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Topic Suggestion Description

View Topic Suggestion Disposition (PDF) 174 kB

Date submitted: September 07, 2011

Briefly describe a specific question, or set of related questions, about a health care test or treatment that this program should consider.
Women are disproportionately affected with thyroid disorders. When I was diagnosed with moderate hyperthyroidism of the Graves' type, I was told that only surgery to remove my entire gland or radioablation were options and to take replacement hormone for the rest of my life. The natural history of Graves is to burn-out the thyroid. The physician could not explain to me why I could not take medical therapy with thyroid suppressant medications until I became hypothyroid as part of the natural course of the disease, as opposed to accepting the risks of surgery in the present. Is there misinformation as a result of a conflict of interest on the part of the surgeons who are recommending thyroid ablation? What are the facts? The side effects of antithyroid drugs are rare and idiosyncratic. The vast majority of patients do not experience agranulocytosis or liver failure. However, the surgery definitely causes sudden and profound hypothyroidism, and could also result in hypoparathyroidism and recurrent laryngeal nerve paralysis. There are papers in the literature that indicate that damage to the heart and other organs from hypertension or tachycardia, has often taken place even before diagnosis, so this should not necessarily rule out medical therapy. Why can't medical therapy be one of the possible longer term treatments for Graves disease? What is the comparative effectiveness and comparative risk profile of medical therapy with antithyroid medications, vs surgery or radioablation?
Does your question include a comparison of different health care approaches? (If no, your topic will still be considered.)
yes
If yes, explain the specific technologies, devices, drugs, or interventions you would like to see compared:
What is the comparative effectiveness and comparative risk profile of medical therapy with antithyroid medications, vs surgery or radioablation?
What patients or group(s) of patients does your question apply to? (Please include specific details such as age range, gender, coexisting diagnoses, and indications for therapy.)
Middle aged Women (50-70 yo)
Are there subgroups of patients that your question might apply to? (For example, an ethnic group, stage or severity of a disease.)
mild to moderate Graves disease
Describe the health-related benefits you are interested in. (For example, improvements in patient symptoms or problems from treatment or diagnosis.)
Medical therapy avoids surgical risks, below, and entails taking one pill daily (methimazole), whereas surgery or ablation replaces one pathological condition with another (exchanges hyperthyroidism for hypothyroidism). Costs of medical therapy could well be less than surgical intervention.
Describe any health-related risks, side effects, or harms that you are concerned about.
avoidance of surgical risks (fulminant hypothyroidism, hypoparathyroidism, recurrent laryngeal nerve damage, operative risk and complications)

Appropriateness for EHC Program

Does your question include a health care drug, intervention, device, or technology available (or likely to be available) in the U.S.?
yes
Which priority area(s) and population(s) does this topic apply to? (check all that apply)
EHC Priority Conditions (updated in 2008)
  • Cardiovascular disease, including stroke and hypertension
  • Obesity
AHRQ Priority Populations
  • Women
Federal Health Care Program

Importance

Describe why this topic is important.
I was motivated as a physician, because I was taking medical therapy without a problem, but had an endocrinologist insisting to me that I needed to have my gland ablated. I cannot reconcile his concern about the rare idiosyncratic side effects of methimazole with the complications of surgery or ablation. The thyroid gland itself is not pathologically involved but is the target of stimulating antibodies created by autoimmune dysregulation. Recently, I heard of some NIH research targeting the autoimmunity aspect of the disease.
The treatment for hyperthyroidism has not been questioned by the profession or the public for over 50 years and endocrinology as a profession is not admitting that there is flawed logic that goes into the recommendation to destroy the gland as a treatment for this disease. The
What specifically motivated you to ask this question? (For example, you are developing a clinical guideline, working with a policy with large uncertainty about the appropriate approach, costly intervention, new research you have read, items in the media you may have seen, a clinical practice dilemma you know of, etc.)
Does your question represent uncertainty for clinicians and/or policy-makers? (For example, variations in clinical care, controversy in what constitutes appropriate clinical care, or a policy decision.)
no
If yes, please explain:

Potential Impact

How will an answer to your research question be used or help inform decisions for you or your group?
Women who have mild to moderate hypothyroidism have to choose whether to undergo ablative therapy and we need more information on the magnitude of the risk of continuing methimazole or carbimazole vs. ablation.
Describe the timeframe in which an answer to your question is needed.
open-ended
Describe any health disparities, inequities, or impact on vulnerable populations your question applies to.
There is significant economic incentive for thyroid surgeons to continue the current practice. In addition, the ablative radioactive material is in control of endocrinologists and has a cost (and also side effects which are being underplayed by the profession). Women are disadvantaged due to their relative societal position relative to (overwhelmingly) male physicians. Also, the information has been suppressed, and the profession is not openly discussing the risk-benefit questions. Only this year, after more than 50 years, did the guideline of the Endocrinology Society, acknowledge in the guideline that the purpose of surgical or radioactive treatment was total ablation of the thyroid. In practice, endocrinologists are not truthful with patients that the surgery and ablative radioactivity will cause irreversible and total destruction of the gland. There is a common attempt to pretend that partial destruction is possible.

Nominator Information

Other Information About You: (optional)
Please choose a description that best describes your role or perspective: (you may select more than one category if appropriate)
  • Physician
  • Researcher
Are you making a suggestion as an individual or on behalf of an organization?
Individual
Please tell us how you heard about the Effective Health Care Program
I met Dr. Clancy once thirty years ago through David Himmelfarb