蒋宁一共识解读.ppt

1、131I治疗Graves甲亢专家共识,解读,中山大学孙逸仙纪念医院核医学科 蒋宁一,内容提要,共识形成的背景 共识导读要点 临床基础 疗效评价与随访 安全性评价 合并症处理原则 几个主要观点 131I治疗甲亢的目的 对甲减的认识 关于预处理问题,20101019,同时配发“编写说明”,中华核医学杂志2010，30（5）：346-351,2010年10月,参编专家,（按姓氏笔画排名） 丁 虹 王 铁 王 辉 石洪成 包建东 冯 珏 匡安仁 安 锐 李 林 李亚明 李思进 汪 静 张永学 陆汉魁 陈 启 林岩松 袁卫红 高再荣 蒋宁一 覃伟武 管 樑 谭 建 颜 兵 （共23位专家，18家单位）,

2、一、“共识”形成背景,我国131I治疗甲亢的现状： 1958年开始131I治疗甲亢，已有50余年历史 全国多数核医学科均已常规开展 积累了丰富的经验，有一定的影响 取得了一定的成绩，但存在许多的不足 科学在发展，观念在更新，需要进一步规范,中华医学会核医学分会普查结果,甲亢年治疗量超过万人次以上的省份有： 广东 25110， 四川 15526， 广西 12629， 湖北 11691， 吉林 10650，,甲亢年治疗量较多的单位有： 核工业416医院 8235 解放军321医院 5000 枝江市人民医院 3778 梅州市人民医院 3714 解放军303医院 3260 哈尔滨医大二院 3260,李

3、亚明教授提供,“共识”形成背景,目前存在的问题（131I治疗甲亢）,全国发展不平衡，存在地区差异； 临床路径（治疗方案）不规范（某些基层单位）； 有许多问题存在争议（甲减的认识）； 某些治疗环节与措施各地差距较大（治疗前用药）； 医患沟通内容偏差大（无统一模式）； 相关科普工作及兄弟学科交流不足。,“共识”形成背景,“共识”形成,在中华医学会核医学分会的指导下 由 20余位核医学专家经多次共同商讨，数易其稿，历时2年，就有关131I治疗Graves甲亢临床相关问题形成此“共识”。 “共识”立足甲状腺核医学，参考国内外多年来相关文献和临床应用情况，遵循先进性、实用性、公认性和时效性原则，重点阐述

4、131I治疗Graves甲亢相关问题。而对其他有关内容主要参考中国甲状腺疾病诊治指南（内分泌学会2007版）。,“共识”形成背景,“共识”目的： 集思广益 行业规范 指导临床 “解读”目的： 进一步广泛征求意见，修订为指南,“指南”,兄弟学科 本专业专家,共识,已经收到许多兄弟学科及本专业专家的建设性意见,“共识”主要内容,简要介绍： Graves甲亢的临床表现、实验室检查、甲亢危象处理和抗甲状腺药物治疗等内容。 重点介绍： 131I治疗Graves甲亢方法、疗效评价、随访和安全性及Graves甲亢合并症的处理。,二、“共识”解读要点,临床基础 疗效评价与随访 安全性评价 合并症处理原则,（一

5、）131I治疗Graves甲亢临床基础,1.主要参照中国甲状腺疾病诊治指南。 2. 在诊断标准中增加了甲状腺摄131I率增高，作为辅助条件之一。（与指南的区别） 摄131I率是决定能否使用和制定131I剂量的重要指标，同时也是治疗前基本检查项目之一。 临床表现为甲亢而不能诊断为Graves甲亢时应进行131I摄取试验。还可以评价治疗效果。,1.“共识”专家讨论意见 2. A practical method for the estimation of therapeutic activity in the treatment of Graves hyperthyroidism Q J Nucl

6、 Med Mol Imaging. 2010 Nov 11 3.影响131I 治疗甲状腺功能亢进疗效的因素。解放军医学杂志2003，28(2):180-181,3.关于适应证与禁忌证,适应证： Graves甲亢患者均适用131I治疗。 特别提出: 抗甲状腺药物疗效差或多次复发者; 病程较长或中老年患者; 对抗甲状腺药物过敏或出现其他不良反应; 甲亢合并肝功能损伤; 甲亢合并白细胞或血小板减少; 甲亢合并心脏病; 其他特殊类型甲亢 。,适应证解读,比较内分泌指南及核医学以往规范等 特点：1.不提相对适应证。 2.不设限：如年龄限制、突眼限制、甲状腺肿大程度限制、甲亢病情的限制等。 目的：开放患者

