Latest news with #hyperthyroidism
Medscape
12 hours ago
- Health
- Medscape
Thyroid Storm Deaths Rose With Covid-19, Other Risk Factors
Orlando, Fla — A surge in mortality due to thyroid storm occurred in the US during 2020-2021, likely partially, but not entirely, due to the COVID-19 pandemic, a new analysis of people hospitalized with thyrotoxicosis in the National Inpatient Sample (NIS) between 2016 and 2021 showed. However, 'the increased mortality observed was not solely attributable to COVID-19 infection. Critical comorbid conditions markedly heightened the risk of death,' study author Muhammad Sohaib Asghar, MD, a resident physician at AdventHealth, Sebring, Florida, told Medscape Medical News . 'This underscores the importance of early recognition and aggressive management of thyrotoxicosis, especially during healthcare system stressors such as pandemics,' said Asghar. The condition — an endocrine emergency of extreme hyperthyroidism — commonly occurs in people with Graves' thyrotoxicosis but is often precipitated by a secondary inciting factor such as infection or cardiac event, explained co-study author, Shehar Bano, MD, a resident physician at AdventHealth, Sebring, Florida, who presented the results at American Association of Clinical Endocrinology (AACE) Annual Meeting 2025. Racial and demographic factors appeared to play a role in the development of thyroid storm among those with thyrotoxicosis, with higher rates among ethnic minorities and those of lower socioeconomic status, Bano added. Given the high mortality risk in patients with thyrotoxicosis with severe systemic illness, Asghar noted, 'clinicians should prioritize early risk stratification and consider prompt escalation of care. Tailored treatment plans and closer monitoring of patients with high-risk features can potentially improve outcomes, particularly in resource-limited or high-stress clinical settings.' 'These findings highlight the need for a multidisciplinary approach and proactive management of comorbidities in this patient population,' he added. Thyrotoxicosis Trends: Many Risk Factors Identified The study population included individuals aged 18 years or older in the NIS who had ICD-10 codes for thyrotoxicosis (E.05) regardless of cause, excluding those with a concomitant diagnosis of thyroiditis. Of the 186,474 patients included in the analysis (mean age, 60.91 years; 73% women), 97.83% were discharged alive while 2.17% died in hospital. A total of 3800 patients with thyroid storm (2.04% of the study population) were identified. Patients with thyroid storm were significantly younger (mean age, 47 years vs 61 years), had greater lengths of hospital stay (7 days vs 5 days), and higher inflation-adjusted cost of stay ( P < .001). There was no gender predisposition in relation to thyroid storm ( P = .61), but those with it were more likely Black or Hispanic individuals ( P < .01), and to be on Medicaid or self-paying. They were also more likely to live in low socioeconomic ZIP codes ( P < .01) and the US South region ( P < .01), and to be admitted in Government non-federal hospitals ( P < .01). Those with thyroid storm were significantly more likely to have a long list of concurrent diagnoses, including coagulopathy, drug abuse, history of heart failure with systolic component instead of diastolic, mild liver disease, peripheral vascular disease, weight loss, sepsis, septic shock, cardiogenic shock, rheumatic heart disease, and non-ST-elevation myocardial infarction ( P < .001 for all). The list also included atrial arrythmias, respiratory failure, invasive ventilation, tracheostomy, cardiac arrest, acute heart failure, pneumonia, use of mechanical circulatory support, supraventricular and ventricular tachycardia, mitral valve disease, chronic liver disease, percutaneous endoscopic gastrostomy tube placement, acute venous thromboembolism, and pericardial effusion/pericarditis ( P < .001, except for pneumonia where P = .001). Over the entire study period, age-adjusted mortality per 100,000 hospitalizations was 6825 among those with thyroid storm vs 3601 for those without, Bano reported. For those with thyroid storm, in-hospital mortality appeared to be rising even prior to the COVID-19 pandemic, with a surge beginning in 2019. The percentages were 2.88% in 2016, 6.00% in 2017, 4.78% in 2018, 6.37% in 2019, 6.61% in 2020, and 7.58% in 2021 ( P for trend < .001). Among those without thyroid storm, in-hospital mortality stayed relatively steady until the pandemic, ranging from 1.78% to 1.82% between 2016 and 2019, then jumping to 2.48% in 2020 and 2.87% in 2021 ( P for trend < .001). Annual age-adjusted mortality rates per 100,000 hospitalizations were roughly similar between those with and without thyroid storm in 2019, 3442 and 3107, respectively. In 2020, those numbers rose to 7629 for those with thyroid storm vs 4754 for those without. In 2021, they were 12,859 and 4539, respectively. 'With future National Inpatient Sample data releases in 2023 and beyond, we should expect this mortality rate to be declining,' Asghar told Medscape Medical News . Impressive Sample Size Asked to comment, session moderator Sean Ho Yoon, MD, assistant professor of clinical medicine at Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Long Island, New York, told Medscape Medical News , 'the study has a limitation because it is not randomized, case controlled, or even blinded. It is a retrospective study. So there's an inherent confounding.' But, Yoon added, those limitations were somewhat mitigated by the large sample size from NIS, which includes 86% of healthcare centers in the US. 'I was impressed by the fact that the sample size is really big. Thyrotoxicosis may be commonly seen, but thyroid storm is not,' he said. Having a 3800-patient sample size 'was actually impressive.' Regarding the socioeconomic differences, Yoon said, 'For clinicians, the challenge is the barriers for them to have access to healthcare because thyroid storm, especially, is preventable by just following routinely with doctors and taking the medication or definitive treatment for the hyperthyroidism.' Bano, Asghar, and Yoon have no disclosures.
