Lithium as an Alternative Option in Graves Thyrotoxicosis

I suspect quite a few people have questioned whether lithium could be used in Graves treatment. The answer, in this paper, appears to be yes.

The paper quotes a case in which lithium was used for a month. Obviously, longer treatment periods would tend to show more issues. Nonetheless, there is hope that it could be used at least when carbimazole (they use the very similar methimazole in the USA) and/or propylthiouracil are not tolerated.

Case Report

Lithium as an Alternative Option in Graves Thyrotoxicosis

Ishita Prakash, Eric Sixtus Nylen, and Sabyasachi Sen

Department of Medicine, Division of Endocrinology & Metabolism, Medical Faculty Associates, The George Washington University, Washington, DC, USA

Received 30 June 2015; Revised 25 August 2015; Accepted 26 August 2015

Academic Editor: Takeshi Usui

Copyright © 2015 Ishita Prakash et al. This is an open access article distributed under the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

Abstract

A 67-year-old woman was admitted with signs and symptoms of Graves thyrotoxicosis. Biochemistry results were as follows: TSH was undetectable; FT4 was >6.99 ng/dL (0.7–1.8); FT3 was 18 pg/mL (3–5); TSI was 658% (0–139). Thyroid uptake and scan showed diffusely increased tracer uptake in the thyroid gland. The patient was started on methimazole 40 mg BID, but her LFTs elevated precipitously with features of fulminant hepatitis. Methimazole was determined to be the cause and was stopped. After weighing pros and cons, lithium was initiated to treat her persistent thyrotoxicosis. Lithium 300 mg was given daily with a goal to maintain between 0.4 and 0.6. High dose Hydrocortisone and propranolol were also administered concomitantly. Free thyroid hormone levels decreased and the patient reached a biochemical and clinical euthyroid state in about 8 days. Though definitive RAI was planned, the patient has been maintained on lithium for more than a month to control her hyperthyroidism. Trial removal of lithium results in reemergence of thyrotoxicosis within 24 hours. Patient was maintained on low dose lithium treatment with lithium level just below therapeutic range which was sufficient to maintain euthyroid state for more than a month. There were no signs of lithium toxicity within this time period.

Conclusion. Lithium has a unique physiologic profile and can be used to treat thyrotoxicosis when thionamides cannot be used while awaiting elective radioablation. Lithium levels need to be monitored; however, levels even at subtherapeutic range may be sufficient to treat thyrotoxicosis.

Full paper freely available here:

hindawi.com/journals/crie/2...

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  • Here's a review on this topic which cautions that lithium can in some cases affect autoimmunity so has to be used with care:

    Open access journal:

    Spectrum of lithium induced thyroid abnormalities: a current perspective

    Davis Kibirige, Kenneth Luzinda and Richard Ssekitoleko

    Thyroid Research 2013, 6:3 doi:10.1186/1756-6614-6-3

  • Interesting, Helvella. Lithium can also cause liver problems so LFT and TFT have to be monitored while taking it.

  • So we see that carbimazole, propylthiouracil and lithium all:

    a) act as anti-thyroid agents;

    b) can cause liver problems.

    Anyone spot a trend emerging?

  • Helvella, Low thyroid, natural or drug induced, appears to affect liver. LFT was tested along with TSH and FT4 when I was originally tested. I certainly think patients on anti-thyroid drugs should have 4-6 weekly LFT and TFT, which were the norm when I was on Lithium.

  • Quite so. It strikes me as essential to look at liver function.

    Interesting that some while ago I posted about raised TSH having a direct effect on the liver... Which might be another direction to look in?

  • Helvella, well TSH is raised when thyroid levels are low, so it could be either?