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RADIOAKTIVNI JOD-131 ILI KIRURŠKI ZAHVAT U LIJEČENJU GRAVESOVE HIPERTIREOZE

RADIOIODINE VERSUS SURGERY IN THE TREATMENT OF GRAVES’ HYPERTHYROIDISM

TOMISLAV JUKIĆ, JOSIP STANIČIĆ, VLADO PETRIC, ZVONKO KUSIĆ

Deskriptori: Gravesova bolest – radioterapija, kirurgija; Radioizotopi joda – terapijska primjena, doziranje, nuspojave
Sažetak. Najčešći uzrok hipertireoze u djece i odraslih osoba je autoimunosna Gravesova (Basedowljeva) bolest. U liječenju Gravesove hipertireoze primjenjuju se više od 60 godina tireostatici, kirurški zahvat i radiojodna terapija. Najraširenija je primjena tireostatika. Međutim, remisija uz tireostatike može se očekivati u 20–50% odraslih osoba i 20–30% djece. Metode definitivnog liječenja Gravesove hipertireoze su jod-131 (radiojod) ili kirurški zahvat. Obje metode liječenja imaju prednosti i nedostatke, a odabir uglavnom ovisi o dobi, osobnom izboru, popratnim bolestima i drugim individualnim osobinama bolesnika, ali i dostupnosti pojedine metode liječenja. Radiojodna terapija je jednostavan, siguran, efikasan i ekonomičan postupak definitivnog liječenja Gravesove hipertireoze. Primjenjuje se ambulantno i može se primijeniti u bolesnika u hipertireozi. Zbog toga se u odraslih osoba s Gravesovom hipertireozom većinom preferira liječenje jodom-131, a vrlo malo bolesnika upućuje se na kirurški zahvat. Radiojod je osobito metoda izbora u starijih bolesnika i kardiopata u kojih je indiciran odmah nakon postizanja eutireoze tireostaticima. Kirurški zahvat uglavnom je indiciran u mlađih bolesnika, u slučaju individualnog izbora ili u posebnim indikacijama. Jasne indikacije za operativno liječenje Gravesove hipertireoze su: suspektni ili dokazani malignitet, koegzistirajuća patologija koja zahtijeva kirurški zahvat, trudnoća ili dojenje, velika guša (teža od 80 grama) ili guša sa simptomima i znakovima kompresije, teške toksične nuspojave na tireostatike, potreba brze kontrole bolesti, dob do 5 godina i aktivna oftalmopatija. Rizik od kirurškog liječenja obrnuto je proporcionalan s iskustvom operatera, a danas se preferira gotovo totalna odnosno totalna tireoidektomija. Konačni ishod obaju oblika liječenja često je hipotireoza koju ne treba smatrati posljedicom liječenja jer se nadomjesnom terapijom hormonima štitnjače postiže hormonski ekvilibrij.

Descriptors: Graves disease – radiotherapy, surgery; Iodine radioisotopes – therapeutic use, administration and dosage, adverse effects
Summary. The most common etiologic cause of thyrotoxicosis in children and adults is autoimmune Graves’ (Basedow’s) disease. Antithyroid medications, surgery and radioactive iodine have been used in the treatment of Graves’ hyperthyroidism for more than six decades. The use of antithyroid drugs is the most common therapeutic approach. However, long-term remission with antithyroid drugs can be expected in 20–50% of adults and 20–30% of children. The methods for definitive treatment of Graves’ hyperthyroidism are iodine-131 (radioiodine) and surgery. Both treatment modalities have benefits and risks and the decision is made according to the age, patient preference and the presence of other co-morbidities, individual characteristics of patients and the availability of certain treatment modality. Radioiodine is simple, safe, effective and economic procedure for definitive treatment of Graves’ hyperthyroidism. It is administered ambulatory and can be given to the patient in thyrotoxicosis. Due to many benefits, radioiodine is preferred in most of the adult patients with Graves’ hyperthyroidism while only small proportion of patients is sent to surgery. Radioidine is especially the treatment of choice in elderly patients and patients with heart disease. In these patients radioiodine is indicated immediately after reaching euthyroidism with antithyroid drugs. Surgery is mainly indicated in younger patients, in the case of patient preference or in special indications. Clear indications for surgical treatment of Graves’ hyperthyroidism are: suspected or confirmed malignancy, coexisting pathology that demands surgical treatment, pregnancy and breastfeeding, large goiter (> 80 grams) or goiter with symptoms and signs of compression, severe toxic side effects of antithyroid medications, requirement for immediate control of disease, age younger than 5 years and active ophtalmopathy. The risk of surgical treatment is negatively correlated with the surgeon’s experience and nowadays, total or near-total thyroidectomy is preferred surgical approach. End point of both treatment modalities is usually hypothyroidism that should not be considered as the consequence of treatment. Moreover, due to thyroid hormones replacement therapy equilibrium can be easily achieved.

Liječ Vjesn 2010;132:355–360