Health Line
4 days ago
- Health
- Health Line
How Does Hyperthyroidism Affect Your Face?
Hyperthyroidism can lead to a variety of changes, including face and neck swelling, thinning facial hair or bald patches, and discoloration. Hyperthyroidism, characterized by an overactive thyroid gland producing excessive thyroid hormones, can cause various facial symptoms. These changes can be an early symptom of hyperthyroidism. Usually, treatment for hyperthyroidism can reduce some of these facial changes. What facial features are associated with hyperthyroidism? People with hyperthyroidism may experience several facial changes, including: Swelling and puffiness: This is especially common around the eyes, nose, and cheeks, leading to a fuller facial appearance. Eye symptoms: Bulging eyes (exophthalmos), dryness, and redness. Hair loss: Thinning hair or bald patches — including on your eyebrows, lashes, and beard — can be a sign of hyperthyroidism. Neck swelling: You might have a goiter — a swollen thyroid gland. Skin changes: The skin may become warm, moist, and thin, with possible redness or flushing. Rashes or hives: You might develop a hyperthyroidism rash on your face. Hyperpigmentation: Darkened areas of skin, particularly on the face and neck, may develop. These symptoms result from the increased metabolic rate and immune responses associated with excess thyroid hormones. What causes face changes to occur? Facial changes in hyperthyroidism are mostly caused by the body's heightened metabolic state and autoimmune responses. According to research, hyperthyroidism facial changes can be caused by: Increased metabolism: High levels of thyroid hormones can speed up certain bodily functions, leading to increased blood flow and fluid retention, causing facial swelling and skin warmth. Autoimmune reactions: Graves' disease, an autoimmune condition, is the most common cause of hyperthyroidism. In this case, the immune system might attack tissues around the eyes, leading to inflammation and protrusion. Skin changes: The fast turnover of skin cells can result in thinning, redness, and increased sensitivity. These changes can be among the first noticeable signs of hyperthyroidism. Is there anything you can do to help restore your previous facial features? Getting hyperthyroidism treatment can reduce many facial symptoms. Treatments for hyperthyroidism can include: Antithyroid medications Radioactive iodine therapy Surgery (when needed) If hyperthyroidism is causing skin issues, you might find it helpful to use gentle, hydrating skin care products. This can help reduce dryness and sensitivity. For eye-related symptoms, a healthcare professional might prescribe corticosteroids or eye drops. In some cases, surgery can help relieve pressure and correct eye protrusion. As with most conditions, it's best to treat hyperthyroidism as early as possible. If you suspect you have a thyroid problem, it's a good idea to make an appointment with a healthcare professional as soon as possible. What can you do to help prevent unwanted changes to your face? It's not always possible to prevent hyperthyroidism-related facial changes. Generally, consistent treatment is the best way to reduce the symptoms of hyperthyroidism. Here are some tips for managing hyperthyroidism: Adhere to your medication: Consistently taking your treatments as prescribed helps control symptoms. Get regular checkups: Ask a healthcare professional how often you should have checkups or blood tests to monitor your thyroid hormone levels. Avoid known triggers: Smoking, for example, can exacerbate eye-related symptoms. Maintain a healthy lifestyle: A balanced diet, regular exercise, and stress management can support overall thyroid health. By sticking to a comprehensive care plan, you can minimize the impact of hyperthyroidism on your facial appearance. Learn more about the best foods for hyperthyroidism and practicing self-care with Graves' disease.
