Amiodarone associated thyrotoxicosis occurs in 610% of people given the drug and is. Pdf context amiodarone induced thyrotoxicosis ait is a difficult diagnostic and management challenge, especially during severe. We discuss the medical management of ait and anesthetic considerations for management of patients with thyrotoxicosis. Two types of amiodarone induced thyrotoxicosis are recognized, designated type 1 and type 2, based on whether or not the patient had a preexisting thyroid disorder. Amiodarone can lead to both hypothyroidism amiodaroneinduced hypothyroidism and less commonly hyperthyroidism amiodaroneinduced thyrotoxicosis. Ait represents a diagnostic and therapeutic challenge, while aih does not cause critical problems in most cases. To determine how expert european thyroidologists assess and treat amiodarone induced thyrotoxicosis ait. Amiodarone cordarone induced hyperthyroidism can be found in up to 12 percent of treated patients, especially those in iodinedeficient areas, and occurs by two mechanisms. Hypotension, bradycardia, ventricular fibrillation, and asystole have been seen in a few people given amiodarone. The most common form in the united kingdom is type 2 amiodarone induced thyroiditis, and a recent randomised controlled trial found that the most effective treatment for this was prednisolone. The effects range from abnormal thyroid function test findings to overt thyroid dysfunction, which may be either amiodarone induced thyrotoxicosis ait or amiodarone induced hypothyroidism aih. Despite antithyroid drug therapy, some patients demonstrated refractory hyperthyroidism. Amiodarone is used to treat lifethreatening ventricular arrhythmias with an additional offlabel indication for intractable atrial fibrillation.
Amiodarone induced thyrotoxicosis is a predictor of adverse cardiovascular outcome. Apr 02, 2020 thyrotoxicosis is a welldocumented complication of amiodarone treatment, but little has been written about the risks and treatment of recurrent thyrotoxicosis on reexposure to amiodarone. Treatment of amiodarone induced thyrotoxicosis is difficult since the drug. Amiodaroneinduced thyrotoxicosis associated with thyrotropin. A new study provides evidence that glucocorticoid therapy is safe, effective and associated with prompt restoration.
Amiodaroneinduced thyrotoxicosis develops in 3% of amiodaronetreated patients. Type 1 occurs in patients with underlying thyroid pathology such as autonomous nodular goiter, graves disease or hashimotos thyroiditis. He subsequently reverted to sinus rhythm and his medication was stopped 1 year prior. When surgical treatment is planned for patients with a solitary thyroid nodule and amiodarone induced hyperthyroidism, preoperative thyroid scanning will direct the surgeon to perform either subtotal thyroidectomy for diffuse disease or lobectomy for a hyperfunctioning nodule. Pdf thyroid hormones and proinflammatory cytokines. Amiodaroneinduced thyrotoxicosis with cardiopulmonary arrest. In addition, it can also cause type ii amiodarone induced thyrotoxicosis, which occurs from actual thyroid tissue destruction. Amiodarone induced thyrotoxicosis ait occurs in 3% of all the patients treated and is subclassified into type 1 and 2. A new study provides evidence that glucocorticoid therapy is safe, effective and.
In europe, amiodaroneinduced hyperthyroidism aih is more frequent than hypothyroidism, occurring in up to 10% of patients treated with amiodarone. Anesthetic considerations in a patient with amiodarone. Amiodaroneinduced thyrotoxicosis the journal of clinical. Use of glucocorticoids in amiodaroneinduced thyrotoxicosis.
Treatment of amiodaroneinduced thyrotoxicosis, a diffkult challenge. However, amiodarone is associated with a number of side effects, including thyroid dysfunction both hypo and hyperthyroidism, which is due to amiodarones high iodine content and its direct toxic effect on the thyroid. He was diagnosed with atrial fibrillation 2 years previously and started on amiodarone and warfarin. Successful treatment of amiodaroneinduced thyrotoxicosis.
Clinical course and predictors of outcome david conen, ludovic melly, christoph kaufmann, stefan bilz, peter ammann, beat schaer, christian sticherling, beat muller, stefan osswald this study evaluated the clinical course and predictors of longterm outcome in 84 patients with amiodaroneinduced thyrotoxicosis ait. The thyrotoxicosis is mediated by amiodarone s iodine content. The adverse effects of amiodarone may be seen months after discontinuation because its long halflife 107 days. Amiodarone hydrochloride, an iodinerich drug used in the treatment of tachyarrhythmias, is responsible for the development of thyrotoxicosis in approximately 10% of patients who reside in areas of moderate iodine deficiency. Amiodaroneinduced thyrotoxicosis ait develops in 3% of amiodaronetreated patients in north america.
