Amiodarone-induced thyrotoxicosis: Should surgery be considered? - 16/04/24

Doi : 10.1016/j.ando.2024.01.006

Samuel Frey ^a,^b, Cécile Caillard ^a, Pascale Mahot ^c, Delphine Drui ^c, Eric Mirallié ^a,^⁎
^a Nantes université, CHU de Nantes, chirurgie cancérologique, digestive et endocrinienne, institut des maladies de l’appareil digestif, 44000 Nantes, France
^b Institut du thorax, CHU de Nantes, CNRS, Nantes université, Inserm, 44000 Nantes, France
^c Service d’endocrinologie, diabétologie et nutrition, l’institut du thorax, Nantes université, CHU de Nantes, 44000 Nantes, France

^⁎Corresponding author: Chirurgie cancérologique, digestive et endocrinienne, institut des maladies de l’appareil digestif, centre hospitalier universitaire de Nantes, Hôtel Dieu, place Alexis-Ricordeau, 44093 Nantes, France.Chirurgie cancérologique, digestive et endocrinienne, institut des maladies de l’appareil digestif, centre hospitalier universitaire de Nantes, Hôtel Dieuplace Alexis-RicordeauNantes44093France

Highlights

•	Amiodarone-induced thyrotoxicosis, diagnosed by low serum TSH and elevated free T3 and T4, increases cardiovascular morbidity and mortality.
•	Medical treatment tailored to the type of amiodarone-induced thyrotoxicosis, administered at effective doses, should always be initiated in first line.
•	Cardiac status (left ventricular ejection fraction) and duration of hyperthyroidism are the two essential prognostic factors for cardiovascular mortality or morbidity.
•	Total thyroidectomy is a rare option for amiodarone-induced thyrotoxicosis. Surgery is associated with low rates of surgical complications, but higher mortality than thyroidectomy for other indications, due to comorbidities.
•	Surgery is indicated in the absence of response to medical treatment and side effects of medication, and rapidly for patients with an underlying heart condition and impaired left ventricular ejection fraction.

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Abstract

Amiodarone is the most widely prescribed antiarrhythmic drug worldwide, but induces thyrotoxicosis or hypothyroidism in 15 to 20% of patients. Hyperthyroidism is less frequent than hypothyroidism, and two types of thyrotoxicosis are distinguished according to presence of underlying thyroid disease. Diagnosis is made in case of low TSH and high levels of T3 and T4. Initial treatment is based on anti-thyroid drugs and/or glucocorticoids. Some patients do not respond to medication, which increases the time spent with hyperthyroidism. A long interval between diagnosis and euthyroidism and low left ventricular ejection fraction (LVEF) are predictive of major adverse cardiovascular events. Here, after describing the current state of knowledge of amiodarone-induced thyrotoxicosis, we analyze the literature on the impact of surgery. We suggest that early surgery should be the first option in case of ineffective medical treatment or LVEF<40%. In expert centers, surgical morbidity is no longer different than in other indications for thyroidectomy.

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Keywords : Amiodarone, Thyrotoxicosis, Hyperthyroidism, Thyroidectomy, Postoperative morbidity, Cardiovascular mortality