eMedicine Specialties > Endocrinology > Thyroid

Goiter: Treatment & Medication

Author: James R Mulinda, MD, FACP, FACE, Consulting Staff, Department of Endocrinology, Endocrinology Associates, Inc
Contributor Information and Disclosures

Updated: Aug 18, 2009

Treatment

Medical Care

Small benign euthyroid goiters do not require treatment. The effectiveness of medical treatment using thyroid hormone for benign goiters is controversial. Large and complicated goiters may require medical and surgical treatment. Malignant goiters require medical and surgical treatment.

  • The size of a benign euthyroid goiter may be reduced with levothyroxine suppressive therapy. The patient is monitored to keep serum TSH in a low but detectable range to avoid hyperthyroidism, cardiac arrhythmias, and osteoporosis. The patient has to be compliant with monitoring. Some authorities suggest suppressive treatment for a definite time period instead of indefinite therapy. Patients with Hashimoto thyroiditis respond better.
  • Treatment of hypothyroidism or hyperthyroidism often reduces the size of a goiter.
  • Thyroid hormone replacement is often required following surgical and radiation treatment of a goiter. Use of radioactive iodine for the therapy of nontoxic goiter has been disappointing and is controversial.
  • Medical therapy of autonomous nodules with thyroid hormone is not indicated.
  • Ethanol infusion into benign thyroid nodules has not been approved in the United States, but it is used elsewhere.

Surgical Care

Surgery is reserved for the following situations:

  • Large goiters with compression
  • Malignancy
  • When other forms of therapy are not practical or ineffective

Consultations

An endocrinologist should assess a patient at least once, and assessment should be even more frequent if the goiter is complicated by thyroid dysfunction or malignancy or if the patient is being considered for surgical management.

Diet

Nutrition plays a role in the development of endemic goiters. Dietary factors include iodine deficiency, goitrogens, protein malnutrition, and energy malnutrition. Often these factors occur concurrently.

  • Iodine: If it is practical, treat endemic goiters in iodine-deficient regions with iodine supplementation in the diet and avoidance of goitrogens. Treatment with iodine supplementation or levothyroxine may reduce goiter size.1
  • Goitrogens
    • Cyanoglucosides are naturally occurring goitrogens that are digested to release cyanide, which is converted to thiocyanate. Thiocyanate inhibits iodide transport in the thyroid and, at higher levels, inhibits organification. Foods that contain cyanoglucosides include cassava, lima beans, maize, bamboo shoots, and sweet potatoes.
    • Thioglucosides are natural goitrogens found in the Cruciferae family of vegetables and weeds eaten by animals. When digested, they release thiocyanate and isothiocyanate, which have thionamidelike properties and are passed to humans via milk ingestion.

Medication

The goals of pharmacotherapy are to reduce morbidity and to prevent complications.

Thyroid hormone replacements

Benign goiters can be treated with thyroid hormone. The most widely used thyroid hormone is levothyroxine sodium, administered once a day. Liothyronine sodium requires more frequent administration. Desiccated thyroid powder, thyroglobulin, and liotrix are less predictable following ingestion.


Levothyroxine sodium (Synthroid, Levoxyl, Levothroid)

Synthetic thyroxine is converted to the active form, triiodothyronine, in the pituitary by 5'-deiodinase. Inhibits production of thyrotropin, which is the main growth factor for the thyroid gland.

Adult

1.5-2.5 mcg/kg PO qd; use lowest dose possible for TSH suppression; over-replacement of thyroid hormone is to be avoided in older patients; lower doses, more frequent monitoring, and slower titration are necessary in these individuals

Pediatric

5-10 mcg/kg PO qd; younger patients require higher dose for TSH suppression

Increases metabolism of most drugs and may compete for protein transport sites; absorption reduced by iron, bile sequestrants, and antacids; cholestyramine may decrease liothyronine absorption; estrogen may decrease response to thyroid hormone therapy in patients with nonfunctioning thyroid glands; effect of anticoagulants increases when administered with liothyronine; activity of some beta-blockers may decrease when patient with hypothyroidism is converted to a euthyroid state

Documented hypersensitivity; untreated thyrotoxicosis; untreated adrenal insufficiency; hyperfunctioning thyroid nodule

Pregnancy

A - Fetal risk not revealed in controlled studies in humans

Precautions

Caution in cardiac disease, arrhythmias, angina, and hypertension; elderly; prolonged subclinical hyperthyroidism is associated with bone loss and cardiac arrhythmias (monitor TSH q8-12wk)

More on Goiter

Overview: Goiter
Differential Diagnoses & Workup: Goiter
Treatment & Medication: Goiter
Follow-up: Goiter
Multimedia: Goiter
References
Further Reading
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References

  1. Triggiani V, Tafaro E, Giagulli VA, et al. Role of iodine, selenium and other micronutrients in thyroid function and disorders. Endocr Metab Immune Disord Drug Targets. Sep 1 2009;[Medline].

