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parents previously treated with 131I show normal rates of congenital abnormalities Because fetal radiation is harmful, RAI should not be given to pregnant women It is prudent to obtain a sensitive pregnancy test (serum -hCG) on all women of reproductive age prior to 131I therapy Most patients may receive 131I while being symptomatically treated with just propranolol, which is then reduced in dosage as hyperthyroxinemia resolves However, some patients (those with coronary diseases, the elderly, or those with severe hyperthyroidism) are usually rendered euthyroid with a thiouracil drug (see above) while the dosage of propranolol is reduced Treatment with methimazole is discontinued for about 1 week prior to 131I therapy A higher rate of 131I treatment failure has been reported in patients with Graves disease who have been receiving methimazole or propylthiouracil However, therapy with 131I will usually be effective if the methimazole is discontinued about 6 days before RAI therapy and if the therapeutic dosage of 131I is adjusted (upward) according to 123I uptake on the pretherapy scan Following 131I treatment for hyperthyroidism, Graves ophthalmopathy appears or worsens in 15% of patients and improves in none, whereas during treatment with methimazole, ophthalmopathy worsens in 3% and improves in 2% of patients Among patients receiving 3 months of prednisone following 131I treatment, preexistent ophthalmopathy worsens in none and improves in 67% Smoking increases the risk of having a flare in ophthalmopathy following 131I treatment and also reduces the effectiveness of prednisone treatment Therefore, patients who smoke are strongly encouraged to quit prior to 131I treatment FT4 levels may sometimes drop within 2 months after 131I treatment, but then rise again to thyrotoxic levels, at which time thyroid RAI uptake is low This phenomenon is caused by a release of stored thyroid hormone from injured thyroid cells and does not indicate a treatment failure In fact, serum FT4 then falls abruptly to hypothyroid levels There is a high incidence of hypothyroidism several years after 131I even when small doses are given However, hypothyroidism also occurs quite frequently years after surgical or medical treatment of Graves disease, and eventual hypothyroidism may be part of the natural history of this condition Lifelong clinical follow-up is mandatory, with measurements of FT4 and TSH when indicated 5 Thyroid surgery Thyroid surgery for Graves disease and toxic nodular goiter has been performed less frequently as RAI treatment has become more widely accepted Thyroidectomy may be performed for pregnant women whose thyrotoxicosis is not controlled with low doses of thioureas, and for women who desire to become pregnant in the very near future Children with Graves disease usually undergo thyroidectomy Surgery is also an option for nodular goiters, when there is a suspicion for malignancy The Hartley Dunhill operation is the surgical procedure of choice for patients with Graves disease; this operation consists of a total resection of one lobe and a subtotal resection of the other lobe, leaving about 4 g of thyroid tissue Subtotal thyroidectomy of both lobes is often used, but ultimately results in a 9% recurrence rate for hyperthyroidism Total thyroidectomy of.

both lobes poses an increased risk for hypoparathyroidism and damage to the recurrent laryngeal nerve Patients are ordinarily rendered euthyroid preoperatively with a thiourea drug Ipodate sodium or iopanoic acid (500 mg orally twice daily) may be used in addition to a thiourea to accelerate the decline in serum T3 Propranolol is given until the serum T3 (or free T3) is normal preoperatively Thyroid vascularity is reduced by preoperative treatment with either ipodate sodium or iopanoic acid (500 mg twice daily for 3 days) or iodine (eg, Lugol s solution, two or three drops orally daily for several days) If a patient undergoes surgery while thyrotoxic, larger doses of propranolol are given perioperatively to reduce the likelihood of thyroid crisis Morbidity includes possible damage to the recurrent laryngeal nerve, with resultant vocal cord paralysis Hypoparathyroidism also occurs, which means that calcium levels must be checked postoperatively When a thyroidectomy is performed by a competent, experienced neck surgeon, surgical complications are uncommon Thyroid surgery should be performed as an inpatient, with at least an overnight observational period

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Hyperthyroidism caused by a single hyperfunctioning thyroid nodule may be treated symptomatically with propranolol as in Graves disease Definitive treatment is with surgery or RAI For patients under age 40 years, surgery is usually recommended; patients are made euthyroid with a thiourea preoperatively and given several days of iodine, ipodate sodium, or iopanoic acid before surgery as in Graves disease (see above) Transient postoperative hypothyroidism resolves spontaneously Permanent hypothyroidism occurs in about 14% of patients by 6 years after surgery Patients over age 40 years with a toxic solitary nodule are offered RAI Permanent hypothyroidism occurs in about one-third of patients by 8 years after RAI The nodule remains palpable in 50% and may grow in 10% of patients after RAI

Hyperthyroidism caused by a toxic multinodular goiter may also be treated symptomatically with propranolol as in Graves disease This disorder usually affects older individuals, so RAI is ordinarily selected over surgery as the definitive treatment Thioureas do reverse hyperthyroidism, but there is a 95% recurrence rate after they are stopped Older patients who are quite thyrotoxic are rendered nearly euthyroid with methimazole, which is stopped at least 3 days before RAI treatment Meanwhile, the patient follows a low-iodine diet; this is done to enhance the thyroid gland s uptake of RAI, which may be relatively low in this condition (compared to Graves disease) Relatively high doses of RAI are usually required; recurrent thyrotoxicosis and hypothyroidism are common, so patients must be monitored closely Surgery is generally reserved for pressure symptoms or cosmetic indications Patients are prepared for surgery as in Graves disease (see above)

Patients with hyperthyroidism due to subacute thyroiditis are treated symptomatically with propranolol Ipodate sodium or

thyrotoxicosis usually requires a prolonged course of methimazole After two doses of methimazole, iopanoic acid or sodium ipodate may be added to the regimen to further block conversion of T4 to T3; the recommended dosage for each is 500 mg orally twice daily for 3 days, followed by 500 mg once daily until thyrotoxicosis is resolved -Blockers may be required Withdrawal of amiodarone does not have a significant therapeutic effect for several months Therapy with 131I may be successful in some patients with adequate RAI uptake Thyroidectomy is reserved for resistant cases Treatment of type II amiodarone-induced thyrotoxicosis consists of prednisone plus either iopanoic acid or ipodate sodium (see above) -Blockers may be required Withdrawal of amiodarone is not usually necessary Because the condition is transient, thyroidectomy is rarely required

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