7、与医生的选择范围。 理念：ATD、131I和手术治疗都是有效方法，在医患沟通的前提下，都可以选择，不需要对某种方法设限。,近期N Engl J Med 2011;364:542-50，及多篇相关报道 即将发表的ATA-AACE指南，及1993ATA指南均没有明确提出适应证具体细则，而共同表达了以上观点。,Radioiodine Therapy for Hyperthyroidism Douglas S. Ross, M.D. N Engl J Med 2011;364:542-50 A 37-year-old woman presented with palpitations, tremulo

8、usness, shortness of breath, and a 9-kg (20-lb) weight loss, and received a diagnosis of Graves hyperthyroidism. At the time of diagnosis, she had mild proptosis, no diplopia, and no signs of eye inflammation. Her thyroid gland was two times the normal size and nonnodular. Her initial serum triiodot

9、hyronine (T3) concentration was 655 ng per deciliter (9.2 nmol per liter), and her free thyroxine (T4) concentration was 5.7 ng per deciliter (73 pmol per liter). She was treated with methimazole for a year, and her thyroid tests became normal. She discontinued the methimazole 10 weeks before the cu

10、rrent presentation with recurrent palpitations and tremulousness. Her serum T3 concentration is 345 ng per deciliter (5.4 nmol per liter), and her free T4 concentration is 2.8 ng per deciliter (36.0 pmol per liter). The patient does not smoke. She has a 3-year-old daughter and wishes to become pregn

11、ant again. Her endocrinologist recommends radioiodine ablation of her thyroid.,泛指Graves甲亢患者均可选用131I治疗,禁忌证问题,妊娠和哺乳期患者。 与内分泌指南及核医学规范基本一致。 近来国外学者提出：合并或怀疑甲状腺癌； 不能遵循放射安全指引的患者； 计划在4-6月内怀孕的女性患者。 （以上情况，可以灵活处理，不是绝对禁忌证） 原规范有：急性心梗及严重肾功能障碍， “共识”没有表达。 理由：没有大量文献支撑；临床上实施标准难掌握,界定模糊。,（二）治疗前诊断,特指在使用131I治疗前，意在规范； 提出了基

12、本检查项目与针对性检查项目。 基本项目中提出摄131I率和核素显像与B超； 专家强烈推荐 理由：排除非Graves甲亢；了解有无结节及结节功能；提供制定131I治疗剂量依据。 针对性项目，不作强求，因人而定； 其他：特殊检查类，如育龄妇女要注意排除孕娠。,（三）治疗剂量,介绍3种剂量法，不具体推荐，适宜选择； 提出剂量调整因素： 4点减少剂量的因素； 5点增加剂量的因素。,在我国，计算法是目前是最常用的方法，符合个体化治疗。 半固定剂量法和固定剂量法，方法简单，个别医院使用。 无论是使用哪种方法，均会发生治疗后甲减，使用固定剂量法，甲减的发生几率高于其他方法。,减少131I剂量降低了甲亢治愈率

13、,N=443,P0.0001,患者治愈比例（%）,Amit Allahabadia, et al. Radioiodine Treatment of HyperthyroidismPrognostic Factors for Outcome. J. Clin. Endocrinol. Metab. 2001 86: 3611-3617.,单一固定剂量131I(185MBq,370MBq)治疗甲亢，1年内患者转归,N=370,131I治疗的剂量,治愈率降低18%,注：131I治愈包括治疗为甲减及正常甲功者,同理：加大131I剂量提高了甲减发生率,Alexander EK, Larsen PR.

