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Describe the management of amiodarone-induced thyrotoxicosis

belongs to book: CLINICAL CASES IN ENDOCRINOLOGY|Pramila Kalra|| Chapter number:11| Question number:1.7

waelhammad

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2022-11-18

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Mr BK, a 55-year-old male has presented with chief complaints of generalized weakness of 2 months duration, weight loss of two months duration and intermittent palpitation for last 15 days. He is a known case of hypertension on treatment. He had an acute anterior wall myocardial infarction one year ago for which he had to undergo percutaneous transluminal coronary angioplasty. Postcoronary intervention patient developed ventricular tachycardia on three occasions (one in ICU and two times in the ward). For which, he was electroverted and was put on amiodarone (200 mg tablets three times a day since then). Current clinical examination reveals sinus tachycardia with heart rate of 110 per minute, blood pressure is 126/80 mm Hg. He has a grade-1 soft diffuse goiter. On evaluation, his routine hemogram with renal function and liver function tests are normal. His thyroid function test reveals serum T3 of 190 ng/dL (normal range, 80–200 ng/dL), serum T4 of 22 mg/dL (normal range 5.1–14.1 mg/dL) and serum TSH of 0.01 mIU/mL (normal range, 0.27–4.20 mIU/ mL). Serum anti-TPO antibody is within normal range.

Describe the management of amiodarone-induced thyrotoxicosis.

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waelhammad

2022-11-18

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Distinguishing between the two types of AIT is important because it has a major influence on subsequent management. Type 1 AIT: Therapy for type I AIT consists of withdrawal of amiodarone (if possible) with initiation of carbimazole or methimazole. Potassium perchlorate has been used as an adjunct in patients who are given CBZ (or MMI) to a maximum of 5 g/day. Potassium perchlorate reduces the intrathyroidal iodine stores because it decreases the entry of iodine into the thyroid and competitively inhibits thyroid iodine uptake (Basaria and Cooper, 2005). If AIT is associated with underlying Grave’s disease or multinodular goiter than definitive treatment with radioablation or surgery is indicated. Before doing radioablation, iodine uptake by thyroid has to be ascertained for a better outcome. Type-II AIT: Therapy for this type of AIT consists of possible stoppage of amiodarone with starting of oral prednisolone at 40–60 mg/day. Steroid needs to be tapered according to improvement of thyrotoxicosis. Nonspecific beta-blocker can be added for symptomatic improvement.

The patient in case 1 is started on methimazole 15 mg and is asked to follow up after 2 months. The amiodarone dose is continued as the cardiologist opined that it is not possible to reduce the dose of amiodarone at the moment.

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