“Antithyroid drugs remain an important treatment for hyperthyroidism due to Graves’ disease (1). There are two main therapeutic protocols that are used; in the first scenario, antithyroid drugs are given for 12 to 18 months, and, if serum anti-TSH receptor antibody (TRAb) levels have normalized, the drug is discontinued and patients are monitored for recurrence. If antibodies persist, however, definitive treatment with radioiodine or surgery may be recommended (2,3), although continued antithyroid drug therapy is also reasonable in patients with well-controlled mild disease (2,3). In the second scenario, antithyroid drugs are given for as long as necessary, until TRAbs disappear. This could be for years or even for a lifetime (4,5).”
“In patients with Graves’ disease, remissions often occur after 4 to 11 years of antithyroid drug therapy. Some patients have resolution of TRAb within 2 to 5 years, while in others, TRAb levels fluctuate or remain positive for extended periods (>5 years). In this cohort, the odds of remission could not be predicted by baseline clinical or laboratory variables. In patients hoping to avoid ablative therapy, continuous antithyroid drug therapy for >5 years is reasonable.”
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Coconutty
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Thanks for posting this - my endo has someone on Tapazole for 11 years now, so this makes perfect sense to me. If one is not experiencing severe side effects- anti thyroid meds can keep serious procedures at bay and preserve thyroid.
Always looking for those on long term ATD therapy to chat with to learn more, and here's a study with patients followed from 8 - 36 years!!!
So much salient information. A very clear well written piece.
Articles like these provide guide posts for those going long into ATD therapy. Especially those without good or up-to-date doctors.
What's important, is to understand if you are a suitable candidate for long term ATD therapy. This is not something for everyone, simply because of the twists and turns in the disease course.
Still, this does hold out hope, that perhaps the numbers getting RAI or TT at 18-24 months, will become fewer as knowledge gains ground.
However, we with Graves, need to acknowledge the one very important fact about it - yes, you can finally go into remission, but this thing could rear its ugly head any time. And so yes, depending on circumstances, RAI or TT are options we can never rule out : (
Best thing to try and keep this disease in check, guard your health jealously, take up meditation, Tai chi, in general, bring down the tempo and pace at which your life flows, stress less, react less, change your perspective for a quieter, more peaceful life.
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1.antithyroid drugs are given for 12 to 18 months ... If antibodies persist,... continued antithyroid drug therapy is also reasonable in patients with well-controlled mild disease.
2.In the second scenario, antithyroid drugs are given for as long as necessary, until TRAbs disappear. This could be for years or even for a lifetime (4,5).
3.The aim of the current study was to describe long-term outcomes in 549 adult patients with Graves’ disease treated with antithyroid drugs for >8 years and
4.to relate remission and final outcomes to patterns of serum TRAb titers (6).
5.The patients were classified into four groups after follow-up:
1)Group A0 were TRAb-negative at the outset,
2)Group A2 became TRAb-negative within 2 years of methimazole treatment,
3)Group A5 became TRAb-negative after 2 to 5 years of treatment
3)(all combined into Group A),
4)and Group B, in whom TRAbs remained positive after >5 years of continuous treatment.
6.In Group A, following the disappearance of TRAb and normalization of other clinical parameters (e.g., goiter), antithyroid drug therapy was stopped. If patients remained euthyroid with normal thyroid function for >1 year, they were considered to be in remission.
7.However, in approximately 50% of Group A patients whose TRAb became negative, TRAb levels subsequently became positive again (Group 1A); in these patients (n = 226), whose TRAb course was called “fluctuating,” the rates of remission at the end of follow-up were significantly lower than in the group whose TRAb levels remained normal (n = 201) (37.2% vs. 88.9%, P<0.0001).
8.A third group of patients (n = 116, 21.1% of patients) had a “smoldering” course, with TRAb levels remaining positive during continuous antithyroid drug therapy for >5 years (Group B). However, even in this group, TRAb gradually declined and became negative after >5 years in 23 patients (19.8% of the “smoldering” group).
