Thyroidectomy Superior to HRT in Euthyroid Patients With Hashimoto Disease

thyroid surgery
thyroid surgery
Compared with medical management alone, total thyroidectomy significantly improved the health of euthyroid patients with Hashimoto disease.

Compared with medical management alone, total thyroidectomy significantly improved the health of euthyroid patients with Hashimoto disease who continued to experience related symptoms, according to study results published in Annals of Internal Medicine.

The investigators of this randomized controlled study sought to compare outcomes of total thyroidectomy with medical therapy alone in patients with Hashimoto disease who have persistent symptoms despite having normal thyroid gland function from hormone replacement therapy.

The study included 147 adults with persistent Hashimoto-related symptoms with elevated serum antithyroid peroxidase (anti-TPO) antibody levels >1000 IU/mL despite having achieved clinical euthyroid status from adequate hormone substitution. Patients were randomly assigned to undergo total thyroidectomy with standard medical management (n = 73) or to receive medical management alone (n = 74). Both groups were followed for 18 months with visits scheduled every 3 months. The primary study outcome was general health score using the Short Form-36 Health Survey at 18 months; secondary outcomes were serum anti-TPO antibody titers measured at each visit, Short Form-36 Health Survey subscores, fatigue scores, and adverse events related to surgery.

At 18 months, only the surgical group showed improvement in general health scores, which increased from 38 to 64 points, while the control group had a slight decrease in scores for a between-group difference of 29 points (95% CI, 22-35 points). Fatigue scores in the surgical group decreased from an estimated mean total of 23 to 14 points. The control group scores remained essentially unchanged, leading to a mean difference of 9.3 points (95% CI, 7.4-11.2 points) between groups. The percentage of patients with chronic fatigue decreased from 82% to 35% in the surgical group for a difference of 39 percentage points (95% CI, 23-53) compared with the control group.

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From baseline to 18 months, median serum anti-TPO antibody values decreased significantly from 2232 to 152 IU/mL following surgery but were only modestly reduced in the control group (2052 to 1300 IU/mL) for a difference of 1148 IU/mL (95% CI, 1080-1304 IU/mL) between groups. Using multivariable regression modeling, the investigators found that the adjusted treatment effects were similar to unadjusted results.

In the surgery group, a total of 3 patients had postsurgical infections and 3 patients had longstanding hypocalcemia. There were also 4 cases of unilateral recurrent laryngeal nerve palsy, but all 4 improved spontaneously or with speech therapy.

Limitations to the study included its nonblinded trial design in which symptom relief was dependent on participants’ subjective reporting, and where surgery may have produced a strong placebo effect during the short follow-up period of 18 months. Finally, the study findings may only be applicable to a specific subgroup of patients with Hashimoto disease.

Overall, total thyroidectomy markedly improved the health of euthyroid patients with Hashimoto disease by eliminating serum anti-TPO antibodies and improving quality of life and fatigue symptoms; however, medical management of this population alone did not yield any significant improvement.

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Guldvog I, Reitsma LC, Johnsen L, et al. Thyroidectomy versus medical management for euthyroid patients with Hashimoto disease and persisting symptoms [published online March 12, 2019]. Ann Intern Med. doi:10.7326/M18-0284