small capsule that is taken just once. Once swallowed, the radioactive iodine gets into your blood stream and quickly is taken up by the overactive thyroid cells. The radioactive iodine that is not taken up by the thyroid cells disappears from the body within days. Over a period of several weeks to several months (during which time drug treatment may be used to control hyperthyroid symptoms), radioactive iodine destroys the cells that have taken it up. The result is that the thyroid or thyroid nodules shrink in size, and the level of thyroid hormone in the blood returns to normal. Sometimes patients will remain hyperthyroid, but usually to a lesser degree than before. For them, a second radioiodine treatment can be given if needed. More often, hypothyroidism (an underactive thyroid) occurs after a few months and lasts lifelong, requiring treatment. In fact, when patients have Graves’ disease, a dose of radioactive iodine is chosen with the goal of making the patient hypothyroid so that the hyperthyroidism does not return in the future. Hypothyroidism can easily be treated with a thyroid hormone supplement taken once a day (see Hypothyroidism brochure).
Radioactive iodine has been used to treat patients for hyperthyroidism for over 60 years and has been shown to be generally safe. Importantly, there has been no clear increase in cancer in hyperthyroid patients that have been treated with radioactive iodine. As a result, in the United States more than 70% of adults who develop hyperthyroidism are treated with radioactive iodine. More and more children over the age of 5 are also being safely treated with radioiodine.
Your hyperthyroidism can be permanently cured by surgical removal of most of your thyroid gland. This procedure is best performed by a surgeon who has much experience in thyroid surgery. An operation could be risky unless your hyperthyroidism is first controlled by an antithyroid drug (see above) or a beta-blocking drug (see below). Usually for some days before surgery, your surgeon may want you to take drops of nonradioactive iodine—either Lugol’s iodine or supersaturated potassium iodide (SSKI). This extra iodine reduces the blood supply to the thyroid gland and thus makes the surgery easier and safer. Although any surgery is risky, major complications of thyroid surgery occur in less than 1% of patients operated on by an experienced thyroid surgeon. These complications include damage to the parathyroid glands that surround the thyroid and control your body’s calcium levels (causing problems with low calcium levels) and damage to the nerves that control your vocal cords (causing you to have a hoarse voice).
After your thyroid gland is removed, the source of your hyperthyroidism is gone and you will likely become hypothyroid. As with hypothyroidism that develops after radioiodine treatment, your thyroid hormone levels can be restored to normal by treatment once a day with a thyroid hormone supplement.
No matter which of these three methods of treatment are used for your hyperthyroidism, your physician may prescribe a class of drugs known as the beta adrenergic blocking agents that block the action of thyroid hormone on your body. They usually make you feel better within hours to days, even though they do not change the high levels of thyroid hormone in your blood. These drugs may be extremely helpful in slowing down your heart rate and reducing the symptoms of palpitations, shakes, and nervousness until one of the other forms of treatment has a chance to take effect. Propranolol (Inderal®) was the first of these drugs to be developed. Some physicians now prefer related, but longer-acting beta-blocking drugs such as atenolol (Tenormin®), metoprolol (Lopressor®), nadolol (Corgard®), and Inderal- LA® because of their more convenient once- or twice-a-day dosage.