Type 1 ait is characterized by increased thyroid hormone synthesis due to iodine. Racgp evaluating and managing patients with thyrotoxicosis. Amiodarone is an iodinerich drug widely used for the management of various cardiac arrhythmias and severe congestive heart failure. Amiodaroneinduced thyrotoxicosis ait is a clinical condition that is notoriously difficult to manage. Members of the european thyroid association eta with clinical interests were asked to answer a questionnaire on the diagnosis and management.
Evaluation of 99mtcmibi in thyroid gland imaging for the diagnosis of amiodarone induced thyrotoxicosis. To describe the case of a man who developed amiodarone induced thyrotoxicosis ait after a total thyroidectomy for metastatic follicular thyroid cancer because of the effect of the drug on metastasis. We examined whether continuing amiodarone or differentiating ait into 2 subtypes affected outcome. Patients treated with amiodarone may manifest altered thyroid hormone profile without thyroid dysfunction, or they may present with clinically significant amiodarone induced hypothyroidism or amiodarone induced thyrotoxicosis.
Despite the easy management of amiodaroneinduced hypothyroidism, the. Since amiodarone was first marketed in 1992 in japan, the incidence of amiodarone induced thyrotoxicosis ait has been increasing. Amiodaroneinduced hyperthyroidism endocrinology jama. Amiodarone toxicity occurs in about 23% of patients. The researchers performed this study to compare the risk of antithyroid drugassociated agranulocytosis in amiodarone induced thyrotoxicosis patients with those who had thyrotoxicosis from other causes. This increase in iodine delivery and uptake can increase thyroid hormone production and release. Associated with worsening cardiac arrhythmia with recurrence of atrial fibrillation and palpitations ncbi amiodarone induced thyrotoxicosis may occur suddenly in patients treated with amiodarone for several years, likely due to its long half life, lipid solubility and accumulation in almost all tissue. Amiodaroneinduced thyrotoxicosis and thyroid cancer. Methods and results the type and duration of antithyroid treatment and response were recorded in a consecutive series of 28 cases.
Amiodarone induced thyrotoxicosis ait is caused by amiodarone as a side effect of cardiovascular disease treatment. Background amiodarone induced thyrotoxicosis ait is a difficult management problem about which there are little published data. Patients should have their thyroid function tested prior to starting amiodarone. Amiodarone can lead to both hypothyroidism amiodarone induced hypothyroidism and less commonly hyperthyroidism amiodarone induced thyrotoxicosis and relates to high iodine content within the molecule as well as to several unique intrinsic properties of amiodarone. To the best of our knowledge this is the first reported case of this condition. Lithium treatment in amiodaroneinduced thyrotoxicosis. Type 2 ait is a result of amiodarone causing a subacute thyroiditis with release of preformed thyroid hormones into the circulation. Methimazole mmi and potassium perchlorate kclo 4 is the treatment of choice for the former, whereas corticosteroids are used for the latter. Ptu for the treatment of amiodaroneinduced thyrotoxicosis. Mar 18, 2020 the major clinical features of the patient were weight loss and deterioration of the underlying cardiovascular symptoms, which are again characteristic of amiodarone induced thyrotoxicosis ait. Thyroid unit and department of medicine, massachusetts general hospital. Treatment of amiodaroneassociated thyrotoxicosis medscape. Amiodarone, a benzofuranic iodinerich antiarrhythmic drug, causes thyroid dysfunction in 1520% of cases. Diagnosis and management of thyrotoxicosis the bmj.
