Total Thyroidectomy May Ease Persistent Hashimoto Symptoms

Total thyroidectomy may be a treatment option for patients with confirmed Hashimoto's disease who experience persistent symptoms despite adequate thyroid hormone replacement, novel research suggests.

Findings from the new randomized trial comparing total thyroidectomy with medical management alone in 147 such patients were published online March 11, 2019, in Annals of Internal Medicine by Ivar Guldvog, MD, PhD, head of the Department of Breast and Endocrine Surgery, Telemark Hospital Trust, Skien, Norway, and colleagues.

The approach is based on the hypothesis that persistent symptoms such as profound fatigue, poor sleep quality, muscle and joint tenderness, and dry mouth/eyes may relate to the underlying autoimmunity of Hashimoto's thyroiditis and therefore may only partially respond to thyroid hormone substitution with levothyroxine, even if euthyroid status is achieved.

In contrast, the authors say, complete removal of the antigenic tissue via total thyroidectomy may alleviate symptoms by normalizing levels of serum anti-thyroid peroxidase (anti-TPO) antibodies, thereby reducing inflammation.

In the study, thyroidectomy did normalize anti-TPO antibody levels, and only the surgical group reported significant improvement in self-reported symptoms.

"The take-home message should be that Hashimoto's disease is a surgical condition and should be referred as such," Guldvog told.

The new data, he said, "are sufficient to support a change in clinical practice guidelines due to the fact that our [data are] based on a randomized study, it showed highly significant differences, and for the patients there is no alternative treatment."

But endocrinologist Rhoda H. Cobin, MD, clinical professor of medicine at the Icahn School of Medicine at Mount Sinai, New York, disagrees, noting that "their premise may be faulty since it is by no means certain that the symptoms evaluated are indeed related to generalized inflammation caused by thyroid-specific autoimmunity."

Cobin also pointed to the risks involved in the surgery, which included infections in three patients and nerve palsy (which later resolved) in four.

"I empathize with people who continue to suffer despite being euthyroid but I do not believe that the present paper convincingly shows causality between autoimmunity, inflammation, and symptoms. I do not believe that the results justify the risks," she cautioned.

Indeed, Guldvog and colleagues acknowledge that: "The participants in our study were advised to consider surgery because of severe, unspecific symptoms ... therefore, they could be characterized as 'end of the road' in terms of available treatment options, and considered a highly select group ... with high motivation for surgery."

However, they point out that studies have found placebo effects in improved health-related quality of life scores tend to normalize within 6 months and would be unlikely to last 18 months.

Nonetheless, they say, "further studies, ideally with longer follow-up, should be encouraged."

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