14、High dose of (131)I therapy for the treatment of hyperthyroidism caused by Graves disease.J Clin Endocrinol Metab 2002;87:1073-7,国外学者有主张个体剂量：一项随机对照研究认为，根据患者个体化准确计算的摄入量能达到更好的效果。,Eur J Clin Invest. 1995 Mar;25(3):186-93. Radioiodine therapy of Graves hyperthyroidism: standard vs. calculated 131iodine

15、activity. Results from a prospective, randomized, multicentre study. Peters H, Fischer C, Bogner U, Reiners C, Schleusener H. Abstract The present prospective, randomized, multicentre study was performed to directly compare for the first time the effectiveness of a standard activity of 555 MBq 131io

16、dine vs. an activity calculated to deliver 100 Gy for treatment of Graves thyrotoxicosis. Therapeutic success was defined as the elimination of hyperthyroidism 6 months after radioiodine application (range 4.5-8 months). A success rate of more than 90% in eliminating hyperthyroidism was reported for

17、 both approaches, but only in retrospective investigations. Investigated prospectively, hyperthyroidism was eliminated in only 71% of the patients receiving standard activity (70/98) and 58% of those randomized for calculated activity (62/107). In the patients with standard activity, therapeutic suc

18、cess was inversely related to thyroid size. The rate was 100% for thyroid volumes or = 75 mL. In those patients with an activity calculated to deliver 100 Gy (except in those with a volume or = 15 mL) this size/outcome dependency was almost compensated. The rates were 86%, 65%, 45%, 61%, 41% and 45%

19、, respectively. Furthermore, detailed statistical analysis revealed a strong correlation between the success of therapy and the radiation dose actually absorbed by the thyroid. The rate was 11% for a target dose of 50 Gy, 50% for 100 Gy, 67% for 150 Gy, 80% for 200 Gy, 84% for 250 Gy, 88% for 300 Gy

20、, 90% for 350 Gy and 93% for 400 Gy.,也有学者主张采用相对固定剂量法，认为固定剂量与计算剂量效果一样 1.Leslie, W.D,(2003) A randomized comparison of radioiodine doses in Graves hyperthyroidism. Journal of Clinical Endocrinology and Metabolism, 88, 978983.,（四）治疗前医患沟通要点,1.治疗前常规准备：停药、戒碘。 一般情况下嘱患者停服MMI27d,PTU24周,特殊情况需作针对性处理。 嘱患者禁食海带、紫

21、菜、深海鱼油、含碘复合维生素类等2周左右。 提出8点沟通要点。 要求签署知情同意书（文件）。 (患者教育内容，不在此展开),（五）治疗后特殊情况处理,1.重症Graves甲亢。可考虑先用抗甲状腺药物短程治疗,病情缓解后再行 治疗。也可在给予 后48 h加抗甲状腺药物短程治疗。采取住院治疗或密切随访。 2.甲亢危象. (参照中华医学会内分泌学分会中国甲状腺疾病诊治指南)。 3.甲减。 处理甲减的关键在于早发现,及时进行甲状腺激素替代治疗。,（六）疗效评价与随访,疗效评价分为 临床治愈、好转、无效、复发、甲减。 甲减可作为临床治愈的指标之一。 随访 轻中度Graves甲亢且无严重合并症者,可在治疗

22、后13个月内复诊,以初步评价疗效。治疗后6个月再复诊,如确定已临床治愈,随访间隔时间可延长,每年随访复查1次。 重复治疗： 再次 治疗,建议与初次治疗时间间隔36个月。,鉴于TSH受抑制的情况可能在治疗成功后继续存在，故治疗后数月内FT4和FT3的监测尤为重要。 临床出现甲减症状，仅甲状腺激素水平低于正常范围,即使TSH仍处于受抑状态,应考虑早发甲减，及时替代治疗。,共识已有表达,特别指出,Uy HL, Reasner CA, Samuels MH. Pattern of recovery of the hypothalamic-pituitary-thyroid axis following

23、 radioactive iodine therapy in patients with Gravesdisease. Am J Med 1995;99:173-9.,（七）安全性评价,131I治疗Graves甲亢 不影响生育能力； 不会导致遗传损害； 不会增加甲状腺癌、白血病及其他癌症的发病率； 儿童和青少年其生育能力和后代生长情况与普通人群比较无明显差别。,131I治疗甲亢安全性良好恶性肿瘤总发病率低于普通人群,恶性肿瘤标化发病率（SIR）,注：SIR, Standardised Incidence Ratio，标化发病率,P=0.0001,Jayne A Franklyn, et al.

