Table 6.
50 recommendations that form these guidelines
| Number | Recommendation | Strength and level of evidence |
|---|---|---|
| 1 | The measurement of TSH-R-Ab is a sensitive and specific tool for rapid and accurate diagnosis and differential diagnosis of Graves' hyperthyroidism | 1, ØØØØ |
| 2 | When technically available, differentiation of TSH-R-Ab functionality is helpful and predictive in Graves' patients during pregnancy/post-partum, as well as for extra-thyroidal manifestations | 2, ØØØO |
| 3 | US examination, comprising conventional grey scale analysis and color-flow or power Doppler examination is recommended as the imaging procedure to support the diagnosis of Graves' hyperthyroidism | 1, ØØØØ |
| 4 | Scintigraphy of the thyroid is suggested when thyroid nodularity coexists with hyperthyroidism, and prior to radioactive iodine therapy | 2, ØØØO |
| 5 | Patients with newly diagnosed Graves' hyperthyroidism should be treated with ATD. RAI therapy or thyroidectomy may be considered in patients who prefer this approach | 1, ØØØØ |
| 6 | MMI (CBZ) should be used in every non-pregnant patient who chooses ATD therapy for Graves' hyperthyroidism | 1, ØØØØ |
| 7 | MMI is administered for 12–18 months then discontinued if the TSH and TSH-R-Ab levels are normal | 1, ØØØØ |
| 8 | Measurement of TSH-R-Ab levels prior to stopping ATD therapy is recommended, as it aids in predicting which patients can be weaned from the medication, with normal levels indicating a greater chance of remission | 1, ØØØØ |
| 9 | Patients with persistently high TSH-R-Ab at 12–18 months can continue MMI therapy, repeating the TSH-R-Ab measurement an after additional 12 months, or opt for RAI or thyroidectomy | 1, ØØØO |
| 10 | Patients should be informed of potential side effects of ATD and the necessity of informing the physician promptly if they should develop jaundice, light-colored stools, dark urine, fever, pharyngitis, or cystitis | 1, ØØOO |
| 11 | In patients taking ATD, a differential white blood cell count should be obtained during febrile illness and/or pharyngitis, and liver function should be assessed in those who experience jaundice, light-colored stools, or dark urine | 1, ØØOO |
| 12 | Beta-adrenergic blockade is recommended in all suitable patients with Graves' hyperthyroidism | 1, ØØØØ |
| 13 | If a patient with GD becomes hyperthyroid after completing a first course of ATD, definitive treatment with RAI or thyroidectomy is recommended. Continued long-term low-dose MMI can be considered in patients not in remission who prefer this approach | 1, ØØØO |
| 14 | Treatment of SH is recommended in Graves' patients 7gt;65 years with serum TSH levels that are persistently <0.1 mIU/L | 1, ØØOO |
| 15 | ATD should be the first choice of treatment of Graves' SH | 1, ØØOO |
| 16 | A multimodality treatment approach to GD patients with thyroid storm should be used, including ATD therapy, glucocorticoid administration, beta-adrenergic blockade, cooling blankets, volume resuscitation, nutritional support, respiratory care, and monitoring in an intensive care unit | 1, ØØOO |
| 17 | There are no absolute indications for RAI therapy, but it is often recommended for patients with side-effects to, or recurrence after a course of ATD | 1, ØØOO |
| 18 | Verbal as well as written information on all aspects of efficacy and potential side-effects of RAI therapy should be provided | 1, ØØOO |
| 19 | If ATD are used before RAI therapy they should be paused around 1 week before and after therapy in order not to decrease the efficacy of RAI | 1, ØØØØ |
| 20 | No dose calculation can secure long-term euthyroidism and it is fully acceptable to offer a fixed dose of RAI | 1, ØØØO |
| 21 | Pregnancy and breast feeding constitute absolute contraindications to RAI therapy | 1, ØØØO |
| 22 | Conception should be postponed until at least 6 months after RAI in both males and females | 1, ØØØO |
