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Review
. 2023 Oct 17;330(15):1472-1483.
doi: 10.1001/jama.2023.19052.

Hyperthyroidism: A Review

Sun Y Lee  1 , Elizabeth N Pearce  1
Affiliations
Review

Hyperthyroidism: A Review

Sun Y Lee et al. JAMA. .

Abstract

Importance: Overt hyperthyroidism, defined as suppressed thyrotropin (previously thyroid-stimulating hormone) and high concentration of triiodothyronine (T3) and/or free thyroxine (FT4), affects approximately 0.2% to 1.4% of people worldwide. Subclinical hyperthyroidism, defined as low concentrations of thyrotropin and normal concentrations of T3 and FT4, affects approximately 0.7% to 1.4% of people worldwide. Untreated hyperthyroidism can cause cardiac arrhythmias, heart failure, osteoporosis, and adverse pregnancy outcomes. It may lead to unintentional weight loss and is associated with increased mortality.

Observations: The most common cause of hyperthyroidism is Graves disease, with a global prevalence of 2% in women and 0.5% in men. Other causes of hyperthyroidism and thyrotoxicosis include toxic nodules and the thyrotoxic phase of thyroiditis. Common symptoms of thyrotoxicosis include anxiety, insomnia, palpitations, unintentional weight loss, diarrhea, and heat intolerance. Patients with Graves disease may have a diffusely enlarged thyroid gland, stare, or exophthalmos on examination. Patients with toxic nodules (ie, in which thyroid nodules develop autonomous function) may have symptoms from local compression of structures in the neck by the thyroid gland, such as dysphagia, orthopnea, or voice changes. Etiology can typically be established based on clinical presentation, thyroid function tests, and thyrotropin-receptor antibody status. Thyroid scintigraphy is recommended if thyroid nodules are present or the etiology is unclear. Thyrotoxicosis from thyroiditis may be observed if symptomatic or treated with supportive care. Treatment options for overt hyperthyroidism from autonomous thyroid nodules or Graves disease include antithyroid drugs, radioactive iodine ablation, and surgery. Treatment for subclinical hyperthyroidism is recommended for patients at highest risk of osteoporosis and cardiovascular disease, such as those older than 65 years or with persistent serum thyrotropin level less than 0.1 mIU/L.

Conclusions and relevance: Hyperthyroidism affects 2.5% of adults worldwide and is associated with osteoporosis, heart disease, and increased mortality. First-line treatments are antithyroid drugs, thyroid surgery, and radioactive iodine treatment. Treatment choices should be individualized and patient centered.

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Conflict of interest statement

Conflict of Interest Disclosures: Dr Pearce reported personal fees from National Dairy Council honoraria for speaking and travel support, personal fees from Iodine Global Network for travel support and serving as North American Regional Coordinator, and personal fees from Merck China Symposium honoraria for speaking outside the submitted work; and Member of the American Thyroid Association’s task force for the revision of thyroid in pregnancy guidelines. Dr Lee reported grants from National Institute of Health - National Institute of Environmental Health Science during the conduct of the study; personal fees from National Dairy Council honorarium for speaking outside the submitted work.

Figures

Figure 1.
Figure 1.
Assessment of Thyrotoxicosis TSH = thyroid stimulating hormone; T3 = triiodothyronine; T4 = thyroxine; TRAb = TSH-receptor antibody; Tg = thyroglobulin.
Figure 2.
Figure 2.
Treatment of Hyperthyroidism TSH = thyroid stimulating hormone; MMI = methimazole; PTU = propylthiouracil; LFTs = liver function tests; CBC = complete blood count; ATD = antithyroid drug; TRAb = antibody to TSH receptor; TFTs = thyroid function tests.
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Comment in

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