24、 Cancer incidence and mortality after radioiodine treatment for hyperthyroidism: a population-based cohort study. Lancet 1999; 353: 211115.,7417例应用131I治疗的甲亢患者（72073人*年随访）,131I治疗甲亢安全性良好恶性肿瘤死亡率与普通人群无异,标化恶性肿瘤死亡率（SMR ）,注：SMR（ Standardized cancer mortality ratios），标化恶性肿瘤死亡率,回顾性研究，35593例甲亢患者，分别接受131I、手术、抗

25、甲状腺药物治疗。其中65%的患者接受131I治疗。评估这些甲亢患者尤其是应用131I治疗后的癌症死亡率。,Elaine Ron, et al. Cancer Mortality Following Treatment for Adult Hyperthyroidism. JAMA, 1998,280(4):347-355.,Graves甲亢合并症的处理,1、甲亢性心脏病 进行一定的预处理：如减慢心率、控制心衰、改善心功能、控制血压等。 治疗目标：直接选择甲减。 建议131I 治疗时宜加强心脏动态监控,住院密切观察。 推荐：甲亢性心脏病确诊后,宜尽早采取 一次性决定性治疗。（一次到位：甲减）,治

26、疗转归,多数甲亢性心脏病患者经131I治疗，甲状腺功能正常后，其心脏功能完全或部分恢复正常； 如甲亢性心脏病病程长、甲状腺肿大明显者，131I缓解甲亢性心脏病的疗效较差。,强调131I治疗后终生随诊的重要！及时纠正甲减！,研究报道：并发有甲状腺功能亢进性心脏病的患者应用放射碘治疗作为单一方案治疗后并不使心脏症状加重。,Thyrocardiac Disease and Its Management with Radioactive Iodine I131 Clement Delit;Solomon Silver;Stephen B. Yohalem;Robert L. Segal. Abstra

27、ct Hyperthyroidism was treated with I131 in 1,603 cases. These included cases of diffuse toxic goiter and nodular goiter with hyperthyroidism. There were 187 patients with congestive heart failure, 30 with angina pectoris, and 32 with combined angina pectoris and congestive failure. In addition, the

28、re were 107 patients with atrial fibrillation but without congestive failure or angina. Radioiodine was the only treatment used for the hyperthyroid state. The cardiac status was strikingly improved in all groups studied. The number of treatments and incidence of myxedema was almost the same for the

29、 cardiac and noncardiac patients. The total administered dose averaged 7.0 millicuries for the entire series and 11.5 for the cardiac patients. The recurrence rate was less than 1%. The authors believe that I131 is the treatment choice for thyrocardiac disease.,2、甲亢合并肝功能损害,治疗原则：及时有效地控制甲亢,同时辅以保肝治疗。 确

30、诊甲亢伴肝损害时,应首选一次临床治愈或甲减。 即使是肝损害严重者,在加强护肝保肝、拮抗应激、抑制免疫的同时,仍可考虑用 治疗。 经治疗后,绝大多数Graves甲亢肝损害在甲状腺激素水平恢复正常后肝功能可逐渐恢复。,3、甲亢合并白细胞、粒细胞或血小板减少,治疗Graves甲亢所用的131I剂量水平不会导致白细胞、粒细胞或血小板减少； 应积极进行131I 治疗,同时给予对症、支持 、升白细胞药物治疗,定期检查血常规; 建议血液科医生会诊,联合制定治疗方案; 甲亢合并血白细胞、粒细胞或血小板减少及粒细胞缺乏症者采用 治疗明显优于抗甲状腺药物或手术治疗 。 黄勤,邹大进,潘文舟. 治疗伴白细胞减少Gr

31、aves病的临床观察. 中华内分泌代谢杂志, 2006, 16: 184-185.,4、甲状腺相关眼病,甲亢伴GO患者是否采用131I治疗？ 学术界一直存在争议。 大量文献报道：可以采用131I治疗。强烈推荐接受糖皮质激素联合治疗。 内分泌指南： 轻度、稳定期的中-重度单独应用131I ； 进展期加用泼尼松。(我们认同此观点),131I治疗法对GO的影响,131I治疗法是甲状腺眼病的高危因素之一。 GO明确的危险因素包括甲亢的131I治疗、吸烟、治疗前T3高水平、治疗前TRAb高水平和放射碘治疗后甲减。 （多篇文献报道） 2. 131I治疗后眼病的恶化往往是短暂的，可以采用糖皮质激素抵销。（

