Early Treatment for Hyperthyroidism Reduces CV Morbidity, Mortality in Graves Disease

Graves Disease
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Early and intensive treatment for hyperthyroidism in Graves disease is associated with improvements in cardiovascular morbidity and all-cause mortality, regardless of treatment method used.

Regardless of the method used, an early and intensive treatment approach to hyperthyroidism in Graves disease is associated with improvements in cardiovascular morbidity and all-cause mortality, according to study results published in The Lancet Diabetes & Endocrinology.

This retrospective cohort study was designed to assess initial therapy choices for patients with Graves disease by identifying associations between treatment method and long-term cardiovascular morbidity and all-cause mortality. From a cohort of patients diagnosed with hyperthyroidism between January 1998 and December 2013 in South Wales, United Kingdom, patients with Graves disease were identified using a thyroid-stimulating hormone (TSH) receptor antibody test register. Participants’ clinical data were linked to study outcomes using the All-Wales Secure Anonymised Information Linkage Databank. The study had no exclusion criteria, and participants were age- and sex-matched 1:4 to a control population within the same database.

Participants with Graves disease were grouped by primary treatment method: patients who received only antithyroid drugs, patients who received radioiodine with resolved hyperthyroidism (radioiodine group A), or patients who received radioiodine with unresolved hyperthyroidism group (radioiodine group B), with a landmark set for 1 year after diagnosis. Cox and Kaplan-Meier regression models were used to evaluate associations between treatment method and all-cause mortality and cardiovascular morbidity (heart failure, myocardial infarction, ischemic stroke, or death). In addition, Cox regression models were used to analyze associations between TSH concentration and outcomes, and cubic-spline regression models were used to analyze associations between free thyroxine concentration and outcomes.

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Patient-level data were extracted for 4189 patients with Graves disease (81.5% female) and 16,756 controls (81.5% female). The antithyroid drug group had 3587 participants, the radioiodine group A had 250 participants, and the radioiodine group B had 182 participants. Compared with controls, participants with Graves disease had increased all-cause mortality (hazard ratio [HR], 1.22; 95% CI, 1.05-1.42). Mortality was lower in radioiodine group A (HR, 0.50; 95% CI, 0.29-0.85) compared with the antithyroid drug group, but was higher in radioiodine group B (HR, 1.51; 95% CI, 0.96-2.37) compared with the antithyroid drug group. Regardless of treatment method, persistently low concentrations of TSH 1 year after diagnosis were associated with increased mortality (HR, 1.55; 95% CI, 1.08-2.24) and a positive nonlinear relationship was shown between free thyroxine concentrations at 1 year and all-cause mortality.

Study investigators concluded that “early and intensive control of hyperthyroidism in [Graves disease] is associated with improvements in long-term cardiovascular morbidity and all-cause mortality, regardless of the treatment method. Increased emphasis should be placed on ensuring prompt elimination of hyperthyroidism and maintenance of a normal thyroid status in the management of [Graves disease].”

Several authors declared affiliations with the pharmaceutical industry. Please refer to the original reference for a complete list of disclosures.

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Reference

Okosieme OE, Taylor PN, Evans C, et al. Primary therapy of Graves’ disease and cardiovascular morbidity and mortality: a linked-record cohort study [published online February 28, 2019]. Lancet Diabetes Endocrinol. doi:10.1016/S2213-8587(19)30059-2