Clinical Thyroidology® for the Public

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Is surgery more cost-effective than radioactive iodine therapy as an alternative to antithyroid medication in the management of Graves’ disease?

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Graves’ disease is the most common cause of hyperthyroidism. Graves’ disease is often treated with antithyroid medications at first, with the most common antithyroid medication being methimazole. Antithyroid medications can be used until the Graves’ disease goes into remission. However, once antithyroid medications are stopped, about half of the patients become hyperthyroid again after a period of time. So, in order to permanently treat Graves’ disease, definitive treatments are often offered to those patients who relapsed or at a high risk for relapse. The two definitive treatments available include radioactive iodine therapy and surgery. Radioactive iodine therapy is given as a capsule by mouth and the radioactive iodine is taken up by the thyroid cells and are destroyed. Surgery involves removal of the thyroid (total thyroidectomy). Both radioactive iodine therapy and surgery result in making the patient’s hypothyroid. This study was done to compare the cost-effectiveness of surgery as compared to radioactive iodine therapy.

Ma EZ et al 2023 Total thyroidectomy is more cost-effective than radioactive iodine as an alternative to antithyroid medication for Graves’ disease. Surgery 173:193–200. PMID: 36208983.

The authors created a model to estimate what the total cost would be if a patient with Graves’ disease were to receive surgery or radioactive iodine therapy.

In calculating the costs of each treatment, they included the costs of possible complications and quality of life measures assigning them a value.

Their model showed that total thyroidectomy was a more cost-effective treatment option for the majority of patients with Graves’ disease, even though it was more expensive than radioactive iodine therapy. This is because patients who had surgery have improved quality of life over time as compared to patients who had radioactive iodine therapy, which outweighs the lower costs of radioactive iodine therapy. Even for older patients, surgery remained more cost-effective according to this study.

This study found that, although surgery is more costly upfront as compared to radioactive iodine therapy, it provided the patients a better quality of life over time. This study, however did not compare surgery with long term use of antithyroid drugs, which is now becoming a more acceptable treatment option to endocrinologists and patients. For now, after a thorough discussion with their physicians, patients’ preferences and their specific clinical situation should guide treatment choices for Graves’ disease in this age of personalized medicine.

— Susana Ebner MD


Hyperthyroidism: a condition where the thyroid gland is overactive and produces too much thyroid hormone. Hyperthyroidism may be treated with antithyroid meds (Methimazole, Propylthiouracil), radioactive iodine or surgery.

Graves’ disease: the most common cause of hyperthyroidism in the United States. It is caused by antibodies that attack the thyroid and turn it on.

Total thyroidectomy: surgery to remove the entire thyroid gland.

Radioactive iodine (RAI): this plays a valuable role in diagnosing and treating thyroid problems since it is taken up only by the thyroid gland. I-131 is the destructive form used to destroy thyroid tissue in the treatment of thyroid cancer and with an overactive thyroid. I-123 is the nondestructive form that does not damage the thyroid and is used in scans to take pictures of the thyroid (Thyroid Scan) or to take pictures of the whole body to look for thyroid cancer (Whole Body Scan).