32、N Engl J Med. 1998 Jan 8;338(2):73-8.Relation between therapy for hyperthyroidism and the course of Graves ophthalmopathy.）,ATA316-317,甲亢治疗方法 例数 改善% 无变化% 恶化% 甲巯咪唑 148 2 95 3 131I 150 0 85 15 131I + 泼尼松 145 35 65 0,GO恶化率,Bartalena et al N Engl J Med 1989, 321:1349,戒烟很重要,在激素联合131I 治疗期间宜辅以指导患者饮食和生活习惯,尤

33、其告知患者戒烟。,Bartalena L, Baldeschi L, Dickinson A, et al. Consensus statement of the European Group on Graves orbitopathy(EUGOGO) on management of GO. Eur J Endocrinol, 2008, 158: 273-285.,2.Pinchera A 1998 Relation between therapy for hyperthyroidism and the course of Graves ophthalmopathy. N Engl J M

34、ed. 338:73-78 3.Thyroid-associated ophthalmopathy after treatment for Graves hyperthyroidism with antithyroid drugs or iodine-131. J Clin Endocrinol Metab 2009;94:3700-7,一项大型的随机对照研究显示放射碘治疗GD与GO进展的风险升高相关（与ATDs相比RR=5.8），且这种风险能够被糖皮质激素联合治疗抵销2 。,研究提示主动吸烟者接受放射碘治疗后1年随访中GO发生或恶化的发生率最高(23-40%) 2,多项研究都一致认为：吸烟对

35、放射碘治疗患者GO存在有害的影响。这种风险是与每日吸烟数量成比例的，既往吸烟患者的风险仍明显低于目前吸烟患者,1.Pfeilschifter J, Ziegler R 1996 Smoking and endocrine ophthalmopathy: impact of smoking severity and current vs lifetime cigarette consumption. Clin Endocrinol (Oxf). 45:477-481,文献报道,131I治疗加重突眼病情在吸烟者中更明显3,高度关注甲减,众多研究表明治疗后出现的持续、未处理的甲状腺功能减退症是GO进

36、展的有害因素。 131I治疗后早期使用左旋甲状腺素预防甲减发生（血清甲状腺激素正常后即给予），这类患者GO极少出现恶化(0%-2%)。,Tallstedt L, Lundell G, Blomgren H, Bring J 1994 Does early administration of thyroxine reduce the development of Graves ophthalmopathy after radioiodine treatment? Eur J Endocrinol. 130:494-497.,Perros P, Kendall-Taylor P, Neoh C,

37、Frewin S, Dickinson J 2005 A prospective study of the effects of radioiodine therapy for hyperthyroidism in patients with minimally active graves ophthalmopathy. J Clin Endocrinol Metab. 90:5321-5323.,三、几个主要观点,(一)131I治疗甲亢的目的,尽早治愈甲亢（甲减或甲功正常）、缩短甲亢持续时间而不是避免甲减的发生，已成为公认的131I治疗目标要求。,Saara Metso, et al. Lo

38、ng-term follow-up study of radioiodine treatment of Hyperthyroidism. Clinical Endocrinology (2004) 61, 641648. Joyce Sy, et al. Usage of a fixed dose of radioactive iodine for the treatment of hyperthyroidism: one-year outcome in a regional hospital in Hong Kong. Hong Kong Med J 2009;15:267-73. Robe

39、rt A, et al. Optimal iodine-131 dose for eliminating hyperthyroidism in Graves disease. J Nucl Med 1991,32:411-416.,大剂量131I比小剂量131I治疗能更快实现甲亢治愈，从而降低甲亢相关的死亡率。131I治疗是安全的，但是大多数患者会发生治疗后甲减，需要个体化剂量的甲状腺激素终生替代治疗。这种疗法既解决了甲亢的治疗问题，也最大限度降低了甲减相关性疾病发生率6 美国内分泌医师学会（AACE）甲亢及甲减临床指南,甲亢不及时治愈可导致诸多并发症,1. 放射性碘（131I）治疗Grave