  2. Tunbridge WM, Evered DC, Hall R, Appleton D, Brewis M, Clark F, et al. The spectrum of thyroid disease in a community: the Wickham survey. Clin Endocrinol (Oxf). Dec 1977;7(6):481-93. [Medline].

  3. Sawin CT, Geller A, Hershman JM, Castelli W, Bacharach P. The aging thyroid. The use of thyroid hormone in older persons. JAMA. May 12 1989;261(18):2653-5. [Medline].

  4. Guth S, Theune U, Aberle J, Galach A, Bamberger CM. Very high prevalence of thyroid nodules detected by high frequency (13 MHz) ultrasound examination. Eur J Clin Invest. Aug 2009;39(8):699-706. [Medline].

  5. Duarte GC, Tomimori EK, de Camargo RY, Catarino RM, Ferreira JE, Knobel M, et al. Excessive iodine intake and ultrasonographic thyroid abnormalities in schoolchildren. J Pediatr Endocrinol Metab. Apr 2009;22(4):327-34. [Medline].

  6. Pinchot SN, Al-Wagih H, Schaefer S, Sippel R, Chen H. Accuracy of fine-needle aspiration biopsy for predicting neoplasm or carcinoma in thyroid nodules 4 cm or larger. Arch Surg. Jul 2009;144(7):649-55. [Medline].

  7. Arda IS, Yildirim S, Demirhan B, Firat S. Fine needle aspiration biopsy of thyroid nodules. Arch Dis Chil. 2001;85(4):313-7. [Medline].

  8. Bardin CW. Endemic goiter. In: Current Therapy in Endocrinology and Metabolism. 6th ed. Mosby-Year Book; 1997:101-112.

  9. Becker KL, Bilezikian JP, Bremner WJ. Nontoxic goiter. In: Principles and Practice of Endocrinology and Metabolism. 2nd ed. Lippincott Williams & Wilkins; 1995:338-345.

  10. Bostanci I, Sarioglu A, Ergin H, Aksit A, Cinbis M, Akalin N. Neonatal goiter caused by expectorant usage. J Pediatr Endocrinol Metab. Sep-Oct 2001;14(8):1161-2. [Medline].

  11. Braverman LE, Utiger RD. Thyroid diseases: nontoxic diffuse and multinodular goiter. In: Werner and Ingbar, eds. The Thyroid: A Fundamental and Clinical Text. 7th ed. Lippincott-Raven; 1996:889-900.

  12. Gross JL. Ultrasonography in management of nodular thyroid disease. Annals of internal medicine. 2001;135(5):383-4. [Medline].

  13. Romanchishen AF, Iakovlev PN. [Special surgical treatment of patients with nodular tumors of the thyroid gland against the background of diffuse toxic goiter]. Vestn Khir Im I I Grek. 2005;164(1):21-4. [Medline].

  14. Sawin CT, Geller A, Wolf PA, et al. Low serum thyrotropin concentrations as a risk factor for atrial fibrillation in older persons. N Engl J Med. Nov 10 1994;331(19):1249-52. [Medline].

  15. Schumm-Draeger PM. [Every third German has a sick thyroid gland. Nodules and goiter are a challenge that needs to be met]. MMW Fortschr Med. Feb 5 2004;146(6):20. [Medline].

  16. Thompson L. Dyshormonogenetic goiter of the thyroid gland. Ear Nose Throat J. Apr 2005;84(4):200. [Medline].

  17. Vetshev PS, Chilingaridi KE, Bannyi DA, Dmitriev EE. [Repeated surgeries on the thyroid gland in nodular euthyroid goiter]. Khirurgiia (Mosk). 2004;37-40. [Medline].

  18. Wilson JD, Foster DW. The thyroid gland. In: Williams Textbook of Endocrinology. 8th ed. Harcourt Brace & Co; 1992:463-465.

