title: Rapid preoperative blockage of thyroid hormone production / secretion in patients with Graves' disease.
abstract: BACKGROUND
  Preoperative management of hyperthyroid patients with Graves' disease who are unable to tolerate thionamides or have poor adherence to therapy is a challenging clinical problem. The goal of our study was to demonstrate the clinical efficacy of a rapid preoperative thyroid hormone blocking protocol and to assess specific surgical and treatment-related complications.
  
  
  METHODS
  Ten patients with thyrotoxicosis due to Graves' disease were treated with a rapid thyroid hormone blocking protocol of Lugol's solution, dexamethasone and a beta-blocker. Two patients continued to receive antithyroid therapy with carbimazole. Adrenal function was assessed 4-6 weeks postoperatively with a low dose (1 µg) adrenocorticotrophic hormone-stimulation test.
  
  
  RESULTS
  Before treatment, all patients had severe hyperthyroidism. Baseline median and interquartile range (IQR) of fT4 was 68.9 (45.7-92.1) pmol/l, and baseline median fT3 and IQR, 30 (19.1-40.9) pmol/l. After 10 days of treatment, the levels of free hormones were significantly reduced with fT4 concentrations slightly elevated (fT4, 26.7 [17-36.4] pmol/l, p <0.001 compared with corresponding pretreatment values), and the fT3 concentration was normal in 8/10 patients (fT3, 6.1 [4.6-7.6] pmol/l, p <0.001 compared with corresponding pretreatment values). All patients were clinically euthyroid with a heart rate of <80/min. Drug tolerability was excellent, and there were no side effects or exacerbation of hyperthyroidism. The peri- and postoperative course was uneventful in all cases. Adrenal function was normal in 7 out of 10 patients 4-6 weeks postoperatively. Three patients showed prolonged secondary adrenal insufficiency with normalisation of adrenal function after 3 to 6 months.
  
  
  CONCLUSIONS
  Rapid and effective preoperative preparation of patients with Graves' disease is achievable with Lugol's solution, dexamethasone and a beta-blocker. The risk of temporary hypothalamic-pituitary-adrenal axis suppression has to be taken into account.
authors.affiliation: Division of Endocrinology, Diabetes and Clinical Nutrition, Luzerner Kantonsspital, Luzern, Switzerland.
authors.forename: Stefan
authors.initials: S
authors.lastname: Fischli
authors.affiliation: Division of Endocrinology, Diabetes and Clinical Nutrition, Luzerner Kantonsspital, Luzern, Switzerland.
authors.forename: Barbara
authors.initials: B
authors.lastname: Lucchini
authors.affiliation: Division of Otorhinolaryngology, Head and Neck Surgery, Luzerner Kantonsspital, Luzern, Switzerland.
authors.forename: Werner
authors.initials: W
authors.lastname: Müller
authors.affiliation: Division of Endocrinology, Diabetes and Clinical Nutrition, Luzerner Kantonsspital, Luzern, Switzerland.
authors.forename: Lea
authors.initials: L
authors.lastname: Slahor
authors.affiliation: Division of Endocrinology, Diabetes and Clinical Nutrition, Luzerner Kantonsspital, Luzern, Switzerland.
authors.forename: Christoph
authors.initials: C
authors.lastname: Henzen
mesh_terms: D000319:Adrenergic beta-Antagonists / Q000627:therapeutic use*; D000328:Adult; D013956:Antithyroid Agents / Q000627:therapeutic use*; D002231:Carbimazole / Q000627:therapeutic use; D015331:Cohort Studies; D003907:Dexamethasone / Q000627:therapeutic use*; D005260:Female; D005938:Glucocorticoids / Q000627:therapeutic use*; D006111:Graves Disease / Q000188:drug therapy*; D006801:Humans; D007454:Iodides / Q000627:therapeutic use*; D008297:Male; D008875:Middle Aged; D011300:Preoperative Care / Q000379:methods*; D013963:Thyroid Hormones / Q000096:biosynthesis / Q000097:blood* / Q000378:metabolism; D013965:Thyroidectomy; D013974:Thyroxine / Q000096:biosynthesis / Q000097:blood / Q000378:metabolism; D016896:Treatment Outcome; D014284:Triiodothyronine / Q000096:biosynthesis / Q000097:blood / Q000378:metabolism; D055815:Young Adult
chemical_list: D000319:Adrenergic beta-Antagonists; D013956:Antithyroid Agents; D005938:Glucocorticoids; D007454:Iodides; D013963:Thyroid Hormones; D014284:Triiodothyronine; D003907:Dexamethasone; D002231:Carbimazole; D013974:Thyroxine; C010389:Lugol's solution