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Lithium-Induced Goiter Treatment & Management

  • Author: Nicholas J Sarlis, MD, PhD, FACP; Chief Editor: George T Griffing, MD  more...
 
Updated: Feb 27, 2015
 

Medical Care

Because as many as one fourth to one third of patients on long-term lithium therapy develop hypothyroidism, provide regular follow-up care on a clinical and biochemical basis for symptoms and signs of hypothyroidism and increased serum thyrotropin levels, respectively.

Before the initiation of lithium therapy, identify patients at increased risk for the development of hypothyroidism (eg, patients originating from iodine-deficient areas, those with a strong family history of thyroid disorders, women, elderly patients, patients exposed to other goitrogens). Suspicion of goiter upon physical examination may prompt the physician to order ultrasonography to record the baseline dimensions of the thyroid gland and to exclude underlying structural thyroid disease. Baseline thyroid function tests, including thyrotropin, free T4, total T3, anti-TPO, and anti-Tg antibodies, also are important.

Whether all patients being treated with lithium for a long period require prophylactic therapy with levothyroxine (LT4) is debatable. Such prophylactic treatment is probably not indicated if goiter and hypothyroidism have been excluded prior to initiation of lithium therapy. Provide regular follow-up care for patients on long-term lithium therapy by regularly assessing their history, physical examination findings, and serum thyrotropin levels. Rising levels of thyrotropin should prompt the physician to repeat a full evaluation, including serum measurements of free T4, total T3, anti-TPO, and anti-Tg antibodies.

If the diagnosis of hypothyroidism is established, early initiation of LT4 therapy is indicated, especially when discontinuation of lithium is inadvisable because of the patient's psychiatric status.

For patients who develop goiter over time, even in the absence of hypothyroidism (clinical or subclinical), also consider LT4 therapy aimed at restoring normal serum thyrotropin levels.

Diagnose and treat rare cases of lithium-induced thyrotoxicosis as indicated for similar cases attributable to other causes of hyperthyroidism; discontinuing lithium therapy is not necessary, and it can also be dangerous (in the context of exacerbation of manic-depressive illness).

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Surgical Care

Although specific surgical treatment is not usually necessary, in rare cases, long-term lithium administration may induce hyperthyroidism that is difficult to control, necessitating thyroidectomy. Similarly, the underlying or concomitant thyroid disorder (eg, multinodular goiter, nontoxic endemic goiter) may dictate the need for surgical intervention.

A more expanded discussion of the indications, techniques, and complications of thyroid surgery in each of the above contingencies can be found in respective Medscape Reference articles (eg, Nontoxic Goiter and Hyperthyroidism).

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Consultations

In most cases, the treating psychiatrist or primary care physician may opt to consult with an endocrinology specialist, especially in cases of lithium-induced thyrotoxicosis. The development of compressive local symptoms requires an evaluation by a surgical or ear, nose, and throat specialist.

In cases of lithium-induced thyrotoxicosis, consultation with a cardiologist may be necessary, especially in elderly patients who have a high prevalence of coronary artery disease, arrhythmias, and congestive heart failure.

For all patient referrals from psychiatrists, it is important for the consultant endocrinologist to establish and maintain appropriate regular bidirectional communication with the mental health provider(s) regarding clinical status and specific endocrine management on patients on long-term lithium therapy.

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Diet

No specific dietary restrictions are needed.

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Activity

No restrictions in exercise or activity patterns are advisable or necessary, with the exception of patients who have severe lithium-induced thyrotoxicosis with cardiovascular symptoms, in which case any strenuous activity should be avoided (as in all cases of severe thyrotoxicosis).

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Contributor Information and Disclosures
Author

Nicholas J Sarlis, MD, PhD, FACP Vice President, Head of Medical Affairs, Incyte Corporation

Nicholas J Sarlis, MD, PhD, FACP is a member of the following medical societies: American Association for the Advancement of Science, American Association for Cancer Research, American Association of Clinical Endocrinologists, American College of Physicians, American Federation for Medical Research, American Head and Neck Society, American Medical Association, American Society for Radiation Oncology, American Thyroid Association, Endocrine Society, New York Academy of Sciences, Royal Society of Medicine, Association for Psychological Science, American College of Endocrinology, European Society for Medical Oncology, American Society of Clinical Oncology

Disclosure: Received salary from Incyte Corporation for employment; Received ownership interest from Sanofi-Aventis for previous employment; Received ownership interest/ stock & stock option (incl. rsu) holder from Incyte Corporation for employment.

Specialty Editor Board

Francisco Talavera, PharmD, PhD Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Received salary from Medscape for employment. for: Medscape.

Don S Schalch, MD Professor Emeritus, Department of Internal Medicine, Division of Endocrinology, University of Wisconsin Hospitals and Clinics

Don S Schalch, MD is a member of the following medical societies: American Diabetes Association, American Federation for Medical Research, Central Society for Clinical and Translational Research, Endocrine Society

Disclosure: Nothing to disclose.

Chief Editor

George T Griffing, MD Professor Emeritus 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, International Society for Clinical Densitometry, Southern Society for Clinical Investigation, American College of Medical Practice Executives, American Association for Physician Leadership, American College of Physicians, American Diabetes Association, American Federation for Medical Research, American Heart Association, Central Society for Clinical and Translational Research, Endocrine Society

Disclosure: Nothing to disclose.

Additional Contributors

Steven R Gambert, MD Professor of Medicine, Johns Hopkins University School of Medicine; Director of Geriatric Medicine, University of Maryland Medical Center and R Adams Cowley Shock Trauma Center

Steven R Gambert, MD is a member of the following medical societies: Alpha Omega Alpha, American Association for Physician Leadership, American College of Physicians, American Geriatrics Society, Endocrine Society, Gerontological Society of America, Association of Professors of Medicine

Disclosure: Nothing to disclose.

Acknowledgements

Boaz Hirshberg, MD Associate Director, CVMD, Pfizer

Boaz Hirshberg, MD is a member of the following medical societies: American Dietetic Association

Disclosure: Nothing to disclose.

Acknowledgments

The author wishes to dedicate this article to the late Jacob Robbins, MD (1922-2008), a leading figure in international thyroidology and a force majeure within the Clinical Endocrinology Branch of NIDDK, National Institutes of Health. His legacy lives on.

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