19
TMNG or TA
TMNG or TA
Table 10. Clinical Situations That Favor a Particular
Modality as Treatment for TMNG or TA
Clinical situations RAI ATD Surgery
Pregnancy
a
X
P ! A !
Advanced age, comorbities w/ increased
surgical risk and/or limited life expectancy
P A X
Patients with previously operated or
externally irradiated necks
P A !
Lack of access to a high-volume thyroid
surgeon
P A !
Symptoms or signs of compression within
the neck
A
–
P
yroid malignancy confirmed or suspected X – P
Large goiter / nodule A – P
Goiter/nodule with substernal or
retrosternal extension
A – P
Coexisting hyperparathyroidism requiring
surgery
– – P
P, preferred therapy; A, acceptable therapy; !, cautious use; –, not first line therapy but
may be acceptable depending on the clinical circumstances; X, contraindication.
a
For women considering a pregnancy within 6 months, see discussion under Pregnancy.
62. The ATA suggests that patients with overtly TMNG or TA be treated
with RAI therapy or thyroidectomy. On occasion, long-term, low-
dose treatment with MMI may be appropriate. (W-M)
RAI
63. Because RAI treatment of TMNG or TA can cause a transient
exacerbation of hyperthyroidism, β-adrenergic blockade should be
considered even in asymptomatic patients who are at increased
risk for complications due to worsening of hyperthyroidism — i.e.
elderly patients and patients with co-morbidities. (W-L)
64. In addition to β-adrenergic blockade (see Recs. 2 & 63)
pretreatment with MMI prior to RAI therapy for TMNG or TA
should be considered in patients who are at increased risk for
complications due to worsening of hyperthyroidism, including
the elderly and those with cardiovascular disease or severe
hyperthyroidism. (W-L)
