Evidence-Based Treatment for a Patient with Graves’ Disease_Chinese Journal of Evidence-Based Medicine

Authors：

ZHU Ruxia ,  OUYANG Lingli , CHEN Junqiang , MO Zhengnan

Department of Endocrinology, the First Affiliated Hospital, Guangxi Medical University, Nanning 530021, China;

Corresponding author：

OUYANG Lingli, Email: ouyanglli@yahoo.com.cn

Keywords：

Graves’ disease; Evidence-based treatment

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Objective 　To explore the methods of evidence-based individualized treatment for a patient with Graves’ disease.
Method 　We searched The Cochrane Library (Issue 3, 2006), SUMSEARCH (Jan.1980 to Mar. 2006), PubMed (1980 to Mar.2006), CNKI (Jan.1980 to Mar. 2006) and VIP (Jan.1980 to Mar.2006) to identify the best evidence for antithyroid drugs, iodine radioisotopes and thyroidectomy for patients with Graves’ hyperthyroidism and evaluate the quality of available evidence.
Results 　We identified 1 clinical guideline, 1 Cochrane systematic review, 1 meta-analysis and 15 randomized controlled trials. There was no significant difference between the titration regimen and the block-replace regimen in the relapse of hyperthyroidism, while the block-replace regimen was associated with more adverse effects. Prescribing replacement thyroxine, either with or after the anti-thyroid drug treatment, had no significant effect on relapse. Methimazole was more effective than propylthiouracil in the induction of euthyroidism. There was no significant difference in the quality of life between the drugs, 131I and the thyroidectomy therapy, and the relapse was lower with thyroidectomy therapy but the cost was higher. Given the current evidence together with our clinical experience and considering the patient and her family’s values and preferences, methimazole (10 mg tid) was administered to her and then gradually reduced. No obvious adverse effects occurred within 4 months’ follow-up.
Conclusion　 Drugs, radioactive iodine and thyroidectomy are all effective in the treatment of Graves’ hyperthyroidism. Methimazole is an effective and well tolerated drug for the treatment of Graves’ hyperthyroidism and further research into side effect are needed. Prescribing replacement thyroxine has no significant effect on relapse.

Citation： ZHU Ruxia,OUYANG Lingli,CHEN Junqiang,MO Zhengnan. Evidence-Based Treatment for a Patient with Graves’ Disease. Chinese Journal of Evidence-Based Medicine, 2006, 06(5): 380-384. doi: Copy

