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Thyroid disease assessment and management: summary of NICE guidance

BMJ 2020; 368 doi: https://doi.org/10.1136/bmj.m41 (Published 29 January 2020) Cite this as: BMJ 2020;368:m41

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Re: Thyroid disease assessment and management: summary of NICE guidance: NICE recommendation of radioactive iodine as first line treatment of Graves’ disease is based on flawed interpretation of published trials.

Dear Editor

The recently published NICE guidance on the management of thyroid disease recommends radioactive iodine (RAI) as the first-line treatment for Graves’ disease as it “results in better long-term outcomes than long-term anti-thyroid drugs (ATDs) in terms of thyroid status”. This statement is misleading as in all 5 studies of ATDs referenced, the failure to achieve euthyroidism was because the thyrotoxicosis relapsed after ATDs were discontinued (1, 2, 3, 4, 5). All available evidence suggest that very high rates of euthyroidism are achieved whilst the patients remain on ATDs (6, 7, 8, 9) and that life-long ATD therapy is affective at maintaining a euthyroid state in both Graves’ disease (6) and multinodular goitre (10).

Patients given RAI usually require life-long levothyroxine therapy and most can achieve biochemical euthyroidism. However, this does not equate with having normal thyroid physiology. Subjects on levothyroxine have lower serum T3 levels than TSH-matched controls and abnormal lipid profiles as well as higher body mass indices and reduced well-being and quality of life (11, 12).

RAI is an ablative treatment which destroys the physiological function of the thyroid. It is unknown whether Graves’ disease patients euthyroid on long-term ATDs have a normally functioning thyroid but there is no evidence to suggest otherwise. We believe long-term ATDs are a very effective treatment for Graves’ disease and that more research is needed in this area.

1. Abraham-Nordling M, Torring O, Hamberger B, Lundell G, Tallstedt L, Calissendorff J, et al. Graves' disease: a long-term quality-of-life follow up of patients randomized to treatment with antithyroid drugs, radioiodine, or surgery. Thyroid. 2005;15(11):1279-86.
2. Bartalena L, Marcocci C, Bogazzi F, Manetti L, Tanda ML, Dell'Unto E, et al. Relation between therapy for hyperthyroidism and the course of Graves' ophthalmopathy. N Engl J Med. 1998;338(2):73-8.
3. Benker G, Reinwein D, Kahaly G, Tegler L, Alexander WD, Fassbinder J, et al. Is there a methimazole dose effect on remission rate in Graves' disease? Results from a long-term prospective study. The European Multicentre Trial Group of the Treatment of Hyperthyroidism with Antithyroid Drugs. Clin Endocrinol (Oxf). 1998;49(4):451-7.
4. Kansara S, Kotwal N, Kumar K, Singh Y, Upreti V, Nachankar A. Effect of Antithyroid Therapies on Bone and Body Composition: A Prospective, Randomized, Clinical Study Comparing Antithyroid Drugs with Radioiodine Therapy. Indian J Endocrinol Metab. 2017;21(4):531-4.
5. Chen DY, Jing J, Schneider PF, Chen TH. Comparison of the long-term efficacy of low dose 131I versus antithyroid drugs in the treatment of hyperthyroidism. Nucl Med Commun. 2009;30(2):160-8.
6. Azizi F, Ataie L, Hedayati M, Mehrabi Y, Sheikholeslami F. Effect of long-term continuous methimazole treatment of hyperthyroidism: comparison with radioiodine. European Journal of Endocrinology. 2005;152(5):695-701.
7. Abraham P, Avenell A, McGeoch SC, Clark LF, Bevan JS. Antithyroid drug regimen for treating Graves' hyperthyroidism. Cochrane Database Syst Rev. 2010(1):CD003420.
8. Benker G, Vitti P, Kahaly G, Raue F, Tegler L, Hirche H, et al. Response to methimazole in Graves' disease. The European Multicenter Study Group. Clin Endocrinol (Oxf). 1995;43(3):257-63.
9. Torring O, Tallstedt L, Wallin G, Lundell G, Ljunggren JG, Taube A, et al. Graves' hyperthyroidism: treatment with antithyroid drugs, surgery, or radioiodine--a prospective, randomized study. Thyroid Study Group. J Clin Endocrinol Metab. 1996;81(8):2986-93.
10. Azzizi F, Miralireza T, Elham M, Atieh A. Treatment of Toxic Multinodular Goiter: Comparison of Radioiodine and Long-Term Methimazole Treatment. Thyroid. 2019;29(5):625-30.
11. Peterson SJ, McAninch EA, Bianco AC. Is a Normal TSH Synonymous With "Euthyroidism" in Levothyroxine Monotherapy? J Clin Endocrinol Metab. 2016;101(12):4964-73.
12. Saravanan P, Chau WF, Roberts N, Vedhara K, Greenwood R, Dayan CM. Psychological well-being in patients on 'adequate' doses of l-thyroxine: results of a large, controlled community-based questionnaire study. Clin Endocrinol (Oxf). 2002;57(5):577-85.

Competing interests: No competing interests

13 February 2020
David E Price
Consultant Endocrinologist
Kusuma Boregowda MRCP, Maneesh Udiawar MD FRCP, Jeffrey Stephens PhD FRCP
Swansea Bay University Health Board
Morriston Hospital, Swansea SA6 6NL