Toxic Nodular Goiter Follow-up

Updated: Oct 14, 2016
  • Author: Philip R Orlander, MD, FACP; Chief Editor: George T Griffing, MD  more...
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Follow-up

Further Outpatient Care

After starting PTU or methimazole in patients with toxic nodular goiter (TNG), repeat free T4 or free T4 index measurements at 4-6 weeks. TSH levels rise slower because of suppression by elevated thyroid hormone levels and may take several months to normalize.

Radioiodine ablation may take 10 weeks to achieve clinical response. Patients may require treatment with antithyroid drugs and beta blockers in the interim period. Check biochemical evaluation of thyroid function approximately 4 weeks after initial treatment.

Patients who undergo total thyroidectomy should be started on levothyroxine at the time of discharge, unless they are clinically hyperthyroid. Evaluate thyroid function 4-6 weeks after surgery. In the case of subtotal thyroidectomy, thyroid hormone replacement is not required; evaluate thyroid function approximately 1 month after surgery.

Monitor patients with subclinical hyperthyroidism on initial biochemical evaluation every 6 months for the development of overt hyperthyroidism.

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Complications

Hyperthyroid complications

  • The most important complications are related to the heart.

  • Cardiomyopathy resulting in severely depressed function may be observed with hyperthyroidism, possibly in relation to persistent tachycardia. Fortunately, cardiomyopathy resolves remarkably with resolution of the hyperthyroid state.

  • Using anticoagulants to treat patients exhibiting atrial fibrillation remains controversial, although it is recommended by many authorities. Atrial fibrillation of long duration that is associated with other anatomical defects of the heart should be treated with warfarin or another suitable anticoagulant.

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Prognosis

Most treated patients have a good prognosis. A worse prognosis is related to untreated hyperthyroidism. Patients should understand the gravity of hyperthyroidism. If left untreated, hyperthyroidism may lead to osteoporosis, arrhythmia, heart failure, coma, and death. Regular assessment of thyroid function is important in monitoring disease.

Na131 I ablation may result in continued hyperthyroidism, with some patients (up to 73% in some studies, depending on the size of the goiter and the dosing of radioiodine) requiring repeated treatment or surgical removal of the gland. Hypothyroidism after radioiodine ablation has been reported in 0-35% of individuals.

Iodine-131 ablation may result in continued hyperthyroidism, with some patients (up to 73% in some studies depending on size of goiter and dosing of radioiodine) requiring repeated treatment or surgical removal of the gland. Hypothyroidism after radioiodine ablation has been reported in 0-35% of individuals.

Surgical treatment usually consists of a lobectomy of the hyperfunctioning nodule. The rate of hypothyroidism associated with this procedure is very low. Rates of hyperthyroidism recurrence with surgery have been reported to be as low as 0-9%. Larger, multinodular goiters may require total thyroidectomy.

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Patient Education

Many patients fear abnormal weight gain with the attainment of the euthyroid state. Provide patients with education regarding the role of thyroid hormone in metabolism, as well as the cardiovascular and thromboembolic risks of hyperthyroidism. Also provide guidelines for lifestyle modification that will allow the patient to avoid weight gain.

Appraise patients treated with PTU or methimazole of the risk of agranulocytosis and instruct them to contact a physician if they develop a fever, rash, or sore throat, so that a complete blood count (CBC) with differential can be urgently performed.

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