Daily Mail
22-05-2025
- Health
- Daily Mail
Always wake up early? It could be 'hidden' symptom of a life-changing illness that needs treatment
Waking up before your alarm rings could be a sign you're suffering a debilitating hormonal condition that can lead to deadly heart problems, an expert has warned. An overactive thyroid, also known as hyperthyroidism, affects roughly one in 100 people, and means the body produces too much of a collection of hormones that make us alert. According to hormonal disorder specialist Dr Gaurav Agarwal, early wakenings are often the first sign of the condition, as the excess hormones stimulates the nervous system in the early hours. When untreated, the condition can cause a host of unpleasant symptoms such as thin hair, dry eyes, neck swelling, anxiety and unintended weight loss. But most concerning are life-changing complications like weakening of bones and irregular heart beats that could lead to fatal heart failure. Pregnant women should rush to get treated as it can increase the risk of premature birth and miscarriage. The condition is 'relatively common in the UK,' Dr Agarwal said, yet many miss the early signs. 'It's seen more commonly in women than men, usually between the ages of 20 to 40.' Lisa Artis, deputy chief of The Sleep Charity and sleep advisor, explained: 'If your thyroid is overactive, the stress response can become imbalanced, causing you to wake up too early and feel restless.' One common cause of hyperthyroidism is the autoimmune condition Graves' disease, which happens when an excess of 'fighter' proteins cause the thyroid to produce too many hormones. Graves' disease can also cause eye problems like bulging eyes, double vision, and eye irritation. Genetic predisposition and environmental factors like smoking may increase the risk, but it is most common in women over 30. Actress Daisy Ridley, famed for her role as Rey in the Star Wars franchise, recently opened up about her Graves' disease diagnosis in Women's Health Magazine. After suffering from symptoms including hot flashes, racing heart, hand tremors and fatigue following the filming of psychological thriller Magpie, the 33-year-old visited her GP, having put her health woes down to the role. The star says she implemented some lifestyle changes to help her manage the disease, including eating a mindful diet and exercising. Nearly a third of Britons struggle to stay asleep throughout the night, according to a poll by bed brand Simba. And adults between the ages of 25 to 34 are the most likely to suffer from the frustrating early wake-ups, according to the survey.
The Sun
21-05-2025
- Health
- The Sun
Always wake up early? It could be a sign of hidden condition that ‘destroys libido and triggers heart failure'
IT'S not uncommon to occasionally find yourself staring at the clock at 4am. But waking up too early can be a sign of something more serious going on with your health. 2 Nearly a third (32 per cent) of British adults battle this sleep problem almost or every single night, according to a new poll. And younger Millennials and older Gen Z - aged 25 to 34 - are the worst affected, with 37 per cent facing frustrating nightly wake-ups that leave them tossing and turning, according to Simba 's findings. While most nighttime awakenings aren't a cause for serious concern, Lisa Artis, deputy CEO of The Sleep Charity, warns this common sleep habit could be a sign of an overactive thyroid, also known as hyperthyroidism. Tucked away in your neck is a small but powerful butterfly-shaped gland called the thyroid. It makes thyroid hormones - T4 (thyroxine) and T3 (triiodothyronine) - which help control your metabolism, heart rate, body temperature, and energy levels. When the thyroid malfunctions, it can become underactive - known as hypothyroidism or overactive - known as hyperthyroidism. Hyperthyroidism is more likely to cause you to wake up early during the night. This is because excess thyroid hormones can speed up your metabolism and stimulate your nervous system, leading to symptoms like anxiety, rapid heart rate, and restlessness. It can also increase cortisol levels (the stress hormone), which may cause you to wake up earlier than usual, especially in the morning. 'Cortisol plays a role in waking you up in the morning, but if your thyroid is overactive, the stress response can become imbalanced, causing you to wake up too early and feel restless.' explains Artis. The dangerous hidden thyroid health conditions affecting millions - symptoms and treatment According to Dr Gaurav Agarwal, Consultant Physician and Endocrinologist, Nuffield Health Tunbridge Wells Hospital, waking up early can be one of the earliest signs of hyperthyroidism. He added: "Hyperthyroidism is relatively common in the UK. The most common cause is Graves' disease - an autoimmune condition - with smoking being one of the biggest risk factors. "It's seen more commonly in women than men, usually between the ages of 20 to 40." 2 Other symptoms of hyperthyroidism, says Dr Agarwal, include: Hyperactivity and restlessness Feeling tired all the time Increased thirst Feeling excessively hot Mood wings Overactive bowels and bladder Muscle weakness Itchy skin Frequent and/or lighter periods in woman Reduced sexual desire Dr Agarwal added: "One may notice their hair thinning, dry eyes, flushed palms, palpitations, swelling in the front of the neck, unintended weight loss as well as tremors." It's advisable to seek help early, so the correct diagnosis can be made and treatment started immediately, leading to quicker resolution of symptoms and restoration of health and well-being. Long-term hyperthyroidism, if left untreated, can have serious health consequences, warned Dr Agarwal. He advised: "Weakening of bones (osteoporosis), irregular heart beat (atrial fibrillation) and even a heart failure can occur. "It may even lead to complications in pregnancy." Hyperthyroidism is diagnosed through a combination of a physical exam, a detailed medical history, and blood tests. If you think you're experiencing any of the symptoms, see your GP. How to manage thyroid issues - top tips from Simba and The sleep Charity 1. Seek medical advice - If you're regularly waking up too early and experiencing other symptoms, it's important to consult with a healthcare professional to rule out thyroid conditions. 