ipertiroidismo - terapia definitiva
DESCRIPTION
Michele Zini Servizio di Endocrinologia - Arcispedale S. Maria Nuova, IRCCS Reggio Emilia [email protected]TRANSCRIPT
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IPERTIROIDISMO: TERAPIA DEFINITIVA.
COME E QUANDO
Michele Zini
Servizio di Endocrinologia - Arcispedale S. Maria Nuova, IRCCS Reggio Emilia
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Definitive treatment
A definitive treatment of GD is recommended in case of:
• Occurrence of a major adverse reaction to ATDs or persistence of unpleasant minor side effects
• Unsatisfactory response to ATDs or poor compliance of the patient
• Coexisting morbidities that suggest a definitive control of thyroid hyperfunction
• Relapse of hyperthyroidism after withdrawal of medical treatment
• Pregnancy planning
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Radioiodine therapy (RAI)
RAI is the most cost-effective treatment for GD and is followed in nearly all patients by a definitive cure of hyperthyroidism. Patients should be informed that in most cases this target is reached at the expense of hypothyroidism induction
Indications for 131I treatment are:• ATDs use contraindications• Presence of comorbidities that cause a high surgical risk• Previous thyroid surgery or external beam irradiation• Lack of an experienced thyroid surgeon
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Radioiodine therapy (RAI)
Contraindications for RAI treatment are:
• Pregnancy and breast feeding• Very young age (< 5 years)• Presence of suspicious or malignant thyroid nodules• Severe active Graves orbitopathy (GO)
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Surgical treatment
• When surgery is needed, total thyroidectomy should be performed as the procedure of choice
• Hyperthyroidism should be carefully controlled with MMI before thyroidectomy
Thyroidectomy should be considered in presence of:• Large goiter not suitable for RAI treatment • Diagnosis or suspect of thyroid malignancy• Need of hyperthyroidism resolution in the short-term
(pregnancy planned within 6 months)• Severe active GO
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Surgical treatment
Surgery is contraindicated in:• First and third trimester of pregnancy• Patients at surgical risk due to relevant
comorbidities or previous thyroid surgery surgery
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Fattori di rischio per ipoparatiroidismo postchirurgico Thomusch O. et al., Surgery 133: 180-185, 2003
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CONCLUSIONS: Extent of resection and surgical technique had a greater impact on permanent postoperative hypoparathyroidism than thyroid pathologic condition.
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CHIRURGIA RADIOIODIO
ETA’ RIDOTTA
NODULARITA’ AVANZATA
ETA’ AVANZATA
NODULARITA’ RIDOTTA
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CONCLUSIONI (1)
• Pazienti stabilmente eutiroidei con basse dosi di metimazolo possono proseguire in sicurezza la terapia per un tempo indefinito
• Per molti pazienti potrebbe essere preferibile mantenere uno steady state con i farmaci rispetto al cambio di strategia che comportano i trattamenti definitivi
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CONCLUSIONI (2)
• Prima di passare ad un trattamento definitivo:• il corso di terapia con metimazolo deve
essere di durata sufficientemente lunga per rendere ragionevolmente improbabile che il m. di Basedow vada in remissione
• ogni volta che è possibile, si deve tentare la sospensione della terapia
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CONCLUSIONI (3)
Se si decide per un trattamento definitivo:• informare il paziente sul carattere
irreversibile del trattamento ablativo
• informare il paziente sul probabile sviluppo di ipotiroidismo
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CONCLUSIONI (4)
Nel decidere sul tipo di trattamento definitivo:• valutare il rischio anestesiologico• valutare l’aspetto ecografico della
tiroide• tenere nella dovuta considerazione i
values del paziente