Short-Term Effects of β-adrenergic Antagonists and Methimazole in New-Onset Thyrotoxicosis Caused by Graves' Disease

Abstract

Objective β-adrenergic antagonists (β-blockers) are often used to attenuate the hyperadrenergic symptoms of Graves' disease (GD), including palpitation. Although β-blockers reduce the heart rate, cardiac output and oxygen consumption, no firm evidence exists regarding the effects of combined therapy with β-blockers and anti-thyroid drugs. The objective is to elucidate the effects of β-blockers on anti-thyroid drug therapy in GD. Methods Patients newly diagnosed with mild GD were randomly assigned to receive methimazole with or without β-blockers in a prospective multi-center survey. The heart rate and thyroid function were measured and the quality of life was assessed using original and SF-36 questionnaires at 0 and 4 weeks. Results A total of 28 patients were enrolled in the study. Fourteen patients (one man, 13 women) were randomly assigned to the group treated with β-blockers and 14 patients (one man, 13 women) were randomly assigned to the group not treated with β-blockers. Although no significant differences in the improvement of thyroid function were observed between the two groups, the heart rates improved more significantly in the group treated with β-blockers. Specific symptoms, such as easy fatigability and shortness of breath, also improved more significantly with the β-blocker treatment. In addition, 'physical functioning' assessed with the SF-36 questionnaires significantly improved only in the group treated with β-blockers. Conclusion Although β-blockers may not reinforce the effects of anti-thyroid drugs on thyroid function, at least during the course of one month, they are effective in reducing heart rates and ameliorating specific symptoms in patients with mild GD.

2016 American Thyroid Association Guidelines for Diagnosis and Management of Hyperthyroidism and Other Causes of Thyrotoxicosis

“…In a randomized controlled trial of MMI alone versus MMI and a b-adrenergic blocking agent, after 4 weeks, patients taking b-adrenergic blockers had lower heart rates, less shortness of breath and fatigue, and improved ''physical functioning'' on the SF-36 health questionnaire (58).…”

Switching Therapy from Intravenous Landiolol to Transdermal Bisoprolol in a Patient with Thyroid Storm Complicated by Decompensated Heart Failure and Gastrointestinal Dysfunction

“…First, the switching therapy from intravenous landiolol to transdermal bisoprolol offers a safe and effective strategy for managing thyroid storm-associated atrial fibrillation with acute heart failure, even when the gastrointestinal function is compromised. β-blockers are the mainstay treatment for managing rapid thyroid storm-associated atrial fibrillation ( 1 , 3 , 4 ). Although the bisoprolol transdermal patch had yet to be approved for the treatment of tachyarrhythmia (such as rapid atrial fibrillation) we used the transdermal patch, instead of oral bisoprolol due to concerns regarding the possibility of poor intestinal absorption in the acute setting of heart failure complicated by gastrointestinal dysfunction due to diffuse peritonitis secondary to duodenal ulcer perforation.…”

“…Thyroid storm is a potentially lethal disease characterized by multiple organ dysfunction secondary to thyrotoxicosis in which rapid atrial fibrillation and acute heart failure are frequent complications ( 1 , 2 ). β-blockers are a drug of choice for the treatment of the cardiovascular symptoms induced by the increased β-adrenergic tone in hyperthyroidism ( 1 , 3 , 4 ). Although the immediate administration of relatively high doses of β-blockers is required to achieve adequate control of profound tachycardia in the setting of thyroid storm, their use can be challenging especially in cases of thyroid storm complicated by decompensated heart failure, and in cases involving patients who cannot tolerate oral medications due to gastrointestinal dysfunction, which is a common manifestation of thyroid storm ( 4 ).…”

Specific Symptoms of Thyrotoxicosis in Japanese Patients: A Reevaluation of Classical Symptoms in Modern Thyroid Function Tests

“…The symptoms were 'swelling of the neck', 'palpitation', 'hyperhidrosis', 'itching of the body', 'thirst', 'heat intolerance', 'tremor', 'muscle weakness', 'easy fatigability', 'general malaise', 'body weight loss', 'low-grade fever', 'edema of the lower extremities', 'shortness of breath', 'irritability', 'apathy', 'lack of concentration', 'insomnia', 'hyperorexia', 'hypoorexia', 'loose stool', 'ophthalmopathy', and 'menstrual disorder'; the last symptom was only for premenopausal females. [2][3][4][5][6] The patients who were already receiving medical treatment for their thyroid dysfunction were excluded. Serum Table 1.…”