9.Overall, the time to remission for all groups combined was a median of 6.8 years
10.The cumulative fraction going into remission was 18.2% after 5 years, 38.3% after 10 years, 41.8% after 15 years, and 52.1% after 20 years.
Approximately 6% of patients became spontaneously hypothyroid over the >8-year follow up period.
11.Overall, about 20% of patients received ablative therapy (2.2% of those in Group 1, 28% of those in Group 1A, and 40.5% of those in Group B).
12.baseline factors predicting failure to remit were male sex and younger age, but the degree of thyroid dysfunction, thyroid volume, or TRAb levels were not predictive.
13.However, there were factors during antithyroid drug therapy that were predictive of failure to remit, including time to normalization of TRAb and persistence of a palpable goiter.
There was no difference in remission rates between patients treated with methimazole versus PTU or the dose of antithyroid drug employed.
14.In patients with Graves’ disease, remissions often occur after 4 to 11 years of antithyroid drug therapy.
Some patients have resolution of TRAb within 2 to 5 years, while in others, TRAb levels fluctuate or remain positive for extended periods (>5 years).
15.In this cohort, the odds of remission could not be predicted by baseline clinical or laboratory variables.
In patients hoping to avoid ablative therapy, continuous antithyroid drug therapy for >5 years is reasonable.
16.The article presents new information regarding patterns of disappearance of serum TRAb concentrations over time, which appear to have an impact on the probability of remission.
17.In selected patients (i.e., younger patients with mild stable disease on a low dose of MMI), long-term MMI is a reasonable alternative approach”
18.The present article confirms data from other series of adult (5) and pediatric (11) patients that show that remissions in Graves’ disease patients continue to be achieved after many years (>5–10) of continuous antithyroid drug therapy.
Therefore, in patients who wish to avoid permanent hypothyroidism or potential complications of ablative therapy, long-term antithyroid drug therapy is a viable option.
19.However, in older patients (e.g., those >60 years of age), definitive therapy should be more strongly considered at the time of initial diagnosis or if TRAb titers persist for more than 1 to 2 years of antithyroid drug therapy (3).
This is because the effects of persistent or recurrent hyperthyroidism that could develop are potentially life-threatening (e.g., atrial fibrillation or other adverse cardiovascular outcome (12)) or clinically significant (e.g., osteoporosis)
20.While it is true that older patients are more likely to achieve remission (7), the worry that remissions are not necessarily lifelong makes definitive treatment more reasonable (3).
21.However, in young and middle-aged patients, long-term therapy with methimazole may become a more widely accepted strategy, especially given recent data on the adverse effects of radioiodine therapy on quality of life (13).
22.Failure to attain normal TRAb levels after 12 to 18 months of methimazole therapy does not rule out the possibility of remission occurring over a longer time horizon of 5 to 10 years.
Even in patients with “smoldering” TRAb, about 20% became negative over prolonged follow-up.
I think we need to change the way we think about Graves’ disease. This obsession with remission that may never come for some people, and certainly won’t for many many in the current short timescales proffered. I can’t think of any other AI disease where doctors think like this. AI disease is a part of us forever whether we like it or not. We can attempt to control it with whatever interventions are needed in terms of medication, lifestyle, nutrition, diet etc. but ultimately we always have to be vigilant. So if I tolerate and remain stable on low doses of carbimazole then why the hell not stay on it? Doctors are eager enough to render me reliant on Levo for the rest of my life. Really what’s the difference? The only one as far as I can see is with the Carbimazole I will always have a little glimmer of hope, an outside chance of things normalising one day. I’ll take it. I’m lucky to not have issues with a goitre or nodules, I’m lucky I do respond to the meds (a little too well perhaps). I know not everyone is in that position, but I’d wager many more people are than are given the chance to try long term ATDs.
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