📖Hyperthyroidism: aetiology, pathogenesis, diagnosis, management, complications, and prognosis

Summary  总结

Hyperthyroidism is a common condition with a global prevalence of 0·2–1·3%. When clinical suspicion of hyperthyroidism arises, it should be confirmed by biochemical tests (eg, low TSH, high free thyroxine [FT₄], or high free tri-iodothyonine [FT₃]). If hyperthyroidism is confirmed by biochemical tests, a nosological diagnosis should be done to find out which disease is causing the hyperthyroidism. Helpful tools are TSH-receptor antibodies, thyroid peroxidase antibodies, thyroid ultrasonography, and scintigraphy. Hyperthyroidism is mostly caused by Graves' hyperthyroidism (70%) or toxic nodular goitre (16%). Hyperthyroidism can also be caused by subacute granulomatous thyroiditis (3%) and drugs (9%) such as amiodarone, tyrosine kinase inhibitors, and immune checkpoint inhibitors. Disease-specific recommendations are given. Currently, Graves' hyperthyroidism is preferably treated with antithyroid drugs. However, recurrence of hyperthyroidism after a 12–18 month course of antithyroid drugs occurs in approximately 50% of patients. Being younger than 40 years, having FT₄ concentrations that are 40 pmol/L or higher, having TSH-binding inhibitory immunoglobulins that are higher than 6 U/L, and having a goitre size that is equivalent to or larger than WHO grade 2 before the start of treatment with antithyroid drugs increase risk of recurrence. Long-term treatment with antithyroid drugs (ie, 5–10 years of treatment) is feasible and associated with fewer recurrences (15%) than short-term treatment (ie, 12–18 months of treatment). Toxic nodular goitre is mostly treated with radioiodine (¹³¹I) or thyroidectomy and is rarely treated with radiofrequency ablation. Destructive thyrotoxicosis is usually mild and transient, requiring steroids only in severe cases. Specific attention is given to patients with hyperthyroidism who are pregnant, have COVID-19, or have other complications (eg, atrial fibrillation, thyrotoxic periodic paralysis, and thyroid storm). Hyperthyroidism is associated with increased mortality. Prognosis might be improved by rapid and sustained control of hyperthyroidism. Innovative new treatments are expected for Graves' disease, by targeting B cells or TSH receptors.
甲状腺功能亢进症是一种常见病症，全球患病率为 0·2-1·3%。当临床怀疑甲状腺功能亢进时，应通过生化检查（如低 TSH、高游离甲状腺素[FT₄]或高游离三碘甲状腺素[FT₃]）确诊。如果通过生化检查确诊甲状腺功能亢进症，则应进行病理学诊断，以找出导致甲状腺功能亢进症的疾病。有用的工具包括 TSH 受体抗体、甲状腺过氧化物酶抗体、甲状腺超声检查和闪烁显像。甲状腺功能亢进症主要由 Graves 甲状腺功能亢进症 （70%） 或毒性结节性甲状腺肿 （16%） 引起。甲状腺功能亢进症也可由亚急性肉芽肿性甲状腺炎 （3%） 和药物 （9%） 引起，例如胺碘酮、酪氨酸激酶抑制剂和免疫检查点抑制剂。给出针对疾病的建议。目前，Graves 甲状腺功能亢进症最好用抗甲状腺药物治疗。然而，大约 50% 的患者在服用抗甲状腺药物 12-18 个月后甲状腺功能亢进症复发。年龄小于 40 岁，FT₄ 浓度为 40 pmol/L 或更高，TSH 结合抑制性免疫球蛋白高于 6 U/L，以及抗甲状腺药物治疗开始前甲状腺肿大等于或大于 WHO 2 级，会增加复发风险。抗甲状腺药物长期治疗（即 5-10 年的治疗）是可行的，并且与短期治疗（即 12-18 个月的治疗）相比，复发率 （15%） 更少。毒性结节性甲状腺肿主要采用放射性碘 （¹³¹I） 或甲状腺切除术治疗，很少采用射频消融术治疗。 破坏性甲状腺毒症通常是轻微和短暂的，仅在严重病例中需要类固醇。特别关注妊娠、COVID-19 或其他并发症（如心房颤动、甲状腺毒性周期性麻痹和甲状腺危象）的甲状腺功能亢进患者。甲状腺功能亢进症与死亡率增加有关。快速和持续控制甲状腺功能亢进症可能会改善预后。预计 Graves 病将采用创新的新疗法，通过靶向 B 细胞或 TSH 受体。