40、s甲亢专家共识讨论稿 2.Luo Y，Jiang DYChanges in seFum interleukin-6 and high-sensitivity C-reactive protein levels in patients with acute coronary syndeome and their responses to sivastatinJHeart Vessels，2004，19(6)：257-262 3.WghgarrdenCecil Textbook of MedicineM19th edit1992：1257 4 叶任高内科学第5版北京：人民卫生出版社，2002：61

41、8，738,甲亢并发症严重危害患者健康,131I治疗甲亢疗效好,P0.01,发生率（%）,治愈时间（月）,Chen DY, et al. Comparison of the long-term efficacy of low dose 131I versus antithyroid drugs in the treatment of hyperthyroidism. Nucl Med Commun. 2009 Feb;30(2):160-8.,前瞻性、随机研究，纳入2021例甲亢患者，分别接受抗甲状腺药物或131I治疗，平均随访98个月。,*,*,*,#,131I治疗甲亢疗效显著,131I治疗

42、甲亢治愈时间快,*P=0.000 #P=0.001,(二)对甲减的认识,甲减是131I治疗的必然转归之一，不是副作用，不是并发症，更不是医疗事故。 “核医学和内分泌专家都一致认为，甲减是131I治疗甲亢难以避免的结果，选择131I治疗主要是要权衡甲亢与甲减后果的利弊关系。 中华医学会内分泌学会中国甲状腺疾病诊治指南，2007，4,几个主要观点,过去认为：甲减是131I治疗的并发症或副作用等。 现在观点：甲减是治疗的一种转归或是期望的结局。,131I治疗甲亢后甲减发生率高，早发晚发有所不同,1.131I治疗Graves甲亢专家共识 2.Aftab M Ahmad, et al. Objectiv

43、e estimates of the probability of developing hypothyroidism following radioactive iodine treatment of Thyrotoxicosis. European Journal of Endocrinology (2002) 146 767775. 3.131I治疗甲状腺功能亢进症远期观察。中华核医学杂志，1984，4：7-11,国外资料,国内资料,晚发甲减发生率与131I治疗剂量无关,晚期甲减发生率（%）,Leslie, W.D,(2003) A randomized comparison of ra

44、dioiodine doses in Graves hyperthyroidism. Journal of Clinical Endocrinology and Metabolism, 88, 978983.,低固定剂量：235 MBq 高固定剂量：350 MBq 低调节剂量：2.96 MBq (80Ci)/g 甲状腺，经24h131I摄取率调节 高调节剂量：4.44 MBq(120Ci)/g 甲状腺，经24h131I摄取率调节,相比甲亢甲减的治疗更容易，危害程度更轻,陈汉华. 131 碘治疗甲状腺功能亢进症7170例疗效总结.柳州医学.2008 年第21 卷第3 期 廖学权等.甲状腺功能减退

45、症的内分泌治疗.中国医药导报. 2010 年5 月第7 卷第13 期 郭根武等. 碘-131治疗甲状腺功能亢进症治疗效果分析. 中国辐射卫生,2009,18(3),优甲乐,支持放射性碘治疗甲亢导致甲减,Thyroid Function and Mortality in Patients Treated for Hyperthyroidism Jayne A. Franklyn, Michael C. Sheppard, Patrick Maisonneuve JAMA. 2005 Jul 6;294(1):71-80 RESULTS: In 15,968 person-years of fol

46、low-up, 554 died vs 487 expected deaths (standardized mortality ratio SMR, 1.14; 95% confidence interval CI, 1.04-1.24, P=.002). Increased risks of all-cause and circulatory deaths vs age- and period-specific mortality were observed in follow-up in those not requiring, or prior to, T(4) therapy. The

47、se increased risks were not observed during follow-up on T(4) therapy (circulatory disease SMR prior to T(4), 1.33; 95% CI, 1.14-1.53 vs SMR, 0.91; 95% CI, 0.70-1.17 during T(4). Patients receiving T(4) had decreased risk of mortality vs risk in the period not requiring, or prior to, T(4) therapy (a

48、ll-cause mortality hazard ratio HR, 0.65; 95% CI, 0.54-0.79; circulatory mortality HR, 0.65; 95% CI, 0.48-0.87). Increased all-cause mortality vs the background population was observed in the period prior to T(4) therapy in follow-up associated with low, normal, and high serum thyrotropin. The SMR f