2. Maintain a consistent sleep schedule - Try to go to bed and wake up at the same time every day to help regulate your body's natural rhythm 3. Exercise regularly - Physical activity can help improve sleep quality, mood, and metabolism - all of which can support thyroid function. 4. 5-A-Day - A poor diet with low-nutrient foods is a key factor in thyroid disorders, as the thyroid relies heavily on essential nutrients to function properly. Add berries to your breakfast cereal or yoghurt, grab an apple or banana as a snack, throw an orange in your bag to cut up at lunch and finish with a juicy pineapple or papaya for dinner. Aim to eat at least five portions of a variety of fruits and vegetables every day. 5. Curb sugar and processed foods - Cut down on sugary snacks, fizzy drinks, and processed foods. Swap them for natural sweeteners with a lower glycemic index like honey, maple syrup, stevia or coconut sugar but use them in moderation. Focus on whole foods - veg, lean proteins, whole grains, and healthy fats. These nutrient-rich foods help keep your blood sugar steady and support your thyroid, giving your overall health a boost. 6. Watch out for soya - Levothyroxine is a medication commonly prescribed to treat hypothyroidism. The potential impact of soya on levothyroxine absorption remains a topic of discussion. While some studies show no effect, others suggest it may influence absorption, particularly in women. To be on the safe side, it's advisable to avoid consuming soya close to the time you take your levothyroxine. A gap of at least four hours between the two should help prevent any potential interference with the medication's effectiveness. 7. Opt for healthy fats and nutrients that support your thyroid - Incorporate healthy fats into your diet with foods like avocados, nuts, seeds and olive oil. These fats help with hormone production and keep blood sugar levels stable. Include iodine-rich foods like seaweed, seafood, dairy and white fish - like cod and haddock - to support thyroid health, and don't forget selenium-rich options such as Brazil nuts, tuna, pork, eggs, cottage cheese and sunflower seeds. Make sure you're also getting enough vitamins B and D, either through food or supplements if needed, to keep your thyroid functioning well. 8. Find your perfect sleep temperature - Temperature regulation is a key factor for those with thyroid conditions, as fluctuating body temperatures can be a common issue. A cool room (around 65°F / 18°C) is ideal for sleep. 9. Go natural: A comfortable mattress is essential for restorative sleep, particularly for people with thyroid problems. Opting for natural, breathable materials that help create a toxin-free sleep environment, can be crucial in reducing inflammation and promoting better health. This is particularly beneficial for those with autoimmune thyroid conditions like Hashimoto's thyroiditis, as it minimises external stressors that can aggravate symptoms. 10. Careful with Coffee - A study found that caffeine can interfere with thyroid medication absorption, leading to unstable thyroid levels. You should take your medication with water and wait at least 30 minutes before drinking coffee.
Medscape
16-05-2025
- Health
- Medscape
Radiofrequency Ablation: A First-Line Treatment Option
This transcript has been edited for clarity. Kaniksha Desai, MD: Welcome to the Thyroid Stimulating Podcast . This podcast was created in partnership with the American Thyroid Association to discuss up-to-date diagnosis and management of a wide array of thyroid diseases. I'm your host, Dr Kaniksha Desai, and today we're exploring an exciting and rapidly growing area in the management of hyperthyroidism: the use of radiofrequency ablation (RFA) for treatment. For those of you less familiar with it, RFA is a minimally invasive technique that uses thermal energy to reduce or eliminate targeted thyroid tissue. Although it has been used internationally since the early 2000s, it was FDA approved in the United States in 2018. Initially adopted for the treatment of benign nonfunctioning thyroid nodules, RFA is now gaining traction as a promising option for patients with hyperthyroidism from toxic adenomas. Joining us today is Dr Iram Hussain, associate professor of medicine in the Division of Endocrinology at UT Southwestern Medical Center in Dallas, Texas. She is the president of NASOIE, the North American Society of Interventional Endocrinologists, and she began one of the first endocrinology-led academic RFA practices in the US at UT Southwestern in 2022. Dr Hussain has published extensively on this topic, including expert reviews in Clinical Thyroidology on the latest thermal ablation papers. She has also co-authored the American Thyroid Association's consensus statement on the safe performance, training, and adoption of ablation techniques for benign thyroid nodules, which was published in 2023. We are honored to have her here today to share her experience and expertise with us. In today's episode, we'll dive into how RFA compares to more traditional therapies, such as surgery and radioactive iodine, including potential benefits, such as fewer side effects and a greater likelihood of preserving normal thyroid function rather than leading to permanent hypothyroidism. Thank you, Dr Hussain, for joining us today. Iram Hussain, MD: Thank you so much for having me. I'm thrilled to be here to talk about this exciting area of thyroid care. Desai: I'd like to start off with a personal question. What piqued your interest in RFA, since it's a newer technique? Hussain: My practice primarily consists of patients with thyroid nodules and thyroid cancer. When I was seeing patients in my clinic, many of them had symptoms or they would need some sort of intervention, but they were very reluctant to get surgery. Some of them were afraid of surgery, some of them didn't want a surgical scar, or they were afraid they would have to be on medication for the rest of their life. When I discovered that this new technique was gaining popularity and a training course was available in the United States in 2018, I thought, Oh, I have to go and see what this is about. When I met Dr Jung Hwan Baek, from South Korea, who did the first