Q:

Should all patients receive ATD prior to administration of radioiodine?

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A 30-year-old woman presents with complaints of palpitations, tremulousness and weight loss of around 4 kg (despite a good appetite) over the last 2 months. On examination, she is anxious, has a pulse rate of 100/min, warm and moist peripheries, fine tremors of the outstretched hands and a visible goiter. No obvious abnormalities in the eyes. Her last menstrual period was 15 days ago. Her primary care physician orders for laboratory examination which reveals normal hemogram with an erythrocyte sedimentation rate of 25 mm in the first hour. Thyroid stimulating hormone (TSH) <0.001 mIU/L and total T4 28 mg/dL. A diagnosis of thyrotoxicosis is made. She is started on beta-blockers and she is asked to get a technetium uptake scan and review.

Should all patients receive ATD prior to administration of radioiodine?

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Ans. Because RAI treatment of GD can cause a transient exacerbation of hyper-thyroidism, beta-adrenergic blockade should be considered even in asympto-matic patients who are at increased risk for complications due to worsening of hyperthyroidism (i.e. elderly patients and patients with comorbidities. Patients who are extremely symptomatic, elderly and with comorbidities that can worsen with increasing thyroid hormone levels and have free T4 levels 2–3 times upper limit of normal are usually candidates for pretreatment with methimazole. ATD should be stopped at least 3–5 days prior to radioiodine administration.

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