1.	minimum radioiodine dose in patients with Graves’ disease: a clinical outcome study. European Journal of Nuclear Medicine, 2001; 28: 1489-1495.
2.	李雪锋, 李艳, 朱大菊. 两种剂量131I治疗甲状腺机能亢进症临床研究. 临床荟萃, 2002; 17(4): 191-192.
3.	胡廷辉, 马永源. 甲状腺一叶全切加对侧大部切除术治疗甲状腺功能亢进的临床评价. 中国普通外科杂志, 2004; 13(5): 346-347.
4.	李雪锋, 李艳, 朱大菊. 两种剂量131I治疗甲状腺机能亢进症临床研究. 临床荟萃, 2002; 17(4): 191-192.
5.	胡廷辉, 马永源. 甲状腺一叶全切加对侧大部切除术治疗甲状腺功能亢进的临床评价. 中国普通外科杂志, 2004; 13(5): 346-347.
6.	AACE Thyroid Task Force. American Association of Clinical Endocrinologists Medical Guidelines for Clinical practice for the Evaluation and treatment of the hyperthyroidism and hypothyroidism. AACE Thyroid Guidelines, Endocr Pract, 2002; 8(6): 457-469.
7.	Abraham P, Avenell A, Watson WA, et al. Antithyroid drug regimen for treating Graves’ hyperthyroidism. The Cochrane Database of Systematic Reviews, 2005; (2): CD003420.
8.	Palit TK, Miller CC, Miltenburg DM. The Efficacy of Thyroidectomy for Graves’ Disease: A Meta-analysis. Journal of Surgical Research, 2000; 90(2): 161-165.
9.	Benker G, Reinwein D, Kahaly G, et al. Herbert Hirche and The European Multicentre Trial Group of the Treatment of Hyperthyroidism with Antithyroid Drugs. Is there a methimazole dose effect on remission rate in Graves’ disease? Results from a long-term prospective study. Clinical Endocrinology, 1998; 49: 451-457.
10.	Raber W, Kmen E, Waldha¨usl W, et al. Medical therapy of Graves’ hyperthyroidism: effect on remission rates of methimazole alone and in combination with triiodothyronine. European Journal of Endocrinology, 2000; 142(2): 117-124.
11.	Nedrebø BG, Holm PI, Uhlving S, et al. Predictors of outcome and comparison of different drug regimens for the prevention of relapse in patients with Graves’ disease. European Journal of Endocrinology, 2002; 147(5): 583-589.
12.	Hoermann R, Quadbeck B, Roggenhuck U, et al. Basedow Study Group. Relapse of Graves’ hyperthyroidism after successful outcome of antithyroid drug therapy: results of a prospective randomized study on the use of levothyroxine. Thyroid, 2002; 12(12): 1119-1128.
13.	He CT, Hsieh AT, Pei D, et al. Comparison of single daily dose of methimazole and propylthiouracil in the treatment of Graves’ hyperthyroidism. Clin Endocrinol (Oxf), 2004; 60(6): 676-681.
14.	Leslie WD, Ward L , Salamon EA, et al. A Randomized Comparison of Radioiodine Doses in Graves’ Hyperthyroidism. The Journal of Clinical Endocrinology & Metabolism, 2003; 88(3): 978-983.
15.	Müller PE, Bein B, Robens E, et al. Thyroid surgery according to Enderlen-Hotz or Dunhill: a comparison of two surgical methods for the treatment of Graves’ hyperthyroidism. International surgery, 2001; 86(2): 112-116.
16.	Palestini N , Grivon M , Carbonaro G, et al. A Surgical treatment of Graves’s disease: results in 108 patients. Ann Ital Chir, 2005; 76(1): 13-18.
17.	Ljunggren JG, Törring O, Wallin G, et al. Quality of life aspects and costs in treatment of Graves’ hyperthyroidism with antithyroid drugs, surgery, or radioiodine: results from a prospective, randomized study. Thyroid, 1998; 8(8): 653-659.
18.	Mastorakos G, Doufas AG, Mantzos E, et al. T4 but not T3 administration is associated with increased recurrence of Graves’ disease after successful medical therapy. J Endocrinol Invest, 2003; 26(10): 979-984.
19.	Howarth D, Epstein M, Lan L, et al. Determination of the optimal minimum radioiodine dose in patients with Graves’ disease: a clinical outcome study. European Journal of Nuclear Medicine, 2001; 28: 1489-1495.
20.	Chi SY, Hsei KC, Sheen-Chen SM, et al. A Prospective Randomized Comparison of Bilateral Subtotal Thyroidectomy versus Unilateral Total and Contralateral Subtotal Thyroidectomy for Graves’ disease. World J. Surg, 2005; 29: 160–163.
21.	Chi SY, Hsei KC, Sheen-Chen SM, et al. A Prospective Randomized Comparison of Bilateral Subtotal Thyroidectomy versus Unilateral Total and Contralateral Subtotal Thyroidectomy for Graves’ disease. World J. Surg, 2005; 29: 160–163.
22.	braham-Nordling M, Törring O, Hamberger B, et al. Graves’ disease: a long-term quality-of-life follow up of patients randomized to treatment with antithyroid drugs, radioiodine, or surgery. Thyroid, 2005; 15(11): 1279-86.
23.	braham-Nordling M, Törring O, Hamberger B, et al. Graves’ disease: a long-term quality-of-life follow up of patients randomized to treatment with antithyroid drugs, radioiodine, or surgery. Thyroid, 2005; 15(11): 1279-86.
24.	Li XF, Li Y, Zhu DJ. Clinical research of two dosages of 131I for Graves ‘disease. Clinical Focus, 2002; 17(4): 191-192.
25.	Li XF, Li Y, Zhu DJ. Clinical research of two dosages of 131I for Graves ‘disease. Clinical Focus, 2002; 17(4): 191-192.
26.	Hu TH, Ma YY. Evaluation of the effect of one side lobectomy plus opposite side partial lobectomy in the treatment of hyperthyroidism. Chinese Journal of General Surgery, 2004; 13(5): 346-347.
27.	Hu TH, Ma YY. Evaluation of the effect of one side lobectomy plus opposite side partial lobectomy in the treatment of hyperthyroidism. Chinese Journal of General Surgery, 2004; 13(5): 346-347.