| 23 | If used in children, ablative doses aiming at rapid hypothyroidism should be administered | 1, ØØOO |
| 24 | If surgery is selected, total thyroidectomy is the procedure of choice, and should be performed by a skilled surgeon with high annual volumes of thyroidectomies | 1, ØØØØ |
| 25 | Euthyroidism should be restored by ATD prior to surgery to avoid peri- or postoperative exacerbation of thyrotoxicosis | 1, ØØØØ |
| 26 | Vitamin D deficiency should be corrected to reduce the postoperative risk of hypocalcemia | 1, ØØØØ |
| 27 | A solution containing potassium iodide can be given for 10 days prior to surgery | 2, ØØØO |
| 28 | In patients with GO, hyperthyroidism should be promptly controlled by ATD, and euthyroidism stably maintained | 1, ØØØØ |
| 29 | Patients treated with RAI should receive steroid prophylaxis if mild and active GO preexists or there are risk factors for RAI-associated GO occurrence or progression | 1, ØØØØ |
| 30 | In patients with moderate-to-severe and active GO, treatment of GO should be the priority. Euthyroidism should be promptly restored with ATD and stably maintained | 1, ØØØØ |
| 31 | Patients with sight-threatening GO should be treated with ATD | 1, ØØOO |
| 32 | Treatment for hyperthyroidism in patients with inactive GO can be selected independently of GO | 1, ØØOO |
| 33 | Women with GD of reproductive age should be offered preconception counseling and be stably euthyroid before attempting pregnancy | 1, ØØOO |
| 34 | Women with GD should be instructed to immediately confirm pregnancy and contact their physician | 1, ØØØØ |
| 35 | Women treated with MMI should be switched to PTU when planning pregnancy and/or during the first trimester of pregnancy | 1, ØØØØ |
| 36 | All patients with a history of autoimmune thyroid disease should have their TSH-R-Ab serum levels measured at the first presentation of pregnancy using either a sensitive binding or a functional cell-based bioassay and, if they are elevated, again at 18–22 weeks of gestation | 1, ØØØØ |
| 37 | If the maternal TSH-R-Ab concentration remains high (>3 times the cut-off), monitoring of the fetus for thyroid dysfunction throughout pregnancy is recommended | 1, ØØØØ |
| 38 | During pregnancy the lowest possible dose of ATD should be given and the block-and-replace ATD regimen is discouraged | 1, ØØØØ |
| 39 | Maternal FT4 (TT4) and TSH should be measured every 2 weeks after initiation of therapy, and every 4 weeks after achieving the target value | 1, ØØOO |
| 40 | A change from PTU to MMI should be considered if ATD are required after 16 weeks gestation | 1, ØOOO |
| 41 | In women on a low dose of MMI (<5–10 mg/day) or PTU (<50–100 mg/day), ATD may be stopped during gestation prior to weeks 6–10 | 2, ØOOO |
| 42 | Lactating women with GD should be offered the same treatments as non-lactating women | 1, ØØOO |
| 43 | MMI is recommended during lactation, given the concerns about PTU-mediated hepatotoxicity | 1, ØØOO |
| 44 | Older patients who have had atrial fibrillation, cardiac failure, or cardiac ischemic symptoms precipitated by hyperthyroidism should undergo definitive therapy, usually RAI | 1, ØØØO |
| 45 | Long-term MMI (CBZ) should be considered as a satisfactory treatment for older individuals with mild GD | 2, ØOOO |
| 46 | PTU should be avoided in children and adolescents | 1, ØØØØ |
| 47 | Long-term MMI (CBZ) should be the mainstay of treatment in children with GD | 1, ØØØØO |
| 48 | Thyroidectomy is the primary definitive therapy in childhood, but in post-pubertal children RAI can be considered | 2, ØØOO |
| 49 | Graves' hyperthyroidism precipitated by an immunomodulatory therapy is not a mandatory indication to stop that precipitating treatment, nor is it a mandatory indication for definitive therapy for hyperthyroidism | 1, ØOOO |
| 50 | Sequential monitoring of serum TSH-R-Ab levels can be used to guide the duration of ATD therapy in patients with immune reconstitution GD | 2, ØOOO |