Comparative Effectiveness of Therapies for Graves' Hyperthyroidism: A Systematic Review and Network Meta-Analysis
Open accessAbstract
CONTEXT: Several treatment options are available for Graves' disease (GD), including antithyroid drugs (ATDs), radioactive iodine (RAI), and thyroidectomy. OBJECTIVE: The primary outcome was to determine the relapse rates of various treatment options. The secondary outcome was to present data regarding adverse effects of ATDs. DATA SOURCES: We searched multiple databases through March 2012. STUDY SELECTION: Eligible studies were randomized clinical trials and comparative cohort studies in adults that included 2 or more treatment options for GD. DATA EXTRACTION: Two reviewers independently selected studies, appraised study quality, extracted outcome data, and determined adverse effect profiles. DATA SYNTHESIS: We found 8 studies with 1402 patients from 5 continents. Mean follow-up duration in months was: ATDs, 57; RAI, 64; and surgery, 59. Studies were at moderate to high risk of bias. Network meta-analysis suggested higher relapse rates with ATDs (52.7%; 352 of 667) than RAI (15%, 46 of 304) (odds ratio = 6.25; 95% confidence interval, 2.40-16.67) and with ATDs than surgery (10%; 39 of 387) (odds ratio = 9.09; 95% confidence interval, 4.65-19.23). There was no significant difference in relapse between RAI and surgery. Examination of 31 cohort studies identified adverse effects of ATDs in 692 of 5136 (13%) patients. These were more common with methimazole, mainly owing to dermatological complications, whereas hepatic effects were more common with propylthiouracil use. CONCLUSION: We confirm the relatively high relapse rate of ATD therapy in comparison with RAI or surgery, along with a significant side effect profile for these drugs. These data can inform discussion between physicians and patients regarding the choice of therapy for GD. The limited quality of the evidence in the literature underlines the need for future randomized clinical trials in this area.
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In a recent systematic review of eight studies including 667 Graves' disease patients receiving MMI or PTU, 13% of patients experienced adverse events.
“In a recent systematic review of eight studies that included 667 GD patients receiving MMI or PTU, 13% of patients experienced adverse events (122).”
From 2016 American Thyroid Association Guidelines for Diagnosis and Management of Hyperthyroidism and Other Causes of Thyrotoxicosis (2016) · cites this paper as [122]
Hepatocellular injury occurred in 2.7% of patients taking PTU and 0.4% of patients taking MMI.
“Hepatocellular injury occurred in 2.7% of patients taking PTU and 0.4% of patients taking MMI.”
From 2016 American Thyroid Association Guidelines for Diagnosis and Management of Hyperthyroidism and Other Causes of Thyrotoxicosis (2016) · cites this paper as [122]
Minor allergic reactions included pruritus or a limited minor rash in 6% of patients taking MMI and 3% of patients taking PTU.
“The minor allergic reactions included pruritus or a limited, minor rash in 6% of patients taking MMI and 3% of patients taking PTU (122).”
From 2016 American Thyroid Association Guidelines for Diagnosis and Management of Hyperthyroidism and Other Causes of Thyrotoxicosis (2016) · cites this paper as [122]
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- Authors
- Sundaresh, V., Brito, J. P., Wang, Z., Prokop, L. J., Stan, M. N., Murad, M. H., & Bahn, R. S.
- Affiliations
- Mayo Clinic (US)
- Corresponding author
- Bahn, Rebecca S.
- ORCID
- Venue
- The Journal of Clinical Endocrinology & Metabolism
- Publisher
- The Endocrine Society
- Published
- 2013-09
- Volume
- 98
- Issue
- 9
- Pages
- 3671-3677
- ISSN
- 0021-972X (ISSN-L)
- 1945-7197
- PMC
- PMC3763977
- OpenAlex
- W1983002130
- Cited by
- 250
- References
- 31
- Citations by year
- 2026: 10 · 2025: 18 · 2024: 22 · 2023: 28 · 2022: 22 · 2021: 28 · 2020: 18 · 2019: 21 · 2018: 20 · 2017: 16 · 2016: 14 · 2015: 18 · 2014: 14 · 2013: 1
- FWCI
- 2.30
- Type
- journal article
- Language
- en
- Open access
- bronze
- doi.org
- Locations
- The Journal of Clinical Endocrinology & Metabolism (publishedVersion)
- Europe PMC (PubMed Central) (publishedVersion)
- PubMed Central (publishedVersion)
- PubMed (publishedVersion)
- Funders
- Georgia Clinical and Translational Science Alliance (UL1 TR000135)
- National Institutes of Health (UL1TR000135, TR000135)
- National Center for Advancing Translational Sciences (CTSA Grant UL1 TR000135, TR000135)
- Topics
- Health Sciences › Medicine › Endocrinology, Diabetes and Metabolism › Thyroid Disorders and Treatments
- Health Sciences › Medicine › Surgery › Thyroid and Parathyroid Surgery
- Health Sciences › Medicine › Pathology and Forensic Medicine › Ophthalmology and Eye Disorders
- Keywords
- Graves' disease, Graves' hyperthyroidism, antithyroid drugs, radioactive iodine, thyroidectomy, relapse rate, adverse drug reactions, methimazole, propylthiouracil, comparative effectiveness
- MeSH terms
- Female, Graves Disease, Humans, Iodine Radioisotopes, Male, Recurrence, Antithyroid Agents, Thyroidectomy, Databases, Factual, Treatment Outcome
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