1. minimum radioiodine dose in patients with Graves’ disease: a clinical outcome study. European Journal of Nuclear Medicine, 2001; 28: 1489-1495.
2. 李雪锋, 李艳, 朱大菊. 两种剂量131I治疗甲状腺机能亢进症临床研究. 临床荟萃, 2002; 17(4): 191-192.
3. 胡廷辉, 马永源. 甲状腺一叶全切加对侧大部切除术治疗甲状腺功能亢进的临床评价. 中国普通外科杂志, 2004; 13(5): 346-347.
4. 李雪锋, 李艳, 朱大菊. 两种剂量131I治疗甲状腺机能亢进症临床研究. 临床荟萃, 2002; 17(4): 191-192.
5. 胡廷辉, 马永源. 甲状腺一叶全切加对侧大部切除术治疗甲状腺功能亢进的临床评价. 中国普通外科杂志, 2004; 13(5): 346-347.
6. AACE Thyroid Task Force. American Association of Clinical Endocrinologists Medical Guidelines for Clinical practice for the Evaluation and treatment of the hyperthyroidism and hypothyroidism. AACE Thyroid Guidelines, Endocr Pract, 2002; 8(6): 457-469.
7. Abraham P, Avenell A, Watson WA, et al. Antithyroid drug regimen for treating Graves’ hyperthyroidism. The Cochrane Database of Systematic Reviews, 2005; (2): CD003420.
8. Palit TK, Miller CC, Miltenburg DM. The Efficacy of Thyroidectomy for Graves’ Disease: A Meta-analysis. Journal of Surgical Research, 2000; 90(2): 161-165.
9. Benker G, Reinwein D, Kahaly G, et al. Herbert Hirche and The European Multicentre Trial Group of the Treatment of Hyperthyroidism with Antithyroid Drugs. Is there a methimazole dose effect on remission rate in Graves’ disease? Results from a long-term prospective study. Clinical Endocrinology, 1998; 49: 451-457.
10. Raber W, Kmen E, Waldha¨usl W, et al. Medical therapy of Graves’ hyperthyroidism: effect on remission rates of methimazole alone and in combination with triiodothyronine. European Journal of Endocrinology, 2000; 142(2): 117-124.
11. Nedrebø BG, Holm PI, Uhlving S, et al. Predictors of outcome and comparison of different drug regimens for the prevention of relapse in patients with Graves’ disease. European Journal of Endocrinology, 2002; 147(5): 583-589.
12. Hoermann R, Quadbeck B, Roggenhuck U, et al. Basedow Study Group. Relapse of Graves’ hyperthyroidism after successful outcome of antithyroid drug therapy: results of a prospective randomized study on the use of levothyroxine. Thyroid, 2002; 12(12): 1119-1128.
13. He CT, Hsieh AT, Pei D, et al. Comparison of single daily dose of methimazole and propylthiouracil in the treatment of Graves’ hyperthyroidism. Clin Endocrinol (Oxf), 2004; 60(6): 676-681.
14. Leslie WD, Ward L , Salamon EA, et al. A Randomized Comparison of Radioiodine Doses in Graves’ Hyperthyroidism. The Journal of Clinical Endocrinology & Metabolism, 2003; 88(3): 978-983.
15. Müller PE, Bein B, Robens E, et al. Thyroid surgery according to Enderlen-Hotz or Dunhill: a comparison of two surgical methods for the treatment of Graves’ hyperthyroidism. International surgery, 2001; 86(2): 112-116.
16. Palestini N , Grivon M , Carbonaro G, et al. A Surgical treatment of Graves’s disease: results in 108 patients. Ann Ital Chir, 2005; 76(1): 13-18.
17. Ljunggren JG, Törring O, Wallin G, et al. Quality of life aspects and costs in treatment of Graves’ hyperthyroidism with antithyroid drugs, surgery, or radioiodine: results from a prospective, randomized study. Thyroid, 1998; 8(8): 653-659.
18. Mastorakos G, Doufas AG, Mantzos E, et al. T4 but not T3 administration is associated with increased recurrence of Graves’ disease after successful medical therapy. J Endocrinol Invest, 2003; 26(10): 979-984.
19. Howarth D, Epstein M, Lan L, et al. Determination of the optimal minimum radioiodine dose in patients with Graves’ disease: a clinical outcome study. European Journal of Nuclear Medicine, 2001; 28: 1489-1495.
20. Chi SY, Hsei KC, Sheen-Chen SM, et al. A Prospective Randomized Comparison of Bilateral Subtotal Thyroidectomy versus Unilateral Total and Contralateral Subtotal Thyroidectomy for Graves’ disease. World J. Surg, 2005; 29: 160–163.
21. Chi SY, Hsei KC, Sheen-Chen SM, et al. A Prospective Randomized Comparison of Bilateral Subtotal Thyroidectomy versus Unilateral Total and Contralateral Subtotal Thyroidectomy for Graves’ disease. World J. Surg, 2005; 29: 160–163.
22. braham-Nordling M, Törring O, Hamberger B, et al. Graves’ disease: a long-term quality-of-life follow up of patients randomized to treatment with antithyroid drugs, radioiodine, or surgery. Thyroid, 2005; 15(11): 1279-86.
23. braham-Nordling M, Törring O, Hamberger B, et al. Graves’ disease: a long-term quality-of-life follow up of patients randomized to treatment with antithyroid drugs, radioiodine, or surgery. Thyroid, 2005; 15(11): 1279-86.
24. Li XF, Li Y, Zhu DJ. Clinical research of two dosages of 131I for Graves ‘disease. Clinical Focus, 2002; 17(4): 191-192.
25. Li XF, Li Y, Zhu DJ. Clinical research of two dosages of 131I for Graves ‘disease. Clinical Focus, 2002; 17(4): 191-192.
26. Hu TH, Ma YY. Evaluation of the effect of one side lobectomy plus opposite side partial lobectomy in the treatment of hyperthyroidism. Chinese Journal of General Surgery, 2004; 13(5): 346-347.
27. Hu TH, Ma YY. Evaluation of the effect of one side lobectomy plus opposite side partial lobectomy in the treatment of hyperthyroidism. Chinese Journal of General Surgery, 2004; 13(5): 346-347.

Chinese Journal of Evidence-Based Medicine

Evidence-Based Treatment for a Patient with Graves’ Disease

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