Should radioiodine now be first line treatment for Graves’ disease?

Abstract

Background: Radioiodine represents a cost-effective treatment option for Graves' disease. In the UK, it is traditionally reserved for patients who relapse after initial thionamide therapy. In a change from current practice, the new guidelines of the National Institute for Health and Care Excellence (NICE) recommends that radioiodine should now be first line therapy for Graves' disease. However, the safety of radioiodine with respect to long-term mortality risk has been the subject of recent debate. This analysis examines evidence from treatment related mortality studies in hyperthyroidism and discusses their implications for future Graves' disease treatment strategies. Main body: Some studies have suggested an excess mortality in radioiodine treated cohorts compared to the background population. In particular, a recent observational study reported a modest increase in cancer-related mortality in hyperthyroid patients exposed to radioiodine. The interpretation of these studies is however constrained by study designs that lacked thionamide control groups or information on thyroid status and so could not distinguish the effect of treatment from disease. Two studies have shown survival advantages of radioiodine over thionamide therapy, but these benefits were only seen when radioiodine was successful in controlling hyperthyroidism. Notably, increased mortality was associated with uncontrolled hyperthyroidism irrespective of therapy modality. Conclusions: Early radioiodine treatment will potentially reduce mortality and should be offered to patients with severe disease. However, thionamides are still suitable for patients with milder disease, contraindications to radioiodine, or individuals who choose to avoid permanent hypothyroidism. Ultimately, a patient individualised approach that prioritises early and sustained control of hyperthyroidism will improve long-term outcomes regardless of the therapy modality used.

Radioiodine for Graves’ Disease Therapy

“…Based on multi-center trials, there was no association of any clinical malignancy of RAI for the therapy. [7,9,11,13,23,29,31]. The malignancy is associate with a small risk of pre-existing or coexisting thyroid cancer in patients with toxic nodular goiter.…”

“…The symptomatic therapy, such as a beta-adrenergic blocker, is given for patients with tachycardia, a history of cardiovascular disease, and elderly patients [2,6]. Therapies for reducing thyroid hormone synthesis are antithyroid drugs (ATDs), radioactive iodine (RAI), and thyroidectomy [2,3,[6][7][8]. All three options have advantages and disadvantages.…”

“…However, RAI is used by most physicians in the United States of America. [3,[6][7][8]. Hertz and Roberts were used radioiodine I-130 for the first time on March 31, 1941, for hyperthyroidism treatment [9,10].…”

“…Radioactive iodine is safe as definitive therapy, cure rates ~80-90%, and cost-effective, rarely or minor side-effects. [4,6,7,[11][12][13][14]. The choice of therapy depends on the patient's preference.…”

“…RAI is recommended for optimal treatment of Graves' disease by the American Thyroid Association (ATA) and American Association of Clinical Endocrinologists (AACE) guidelines for the management of thyrotoxicosis 2011 and ATA 2016 [3,6,15]. The recent guidelines of the United Kingdom (UK) National Institute for Health and Care Excellence (NICE) recommend that radioiodine should now be the first-line treatment for Graves' disease in the UK [7].…”