cases of benign thyroid nodules, I saw that it was very similar to biopsies and fine-needle aspirations that we do in clinic. I thought, We can do this in clinic and this is going to be great for patients. I love procedures, so I got trained and was like, let's set this up. Desai: Thank you. I'm so glad you're here to talk to us about it. Can we start by talking about hyperthyroidism in general for our listeners? What are the different causes of hyperthyroidism and where specifically do toxic adenomas fit in? Hussain: Hyperthyroidism can be caused either by too much production of thyroid hormone or by leakage of preformed thyroid hormone into the systemic circulation, which is usually thyroiditis. Thyroiditis is typically self-limited, but when we're talking about overproduction of thyroid hormone, the most common cause is going to be autoimmune or Graves disease. About 5%-10% of hyperthyroidism is caused by autonomously functioning thyroid nodules. These are nodules that produce thyroid hormone independently of the pituitary's TSH regulation. If there's just one thyroid nodule that's producing too much thyroid hormone, that's a toxic adenoma. If there's more than one, that's a toxic multinodular goiter. Essentially, the nodule just decides to produce hormone on its own, and that leads to suppressed TSH and elevated thyroid hormones. Desai: How do you diagnose a toxic adenoma? Hussain: Typically, you're going to do thyroid function tests first. You can have either subclinical hyperthyroidism, where the TSH is suppressed and you have normal circulating thyroid hormones, or you can have elevated thyroid hormones, which is hyperthyroidism. Then, you are going to do an ultrasound to see if the patient has any nodules. Finally, you're going to do a radioactive iodine uptake and scan. This is going to tell you whether the nodules are producing too much thyroid hormone or if it's the whole gland. Desai: That's very important to distinguish because the treatment options might be slightly different for the different causes of the hyperthyroidism. What are the standard treatment options? Can you go over them for our listeners? Hussain: Traditionally, we've had three options for the treatment of hyperthyroidism. They include antithyroid medications, such as PTU, radioactive iodine therapy, and surgery. Typically, in the case of toxic adenomas or autonomously functioning thyroid nodules, we don't prefer antithyroid medications because these nodules don't go into remission, so people end up being on antithyroid medications for life. In order to get them to definitive therapy, we either choose radioactive iodine or surgery, but both come with disadvantages. Desai: I'm going to have you talk about some of those disadvantages later, but I wanted to switch now to RFA. Can you give us a little bit of background on how it works for thyroid conditions in general and for toxic adenomas? Hussain: RFA is a minimally invasive procedure that uses thermal energy to essentially heat up the cells and cause necrosis. The cells die and then they scar over and shrink, and this shrinks the nodule. It's typically performed under ultrasound guidance using an electrode. It's been used internationally since the early 2000s for benign nodules and it's gaining popularity in the United States now. It's especially effective for solitary hyperfunctioning nodules because it targets a specific area. Desai: When you are ablating it, you just ablate where the nodule is, and then that turns off all the thyroid function that's coming out of there. Hussain: You're essentially going to insert a thin electrode into the nodule and start burning the tissue under ultrasound guidance. The aim is to burn the entire nodule so that there are no viable cells left. This way, the nodule will no longer produce too much thyroid hormone, and your thyroid function tests will normalize. Desai: Can you tell us a little bit about who the ideal candidate for this procedure would be? Hussain: Most of the studies show that this procedure works best in people who have nodules that are less than 12 mL in volume. If they're very big, it might not work in one session. It's particularly attractive for patients who want to avoid surgery or radioactive iodine, or for patients who have many comorbidities that make surgery risky. Also, for patients who are planning pregnancy soon, because after radioactive iodine, you have to typically wait 6-12 months before getting pregnant. And especially for patients who are concerned about becoming hypothyroid, because the risk for hypothyroidism with this procedure is essentially zero. Desai: That's amazing because for some of our other treatment options, including surgery and radioactive iodine, it's not zero. Is there anyone for whom you would not recommend this? Hussain: It's typically not recommended in Graves disease because this is a diffuse disease process rather than a targeted area of excess thyroid production. You also want to avoid it in pregnancy because there are not enough safety data. The procedure uses an alternating current, and the patient has to have grounding pads on their thighs, so there are not enough safety data in pregnancy. You also can't do it in people who have bleeding disorders because that increases the risk for hematomas. Desai: Can you walk us through what the RFA procedure looks like for your patients? Hussain: This is typically going to be an outpatient procedure that you can easily do in the clinic. The patient is lying supine on your exam table, and you ask them to extend their neck. Then you use ultrasound to inject local anesthesia — typically lidocaine — into the skin and the parathyroidal area because the thyroid capsule is where most of the pain is. After that, you insert the electrode into the nodule, keeping an eye on it with your ultrasound. You insert it parallel to the electrode probe and then move it using something called a moving shot technique. You're basically ablating the nodule layer by layer and treating it in sections until the entire nodule is ablated. This usually takes about 30 minutes for a very small nodule, but it can easily take over an hour if it's a very large nodule. Desai: What complications can occur during or after the procedure? Hussain: Because we are burning the