ABSTRACT
BACKGROUND: Amiodarone is a powerful antiarrhythmic drug; however, its use may be complicated by thyrotoxicosis. When this occurs, clinicians must balance the continuation of amiodarone for antiarrhythmic purposes, and the discontinuation of treatment in order to prevent aggravation of the thyrotoxicosis. We studied the consequences of continuation or cessation of amiodarone in patients with type II amiodarone-induced thyrotoxicosis. METHODS: Consecutive patients who developed type II amiodarone-induced thyrotoxicosis between September 1997 and September 2000 were studied. Amiodarone was continued in patients with previous ventricular arrhythmia or supraventricular arrhythmia associated with severe haemodynamic changes and was withdrawn in the other patients. In patients with persistent, severe symptomatic thyrotoxicosis, corticosteroids were added to therapy. RESULTS: Thirteen patients were studied (nine with previous atrial fibrillation/flutter and four with ventricular tachycardia). Amiodarone treatment was continued in ten patients, including eight patients who received corticosteroids, and was temporarily halted in three patients. All patients recovered, with no difference in the duration of thyrotoxicosis between the two groups. Corticosteroid treatment was well tolerated and seemed to hasten the return to a euthyroid state (mean of 3.7 +/- 0.7 months vs 6.3 +/- 1.7 months). No recurrence of hyperthyroidism occurred during long-term follow-up. CONCLUSION: In patients who require amiodarone, treatment may be safely continued despite the development of type II amiodarone-induced thyrotoxicosis.
Subject(s)
Amiodarone/adverse effects , Amiodarone/therapeutic use , Anti-Arrhythmia Agents/adverse effects , Anti-Arrhythmia Agents/therapeutic use , Tachycardia, Supraventricular/drug therapy , Thyrotoxicosis/chemically induced , Ventricular Fibrillation/drug therapy , Adolescent , Adult , Aged , Aged, 80 and over , Databases, Factual , Female , Humans , Male , Middle Aged , Practice Guidelines as Topic , Prospective Studies , Thyrotoxicosis/diagnosis , Treatment OutcomeABSTRACT
OBJECTIVES: To examine the cost-effectiveness of strategies for management of primary asymptomatic hyperparathyroidism: surgical strategies and medical follow-up versus surgery. DESIGN: We used a Markov state-transition decision-analytic model for an hypothetical cohort of 55-year-old women to compare with a lifetime horizon costs and effectiveness of bilateral neck exploration (BNE), unilateral neck exploration (UNE), video-assisted parathyroidectomy (VAP) and lifelong medical follow-up shifting for either BNE or UNE in case of disease progression. METHODS: Data on localization tests, complications and treatment efficacies were derived from a systematic review of the literature. Outcomes were expressed as quality-adjusted life years (QALY). Costs (2002 Euro) discounted at 3% yearly were estimated from the health care system perspective. RESULTS: In the base-case analysis, VAP strategy (VAPS) was the most effective and BNE strategy (BNES) was the least costly. UNE strategy (UNES) had an incremental cost-effectiveness ratio of 2688 Euro/QALY versus BNES and VAPS of 17,250 Euro/QALY in comparison with UNES. Surgical management was more effective than medical follow-up with acceptable incremental cost-effectiveness ratios. VAPS became less effective than UNES over 71 years. Differences between UNES and VAPS were sensitive to success and complication rates, quality-of-life weights and procedural costs. Medical follow-up strategies became the most effective if quality-of-life weight for this condition was higher than 0.99. CONCLUSIONS: Surgery is more effective than medical follow-up at a reasonable cost and can be preferred except in patients choosing medical follow-up. Minimally invasive surgery is cost-effective compared to the traditional surgical approach.
Subject(s)
Decision Support Techniques , Hyperparathyroidism, Primary/surgery , Hyperparathyroidism, Primary/therapy , Cost-Benefit Analysis , Female , Follow-Up Studies , Humans , Middle Aged , Parathyroidectomy , Quality of LifeABSTRACT
Hypothyroidism or hyperthyroidism may develop during iodine excess. Hypothyroidism occurs mostly in newborns or in elderly patients with underlying autoimmune thyroiditis and is treated by substitutive doses of thyroxine. Hyperthyroidism is of two types. Type I develops in patients with pretoxic thyroid glands, the radioactive tracer uptake remains high. This type is treated with thionamides and potassium perchlorate, as well as, in some cases, by thyroidectomy or iodine 131. Type II develops in non pretoxic thyroid gland, and it evoluates spontaneously towards euthyroidism, in several months, despite continuation of iodine excess. It responds to glucocorticoid therapy.
Subject(s)
Hyperthyroidism/chemically induced , Hypothyroidism/chemically induced , Iodine/adverse effects , Adaptation, Physiological , Humans , Hyperthyroidism/physiopathology , Hyperthyroidism/therapy , Hypothyroidism/physiopathology , Hypothyroidism/therapy , Iodine/administration & dosageABSTRACT
TWO TYPES: Hyperthyroidism may develop in around 10% of patients in excess iodine. It may reveal an undetected pretoxic thyroid disease (type I) or have been induced by excess iodine in previously normal thyroid gland or in an euthyroid goiter (type II). IODINE EXCESSE REVEALING THYROTOXICOSIS: In the former situation, symptoms appear shortly after the iodine load, thyroid scintigraphy shows significant uptake and therapy includes discontinuation of iodine excess, antithyroid drugs, potassium perchlorate and, if necessary, thyroidectomy or a therapeutic dose of iodide 131. IODINE-INDUCED THYROTOXICOSIS: In the latter situation (type II) hyperthyroidism may occur several years after the initiation of iodine excess, scintigraphy shows very low or no uptake, spontaneous remission is observed within six months, despite the persistence of iodine excess, and treatment is based on corticosteroids.