Q: 34 years old female is admitted to ICU from ED as an ophthalmologic emergency. Patient recently started on radioiodine treatment for her Grave's disease. What should be the next step of treatment?
Answer: Add glucocorticoids
In patients with Graves' disease, the commencement of therapy with radioiodine aggravates the orbitopathy, popularly known as exophthalmos. It can be sight-threatening. The treatment is the addition of glucocorticoids. Most clinicians start glucocorticoids prophylactically if there is any risk of such deterioration.
Radioiodine treatment is considered relatively contraindication in moderate to severe and/or sight-threatening exophthalmos. Interestingly, besides existing orbitopathy smoking is considered the greatest risk. Baseline high T3 level is also considered a risk for such deterioration.
If started, steroids need to be continued and tapered over 6-8 weeks.
1. Shiber S, Stiebel-Kalish H, Shimon I, et al. Glucocorticoid regimens for prevention of Graves' ophthalmopathy progression following radioiodine treatment: systematic review and meta-analysis. Thyroid 2014; 24:1515.
2. Lai A, Sassi L, Compri E, et al. Lower dose prednisone prevents radioiodine-associated exacerbation of initially mild or absent graves' orbitopathy: a retrospective cohort study. J Clin Endocrinol Metab 2010; 95:1333.
3. Vannucchi G, Covelli D, Campi I, et al. Prevention of Orbitopathy by Oral or Intravenous Steroid Prophylaxis in Short Duration Graves' Disease Patients Undergoing Radioiodine Ablation: A Prospective Randomized Control Trial Study. Thyroid 2019; 29:1828.
4. Hautzel H, Pisar E, Yazdan-Doust N, et al. Qualitative and quantitative impact of protective glucocorticoid therapy on the effective 131I half-life in radioiodine therapy for Graves disease. J Nucl Med 2010; 51:1917.