nodular tissue, all of the complications are related to heat damage. The recurrent laryngeal nerve typically runs behind the thyroid and the tracheoesophageal groove. If there is heat damage to that nerve, there can be voice changes, and that's the most common complication. Similarly, if you nick a vessel, you could potentially have a hematoma. There could also be damage to other surrounding structures, such as the vessels, the trachea, and the esophagus. There could be skin burns. To avoid all of these, we keep the patient awake. We're talking to the patient throughout, making sure that they're not feeling heat or pain, and we're looking very closely on our ultrasound machine to make sure that we're ablating only the nodule and nothing else. Desai: It sounds like it's pretty intensive for those 30 minutes. Hussain: It definitely requires a large amount of concentration, but it gets easier with practice. I think that most people who do many thyroid procedures are quite comfortable doing it. Desai: What happens if your patient who's now talking to you suddenly can't speak anymore? That can be kind of scary. Hussain: That can be very scary. That means that you've caused some heat damage to the nerve, but you've picked it up very early because you're talking to them continuously. As soon as you notice the voice change, you're going to turn the machine off. Then you're going to wait a few seconds and talk to them to see if the voice is coming back. If it's not coming back, then you're going to take a syringe with a needle and fill it with cold dextrose 5% in water, and inject it right on top of the nerve into the tracheoesophageal groove. Sometimes you need to inject a decent volume. If you're injecting enough fluid and cooling down the nerve fast enough, the voice will gradually come back. It's very scary when it happens, but it's very exciting when the voice comes back and everything's fine. Desai: Do you just continue the procedure then or do you have to do something else from there? Hussain: You can continue the procedure if the patient's comfortable with that. It's happened to me twice, and in both cases, the patients continued the procedure successfully and had good outcomes. Desai: Great. It is completely treatable. If that happens during the procedure, you just take a little break and you try to cool down the nerve. We talked a little bit about the preprocedural workup for hyperthyroidism, but is there anything special that you need to do before you consider RFA treatment in a patient? Hussain: I will typically get their baseline thyroid function tests again, just to make sure they're not very, very hyperthyroid prior to the procedure because you may have to pretreat them with methimazole if that happens. Then I'll typically get platelet levels and an INR and PTT to make sure they don't have any risk of bleeding during the procedure. Of course, in the case of toxic adenomas, you do want to have your ultrasound and your radioactive iodine uptake scan because you want to be targeting the correct area. Desai: Speaking of that, you said the best patients would have one toxic nodule, but can you do this for a multinodular goiter? Hussain: There's not much data for multinodular toxic nodular goiter, but I will say that it's possible if most of the thyroid hormone is coming from one dominant thyroid nodule. Otherwise, the challenge is that you would have to ablate each individual nodule that's making too much thyroid hormone, and this might result in the patient having to undergo more than one procedure, which comes with additional risk, additional cost, etc. Desai: That can be a lot if you have three or four nodules. Hussain: Yes, exactly. Desai: Are patients cured immediately? What is the time lapse for this? Hussain: Typically, they're going to notice a decrease in their thyroid hormone levels over the next few weeks. You can check the patient's thyroid function tests in 4-6 weeks, and you might notice an improvement. Some people have a normalization of their thyroid function tests as early as 6 weeks, but most have it within 3 months. If the thyroid function tests have not normalized by 6 months, it usually means that the procedure wasn't successful and the patient may need a second session. Desai: How often is a second session necessary? Hussain: This depends on the initial characteristics of the nodule. As we discussed previously, nodules that are 10-12 mL in volume or lower respond very well and can typically be treated in one session. However, larger nodules, especially those larger than 30 or 40 mL, typically require more than one session. It really depends on the size. Now, what's really interesting is that although all previous papers say that size is very important, recently a paper was published in Thyroid, in December 2024, which was the Latin American multicenter experience in treating solitary autonomously functioning thyroid nodules. They noticed no difference in size. They had similar success rates with nodules that were less than 30 mL and those that were more than 30 mL, which was very interesting. Desai: Do you think it's because they spent more time treating it or they had more experience treating it? Hussain: I think as RFA gets more popular, people are starting to get better at it. Most of the people treating those nodules are very high-volume RFA practitioners, so they probably have been doing it for a while and they probably used a decent amount of energy on those nodules and used advanced techniques, such as the artery-first technique, and making sure that all the vascularity has been treated. I think experience definitely played a role there. Desai: How much experience do you need? Is there an ideal number of hours or number of treated patients? Hussain: There are a few studies on this, not very many. But typically, the learning curve of RFA is such that you continue to get better for the first 30-40 cases or so. After that, you consolidate your skills, and then there's not much improvement seen once you're past 60-90 cases. That's when you reach your peak. If somebody has done over 60-100 cases, they're probably going to be very good at it. Desai: Do you think that makes a difference in the cure rate? Hussain: I think it does in autonomously functioning thyroid