Oct 08, 2018 however, a metaanalysis suggested that with the lower doses of amiodarone 150330 mg incidence of thyroid dysfunction is 3. We examined whether continuing amiodarone or differentiating ait into 2 subtypes. Thyrotoxicosis is a relatively uncommon complication of amiodarone treatment found in 10% to 12% of patients residing in iodinedeficient areas1, 2 and with an approximately 3% incidence in the united states. We report a case of a man who underwent a total thyroidectomy for metastatic follicular thyroid cancer who required amiodarone. Amiodarone induced thyrotoxicosis ait is well recognized and is generally believed to be due to the excess iodine released from the metabolism of the drug, although amiodarone associated. Amiodaroneinduced thyrotoxicosis with cardiopulmonary. Although most patients remain clinically euthyroid, a significant minority up to 15% of patients in the uk and the usa develop amiodarone induced hypothyroidism or thyrotoxicosis. Amiodarone induced thyrotoxicosis ait is a clinical condition fraught with difficulties and uncertainties both from the diagnostic and therapeutic standpoints. Thyroiditis is a condition that may be suitable for management in the general practice setting.
Amiodarone is a heavily iodinated drug used commonly in several forms of arrhythmias. Hyperthyroidism is an excessive concentration of thyroid hormones. However, mixed forms appear frequently and it is not easy to prescribe corticosteroids because of side effects. Reintroduction of amiodarone in patients with a history of amiodarone induced thyrotoxicosis ait is rarely used. Amiodarone induced thyrotoxicosis ait, may occur early after taking the drug, during usage for several years and even long time after withdrawl of the drug because it is stored in tissues and slowly released from them. Radioiodine ablation of the thyroid to allow the reintroduction of amiodarone treatment in patients with a prior history of amiodarone induced. The thyrotoxicosis is mediated by amiodarones iodine content. The former results from the inability of the thyroid to escape from the wolffchaikoff effect.
Amiodarone can cause hyperthyroidism and hypothyroidism. Amiodarone induced thyrotoxicosis thyroid disease manager. There are two main forms of amiodaroneinduced thyrotoxicosis ait. Full paper evaluation of 99mtcmibi in thyroid gland imaging for the diagnosis of amiodarone induced thyrotoxicosis junqi wang and. A read is counted each time someone views a publication summary such as the title, abstract, and list of authors, clicks on a figure, or views or downloads the fulltext. He subsequently reverted to sinus rhythm and his medication was stopped 1 year prior to presentation. Amiodarone is an iodinebased, potent antiarrhythmic drug bearing a structural resemblance to thyroxine t4. Despite the potential risks of anaesthesia associated with uncontrolled thyrotoxicosis, thyroidectomy should be considered in the setting of life. Surgical management of amiodaroneinduced thyrotoxicosis. However, mixed forms appear frequently and it is not easy to.
Background amiodarone, an iodinerich medication used to treat abnormal heart rhythms, can result in thyrotoxicosis in 15% of patients. Both ait and aih may develop either in appar ently normal thyroid. Amiodarone, thyroid dysfunction, thyrotoxicosis, hypothyroidism. Amiodaroneinduced thyrotoxicosis develops in 3% of amiodarone treated patients. Available in pdf format for saving and printing and web page format for viewing online. Among 12 thyrotoxic patients, a patient with arrhythmogenic right. Newnham hh, topliss dj, le grand ba, chosich n, harper rw, stockigt jr. Algorithm for the management of amiodaroneinduced thyrotoxicosis ait.
Amiodarone induced thyrotoxicosis is a complex diagnostic and therapeutic challenge. Amiodarone can lead to both hypothyroidism amiodaroneinduced hypothyroidism and less commonly hyperthyroidism amiodaroneinduced thyrotoxicosis and relates to high iodine content within the molecule as well as to several unique intrinsic properties of amiodarone. Type 1 ait occurs in patients with underlying thyroid pathology such as autonomous nodular goiter or graves disease. Amiodarone induced thyrotoxicosis recurrence after amiodarone reintroduction. Although amiodaroneinduced hypothyroidism poses no particular problem, amiodaroneinduced thyrotoxicosis ait is a diagnostic and therapeutic challenge. Though much less common than hypothyroidism in iodine replete areas such as the uk and usa amiodarone induced thyrotoxicosis hereafter abbreviated to thyrotoxicosis is more complex and the diagnosis and treatment much more difficult. Based on the differences in their pathological and physiological mechanisms, many methods have been developed so far to differentiate ait subtypes such as colour flow doppler sonography cfds and 24h radioiodine uptake raiu. A 69yearold man presented with a 6week history of shortness of breath on exertion, unintentional weight loss, altered bowel habits and lethargy. Nov 29, 2006 amiodaroneinduced thyrotoxicosis ait develops in 3% of amiodaronetreated patients in north america. Amiodarone, thyroid dysfunction, thyrotoxicosis, hy. The mechanism for amiodaroneinduced hyperthyroidism and. Close liaison with a cardiologist is recommended to best manage these patients. A unique underlying pathophysiology discerns one type from another, which is why early.