49、or ischemic heart disease increased slightly when analyzed by serum thyrotropin, high serum thyrotropin being the highest SMR (low thyrotropin SMR, 1.06; 95% CI, 0.75-1.45; normal thyrotropin SMR, 1.17; 95% CI, 0.76-1.71; high thyrotropin SMR, 1.48; 95% CI, 0.86-2.37). Comparison within the cohort s

50、howed that mild hypothyroidism prior to T(4) therapy was associated with increased risk of mortality from ischemic heart disease vs biochemical euthyroidism (HR, 2.08; 95% CI, 1.04-4.19). CONCLUSIONS: Patients treated with radioiodine for hyperthyroidism had increased mortality vs age- and period-sp

51、ecific mortality in England and Wales, a finding no longer evident during T(4) therapy. This supports treating hyperthyroidism with doses of radioiodine sufficient to induce overt hypothyroidism. The association within the cohort of mortality from ischemic heart disease with subclinical hypothyroidi

52、sm suggests T(4) replacement should be considered should this biochemical abnormality develop after radioiodine therapy.,结果认为放射性碘治疗后甲减接受T4治疗的患者死亡率与背景人群相似。,131I治疗GD出现甲减，替代治疗对存活无影响。,甲减的替代治疗是安全、简便的。,但在内科学界尚不能完全接受此观点，有些内科医生经常“告诫”患者，“不要接受131I治疗，甲减比甲亢更难治”等。在有关131I治疗后甲减引起的医疗纠纷中，有些就是因为内科医生的“忠告”而引发的。 希望继续沟通，

53、达成共识。,(三)关于预治疗,对甲亢伴有并发症患者，建议将并发症控制在相对稳定时，采用131I治疗； 对重症甲亢，可考虑先用抗甲状腺药物短程治疗，病情缓解后再行131I治疗；（指严重高代谢症状，而不包含严重并发症“高危”患者） 对一般适应证患者，没有提及或强调在131I治疗前需要预治疗。,几个主要观点,“共识”,一般情况下，131I治疗前停服MMI27d, PTU 24周。,Effects of antithyroid drugs on radioiodine treatment: systematic review and meta-analysis of randomised contro

54、lled trials. Walter MA,et al. BMJ. 2007 Mar 10;334(7592):514 Abstract OBJECTIVE: To determine the effect of adjunctive antithyroid drugs on the risk of treatment failure, hypothyroidism, and adverse events after radioiodine treatment. DESIGN: Meta-analysis. DATA SOURCES: Electronic databases (Cochra

55、ne central register of controlled trials, Medline, Embase) searched to August 2006 and contact with experts. Review methods Three reviewers independently assessed trial eligibility and quality. Pooled relative risks for treatment failure and hypothyroidism after radioiodine treatment with and withou

56、t adjunctive antithyroid drugs were calculated with a random effects model. RESULTS: We identified 14 relevant randomised controlled trials with a total of 1306 participants. Adjunctive antithyroid medication was associated with an increased risk of treatment failure (relative risk 1.28, 95% confide

57、nce interval 1.07 to 1.52; P=0.006) and a reduced risk for hypothyroidism (0.68, 0.53 to 0.87; P=0.006) after radioiodine treatment. We found no difference in summary estimates for the different antithyroid drugs or for whether antithyroid drugs were given before or after radioiodine treatment. CONC

58、LUSIONS: Antithyroid drugs potentially increase rates of failure and reduce rates of hypothyroidism if they are given in the week before or after radioiodine treatment, respectively.,Pretreatment with propylthiouracil but not methimazole reduces the therapeutic efficacy of iodine-131 in hyperthyroid

59、ism. Imseis RE, Vanmiddlesworth L, Massie JD, Bush AJ, Vanmiddlesworth NR. J Clin Endocrinol Metab. 1998 Feb;83(2):685-7 Abstract Ninety-three hyperthyroid patients were treated with 1 dose of iodine-131 (131I) during the past 10 years. Thirty-three were pretreated with propylthiouracil (PTU), 22 with methimazole (MMI), and 38 received no antithyroid drugs (ATD). ATD were discontinued 5-55 days before 131I therapy in three fourths of the cases and more than 4 months bef