nodules because the main difference between this and benign thyroid nodules is that, in autonomously functioning thyroid nodules, you have to ablate the entire nodule. In a nonfunctioning nodule, even if you leave a margin of unablated tissue, it's not going to start producing thyroid hormone. If you leave unablated tissue in an autonomously functioning thyroid nodule, you have a higher risk for recurrence later on. Desai: Usually, is this in the first 6 months or can it be any time? Hussain: It can typically be any time. It's usually after a year or so. Most people in the first 6 months will normalize their thyroid function unless they had an incomplete ablation. Desai: Do you recommend long-term monitoring for these patients to ensure that they're cured years out? Hussain: I think it would be prudent once they are past the first year to monitor at least yearly. They don't necessarily need to do it with their RFA specialist, but thyroid function tests as part of their annual physical should be sufficient. Desai: Let's talk about RFA compared with other treatment procedures. How does it compare with radioactive iodine and surgery in terms of how effective it is? Hussain: RFA is pretty similar in effectiveness to radioactive iodine. Most of the studies report a success rate of approximately 70%-90%, which is similar to radioactive iodine. Here's the interesting thing: When we talk about the success rate of radioactive iodine, we include patients who are made euthyroid and patients who are made hypothyroid. We, as endocrinologists, know that causing hypothyroidism isn't necessarily a success. Because this procedure causes no hypothyroidism, I prefer it to radioactive iodine. It also shrinks the nodule, so if the patient has compressive symptoms, that also goes away. That doesn't happen with radioactive dividing surgery. Surgery comes with surgical risks. It's a good option for a solitary toxic adenoma, to be honest. The hypothyroidism rate for surgery for a single toxic adenoma, getting a partial thyroidectomy, is only approximately 3%. It's fairly low, but you need a high-volume surgeon to avoid surgical risks. The patient has to go under general anesthesia and they do end up with a scar on their neck. All of those considerations factor into which procedure they might prefer. Desai: Can you compare side effects of RFA vs radioactive iodine and surgery? I know you talked a little bit about it, but are there any main concerns? Hussain: I would definitely say that, with surgery, you're going to be feeling the pain and be out of commission a little bit longer than with RFA. Typically, when we do an RFA, our patients just finish up the procedure and they can walk out the door and go live their life. Radioactive iodine is fairly low risk on the side-effect-profile area. The main thing is that most thyroid disease occurs in women, and most of these women are of childbearing age. Many women don't want radiation exposure when they are trying to plan their families. I think that's a major disadvantage of radioactive iodine. RFA is quick and easy. There's no downtime. You can go to work the next day or the same day if you so choose. It's much easier to recover from this procedure. Desai: It seems like it's a better option than radioactive iodine and surgery. With surgery, you are cured the next day, and then there's a little more time delay for the radioactive iodine and RFA, right? Hussain: Definitely. We counsel patients that the nodule is going to shrink slowly over time. It usually shrinks the most in the first 4-6 weeks. Obviously, the results with surgery are immediate, but it depends on patient preferences here. After surgery, patients typically have to wait for the scar to heal up. They can't lift heavy things, and it interferes with their life quite a bit more. People say that surgery is an easy procedure. As far as surgery goes, it is, but those patients are still discharged on pain medications. All you need is Tylenol after an RFA, if that, so it is much easier to recover from. I give patients the option. I'm not opposed to people choosing surgery if that's what they want, if they want immediate relief. I think it's always nice to have an option. Desai: For patients going to surgery, we often control their hyperthyroidism before surgery with antithyroid medications. We sometimes do that with radioactive iodine if they have severe hyperthyroidism. Can you talk about whether we do that for the RFA procedure? Hussain: There is a small risk of causing thyroiditis due to inflammation because you're burning the cells. We try to keep the patient relatively euthyroid. If somebody's starting out with subclinical hyperthyroidism, we might not necessarily start them on medication beforehand. If they have overt hyperthyroidism, then we're probably going to pretreat them with methimazole and at least get their free T3 and free T4 close to normal before starting the procedure. After we've done the procedure, we might slowly taper off and recheck their thyroid function tests in 4-6 weeks, and then decide to stop the medication to see if they're now euthyroid. Desai: How widely available is this procedure in clinical practice? Hussain: It's becoming more popular and definitely growing in popularity. I want to say that there are probably over 250 physicians in the United States who are now offering RFA. More academic centers are starting to offer it, which is good. When academic centers start to offer it, that means people start to accept it more as standard of care. It's definitely growing, Desai: I know you talked about who the ideal candidate is, but for those of our listeners who would be referring patients, how is it best to identify these patients and where do you send them? Hussain: After you've determined that your patient has a toxic adenoma or a single autonomously functioning thyroid nodule, then you want to look at what size it is. There is a formula to calculate the volume, but if you don't want to do that, then you can look at the maximum diameter. If it's lower than 3-4 cm, they're probably a pretty good candidate for RFA. If it's larger, they can probably still get it, but the practitioner doing the RFA might tell them that they may need more than one session. They can counsel them about that. There's