Proportion of type 1 and type 2 amiodarone induced thyrotoxicosis has changed over a 27year period in italy. Amiodarone, a widely used antiarrhythmic drug, is known to cause thyroid dysfunction, such as amiodarone induced thyrotoxicosis ait and amiodarone induced hypothyroidism aih through its pharmacological and toxic actions 1, 2. In this study we aimed to assess amiodarone s effects on thyroid hormones, c reactive protein crp, interleukin 6 il6 and tumor necrosis factor tnf. Thyroid dysfunction is an important sideeffect of amiodarone therapy. However, thyroid tissue is needed in order to develop thyrotoxicosis. Amiodarone induced thyrotoxicosis can occur in either of two forms, type 1 or type 2, depending on whether there was a positive history of thyroid dysfunction prior to the use of amiodarone therapy or not, respectively. Gross appearance of the thyroid showing homogeneous, beefyred, richincolloid thyroid parenchyma a and 2 welldemarcated, light yellow nodules arrowsb.
Background amiodaroneinduced thyrotoxicosis is a condition that is dif. Clinical course and predictors of outcome david conen, ludovic melly, christoph kaufmann, stefan bilz, peter ammann, beat schaer, christian sticherling, beat muller, stefan osswald this study evaluated the clinical course and predictors of longterm outcome in 84 patients with amiodarone induced thyrotoxicosis ait. Background amiodaroneinduced thyrotoxicosis ait is a difficult management problem about which there are little published data. Amiodarone induced thyrotoxicosis ait develops in 3% of amiodarone treated patients in north america.
Amiodarone induced thryrotoxicosis ait is a rare but serious complication of amiodarone use, especially in patients with severe cardiac disease. Diagnosis and treatment are closely linked, because the diagnostic problems may affect the therapeutic approach and lead to suboptimal treatment and delayed resolution of dysfunction. Amiodarone induced thyrotoxicosis ait is a complex therapeutic challenge. This is a condition called type i amiodarone induced thyrotoxicosis hyperthyroidism. Dronedarone is a recently approved antiarrhythmic drug. From the division of medical sciences, university of birmingham, birmingham, uk. Amiodaroneinduced thyroid dysfunction has been reported to affect 224% of users. Jun 29, 2002 siralthough amiodarone is viewed as a highly effective antiarrythmic agent, its use may lead to alterations in thyroid gland function, thyroid hormone metabolism, or both more than rarely. Amiodarone restart after amiodaroneinduced thyrotoxicosis. Amiodaroneinduced thyrotoxicosis is a condition that is difficult to manage, in particular because of the long halflife of amiodarone. Amiodaroneinduced toxic nodular goiter, a form of iodineinduced thyrotoxicosis, was described in europe where large nodular goiters are more prevalent than in the united states.
The incidence of type 2 amiodarone induced thyrotoxicosis ait is increasing. Amiodaroneinduced thyroid dysfunction in clinical practice. We present a patient who developed ait, following administration of amiodarone for lifethreatening ventricular arrhythmias. We discuss the medical management of ait and anesthetic considerations for management of patients with thyrotoxicosis and. Evaluation of 99mtcmibi in thyroid gland imaging for the. These adverse effects may occur in patients with or without preexisting thyroid disease. There are two distinct forms of amiodarone induced thyrotoxicosis ait. Amiodarone induced hyperthyroidism assessment of the predictive value of biochemical testing and response to combined therapy using propylthiouracil and potassium perchlorate. Amiodarone induced thyrotoxicosis ait is a clinically. Approach to the patient with amiodaroneinduced thyrotoxicosis.
It is known to produce thyroid abnormalities ranging from abnormal thyroid function testing to overt hypothyroidism or hyperthyroidism. Amiodarone induced toxic nodular goiter, a form of iodine induced thyrotoxicosis, was described in europe where large nodular goiters are more prevalent than in the united states. Management of severe amiodaroneinduced thyrotoxicosis after. For those living in iodinedepleted areas, the incidence is higher 10%. The time lag between initiation of amiodarone treatment. Pdf thyroidectomy for amiodarone induced thyrotoxicosis.
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