Department of Endocrinology and Metabolism, Academic Medical Center, University of Amsterdam, Netherlands.
Endocrine Unit, CHU Saint-Pierre, Université Libre de Bruxelles, Brussels, Belgium.
Lancet Diabetes Endocrinol. 2023 Apr;11(4):282-298. doi: 10.1016/S2213-8587(23)00005-0. Epub 2023 Feb 24.
Hyperthyroidism is a common condition with a global prevalence of 0·2-1·3%. When clinical suspicion of hyperthyroidism arises, it should be confirmed by biochemical tests (eg, low TSH, high free thyroxine [FT], or high free tri-iodothyonine [FT]). If hyperthyroidism is confirmed by biochemical tests, a nosological diagnosis should be done to find out which disease is causing the hyperthyroidism. Helpful tools are TSH-receptor antibodies, thyroid peroxidase antibodies, thyroid ultrasonography, and scintigraphy. Hyperthyroidism is mostly caused by Graves' hyperthyroidism (70%) or toxic nodular goitre (16%). Hyperthyroidism can also be caused by subacute granulomatous thyroiditis (3%) and drugs (9%) such as amiodarone, tyrosine kinase inhibitors, and immune checkpoint inhibitors. Disease-specific recommendations are given. Currently, Graves' hyperthyroidism is preferably treated with antithyroid drugs. However, recurrence of hyperthyroidism after a 12-18 month course of antithyroid drugs occurs in approximately 50% of patients. Being younger than 40 years, having FT concentrations that are 40 pmol/L or higher, having TSH-binding inhibitory immunoglobulins that are higher than 6 U/L, and having a goitre size that is equivalent to or larger than WHO grade 2 before the start of treatment with antithyroid drugs increase risk of recurrence. Long-term treatment with antithyroid drugs (ie, 5-10 years of treatment) is feasible and associated with fewer recurrences (15%) than short-term treatment (ie, 12-18 months of treatment). Toxic nodular goitre is mostly treated with radioiodine (I) or thyroidectomy and is rarely treated with radiofrequency ablation. Destructive thyrotoxicosis is usually mild and transient, requiring steroids only in severe cases. Specific attention is given to patients with hyperthyroidism who are pregnant, have COVID-19, or have other complications (eg, atrial fibrillation, thyrotoxic periodic paralysis, and thyroid storm). Hyperthyroidism is associated with increased mortality. Prognosis might be improved by rapid and sustained control of hyperthyroidism. Innovative new treatments are expected for Graves' disease, by targeting B cells or TSH receptors.
甲状腺功能亢进症是一种常见疾病，全球患病率为 0.2-1.3%。当临床怀疑甲状腺功能亢进症时，应通过生化检查（如 TSH 降低、游离甲状腺素 [FT] 升高或游离三碘甲状腺原氨酸 [FT] 升高）进行确认。如果生化检查证实甲状腺功能亢进症，应进行病因诊断以确定导致甲状腺功能亢进症的疾病。有用的工具包括促甲状腺激素受体抗体、甲状腺过氧化物酶抗体、甲状腺超声和闪烁扫描。甲状腺功能亢进症主要由格雷夫斯病（70%）或毒性结节性甲状腺肿（16%）引起。甲状腺功能亢进症也可由亚急性肉芽肿性甲状腺炎（3%）和药物（9%）引起，如胺碘酮、酪氨酸激酶抑制剂和免疫检查点抑制剂。本文给出了具体疾病的推荐治疗方法。目前，格雷夫斯病的甲状腺功能亢进症优选抗甲状腺药物治疗。然而，接受抗甲状腺药物治疗 12-18 个月后，约有 50%的患者会出现甲状腺功能亢进症复发。年龄小于 40 岁、FT 浓度为 40 pmol/L 或更高、TSH 结合抑制性免疫球蛋白高于 6 U/L、治疗前甲状腺肿大小相当于或大于世界卫生组织 2 级的患者，复发风险增加。长期（5-10 年）抗甲状腺药物治疗是可行的，与短期（12-18 个月）治疗相比，复发率更低（15%）。毒性结节性甲状腺肿主要采用放射性碘（I）或甲状腺切除术治疗，很少采用射频消融治疗。破坏性甲状腺毒症通常较轻且短暂，仅在严重病例中才需要使用类固醇。本文特别关注患有甲状腺功能亢进症的孕妇、COVID-19 患者或有其他并发症（如心房颤动、甲状腺毒性周期性瘫痪和甲状腺危象）的患者。甲状腺功能亢进症与死亡率增加有关。通过快速和持续控制甲状腺功能亢进症，可能改善预后。针对 B 细胞或 TSH 受体的新型治疗方法有望应用于格雷夫斯病。