no harm in referring out, getting a second opinion, and having the patient talk to somebody who does RFA to go over their options. Reach out to centers with trained operators, so that could be endocrinology, surgery, or interventional radiology. Our society, the North American Society of Interventional Endocrinologists, has a directory, so you can search by city and send them to the person closest to you for a second opinion. Desai: If someone wants to get trained in this procedure, how would they go about it? Hussain: There are multiple training programs now available. Many of them are in collaboration with some major society meetings and many are done by the company representatives that are providing this technology. I think it is important to observe somebody, who already does RFA in their practice, do it on an actual patient. I think that's very helpful when you're learning, so you can see exactly what the setup is like, how the patient tolerates the procedure, and whether or not you think you can incorporate it into your practice. Desai: There you have it. If you want to get trained in the procedure, it's a relatively easy training. Tell me about reimbursement for this. I know that a CPT code recently came out for RFA, and hopefully now it should be covered more by insurance. Hussain: It was very good news for patients when the CPT code came out on the first of this year, and we've noticed that many patients who previously could not get the procedure because they would have had to pay cash are now wanting to schedule it. We have not had any problems getting it reimbursed thus far. I think that access will only continue to grow. Desai: This is wonderful for our patients as well. You mentioned that the ideal patient has a toxic adenoma, but are there any data on Graves disease? Hussain: I reviewed a paper that was published in Thyroid in June of last year, and it was a really interesting paper because they took over 30 patients with Graves disease and treated them with RFA by essentially ablating both lobes. What they were trying to do is mimic a subtotal thyroidectomy. There was no distinct nodule, so they ablated all the tissue that they could safely ablate and then saw what the outcomes were. They were actually not bad. I will say that it worked best in smaller thyroids. If the total volume of the gland was less than 20 mL, those patients tended to go into remission. Patients who had larger glands didn't go into remission that easily or they had recurrence of Graves'. This is not entirely unexpected. When we published our early data in 2021 in the Journal of the Endocrine Society — those cases were done in the United States in 2018, 2019, and 2020, so the very early cases — we noticed that the best outcomes were with nodules that were less than 10 mL. If you have a thyroid that's 20 mL, essentially, one lobe is 10 mL or smaller on each side. Those were the cases that responded best. It's still very early. It's not something that I would recommend except in truly exceptional circumstances. For example: You have a patient with Graves disease and they're allergic to antithyroid medication, so you can't give them that. They have an aversion to radiation exposure, so you can't give them radioactive iodine. They want to avoid hypothyroidism, and they have either strong opposition to a scar or they're not a surgical candidate. In that situation, you could potentially consider this as a treatment option, but we don't have any long-term studies, so it's difficult to say. Desai: How long were the long-term studies for toxic adenomas? Hussain: We have studies for toxic adenomas for up to 5-10 years. It does have a durable response and people stay in remission, so it is a pretty good treatment option. Desai: Do they get other nodules or does that one nodule just go away? Hussain: Most of the studies are for single toxic adenomas, so that nodule just shrinks and becomes really small. Typically, you need about 80% volume reduction in the nodule to have normalization of thyroid function tests. If you have more than 80% volume reduction, the nodule just ends up being a very small nodule on ultrasound at the end of the follow-up time. Desai: What excites you most about the future of RFA in managing thyroid disease? Hussain: I really love that it's so patient centered. As I said before, patients come in and they don't want to be hypothyroid, they don't want a scar, they don't want radiation, and they don't want all these things. This is a way to treat them in such a manner that their nodule shrinks, their thyroid function tests normalize, and their neck looks completely normal. There's no evidence that you ever went in and did anything, so that's really great. Desai: They can have this treated without everyone knowing about it as well. I just want to review for our listeners. We talked about what RFA is and how it offers many more benefits than surgery and radioactive iodine treatment for toxic adenomas. It has an almost 0% rate of hypothyroidism, so patients don't have to take long-term medications of any sort. Can you give us three clinical pearls for our listeners to remember about RFA? Hussain: First, I'd want listeners to know that RFA is a legitimate first-line treatment option for autonomously functioning thyroid nodules. It's not like, oh, you're not a surgical candidate, you can't do this, and only then you can do RFA. It's a first-line treatment option, and if you want to do it, you should go see somebody who can do it for you. Second, I think, personally, that smaller nodules do respond better despite the study that was published out of Latin America, I think it's easier to ablate smaller nodules. If you have a small nodule that's autonomously functioning, you should definitely consider RFA as a treatment option. Finally, if you don't want a scar and/or don't want to be on levothyroxine, then this is the treatment option for you because this is the only treatment option that's going to guarantee that you're not on medication for the rest of your life. Desai: Thank you for joining us today. For our listeners, please stay tuned for next month's episode, which will be on molecular testing for thyroid nodules — are they worth the money? Thank you. Hussain: Thank you so much for having me.