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Further Reading

Clinical guidelines:
 American Association of Clinical Endocrinologists and Associazione Medici Endocrinologi medical guidelines for clinical practice for the diagnosis and management of thyroid nodules.
American Association of Clinical Endocrinologists - Medical Specialty Society
Associazione Medici Endocrinologi - Medical Specialty Society. 1996 Jan (revised 2006 Feb). 40 pages. NGC:004869

Management guidelines for patients with thyroid nodules and differentiated thyroid cancer.
American Thyroid Association - Professional Association. 2006 Feb. 34 pages. NGC:005212

Screening for congenital hypothyroidism: U.S. Preventive Services Task Force reaffirmation recommendation statement.
United States Preventive Services Task Force - Independent Expert Panel. 1996 (revised 2008 Mar). 6 pages. NGC:006354

Clinical trials:
 rhTSH, Radioiodine Uptake and Goiter Reduction Following 131I Therapy in Patients With Benign Nontoxic Nodular Goiter

Block-Replacement Therapy During Radioiodine Therapy

Levothyroxine Treatment in Thyroid Benign Nodular Goiter

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Keywords

goiter, goiter disease, thyroid disease, thyroid cancer, iodine deficiency, hypothyroidism, hyperthyroidism, thyroid nodules, thyroid gland goiter, nontoxic goiter, toxic goiter, multinodular goiter, endemic goiter, Hashimoto disease, iodine, enlarged thyroid gland, inborn errors of thyroid hormone synthesis, goitrogens, TSH receptor antibodies, pituitary resistance to thyroid hormone, adenomas of hypothalamus, adenomas of pituitary gland, tumors producing human chorionic gonadotropin, autoimmune thyroiditis, Hashimoto disease, swelling in the neck, Graves disease, Hashimoto thyroiditis

Riedel struma, toxic multinodular goiter, subacute thyroiditis, diffuse toxic goiter, toxic adenoma, Plummer disease, chronic lymphocytic thyroiditis, sporadic goiter, congenital goiter, physiologic goiter, Pemberton maneuver, postpartum thyroiditis, Wolff-Chaikoff effect, lithium ingestion, pituitary thyroid hormone resistance, thyroid-stimulating immunoglobulins, thyroid hormone resistance, de Quervain thyroiditis, silent thyroiditis, Riedel thyroiditis, granulomatous disease, thyroid malignancy

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Contributor Information and Disclosures

Author

James R Mulinda, MD, FACP, FACE, Consulting Staff, Department of Endocrinology, Endocrinology Associates, Inc
James R Mulinda, MD, FACP, FACE is a member of the following medical societies: American College of Clinical Endocrinologists and American College of Physicians
Disclosure: Nothing to disclose.

Medical Editor

Steven R Gambert, MD, MACP, Chairman, Department of Medicine, Physician-in-Chief, Sinai Hospital of Baltimore; Professor of Medicine, Program Director, Internal Medicine Program, Johns Hopkins University School of Medicine
Steven R Gambert, MD, MACP is a member of the following medical societies: Alpha Omega Alpha, American College of Physician Executives, American College of Physicians, American Geriatrics Society, Association of Professors of Medicine, Endocrine Society, and Gerontological Society of America
Disclosure: Nothing to disclose.

Pharmacy Editor

Francisco Talavera, PharmD, PhD, Senior Pharmacy Editor, eMedicine
Disclosure: eMedicine Salary Employment

Managing Editor

Kent Wehmeier, MD, Professor, Department of Internal Medicine, Division of Endocrinology, Diabetes, and Metabolism, St Louis University School of Medicine
Kent Wehmeier, MD is a member of the following medical societies: American Society of Hypertension, Endocrine Society, and International Society for Clinical Densitometry
Disclosure: Nothing to disclose.

CME Editor

Mark Cooper, MBBS, PhD, FRACP, Head, Diabetes & Metabolism Division, Baker Heart Research Institute, Professor of Medicine, Monash University
Disclosure: Nothing to disclose.

Chief Editor

George T Griffing, MD, Professor of Medicine, St Louis University School of Medicine
George T Griffing, MD is a member of the following medical societies: American Association for the Advancement of Science, American College of Medical Practice Executives, American College of Physician Executives, American College of Physicians, American Diabetes Association, American Federation for Medical Research, American Heart Association, Central Society for Clinical Research, Endocrine Society, International Society for Clinical Densitometry, and Southern Society for Clinical Investigation
Disclosure: Nothing to disclose.

 
 
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