Patients with Hashimoto disease and symptoms despite medication may benefit from thyroidectomy

Persistent extrathyroidal symptoms, including dry mouth and eyes and muscle and joint tenderness, may resolve for up to five years after thyroidectomy in patients with Hashimoto disease and hypothyroidism, but complication rates are high, according to recent research.

Researchers in Norway performed a follow-up study of a randomized trial in which patients with Hashimoto disease and extrathyroidal symptoms despite adequate medication were randomly assigned to receive thyroidectomy plus medical management versus medical management alone with 18-month follow-up. Those assigned to the control group were told at study inclusion that they could opt for surgery 18 months after enrollment, depending on trial results. The goal of the current study was to provide follow-up at five years in the intervention group and until the date of surgery for the control group. Results were published Nov. 28 as a brief research report by Annals of Internal Medicine.

Patients with Hashimoto disease were eligible for the initial study if they had persistent symptoms (fatigue, increased need for sleep with reduced sleep quality, joint and muscle tenderness, and dry mouth and eyes) despite adequate thyroid hormone substitution and antithyroid peroxidase antibody levels greater than 1,000 IU/mL (normal range, <100 IU/mL). After randomization, 73 patients underwent surgery and 74 received medical management. Those randomly assigned to surgery saw significant improvement in the study's primary outcome, general health score on the Short Form-36 Health Survey questionnaire, at 18 months and five years versus those assigned to medical management only. However, 23 surgical patients had complications, including six who had recurrent laryngeal nerve paralysis, 12 who had hypoparathyroidism (with three cases initially considered temporary later reclassified as permanent), and five who had postoperative hematoma and/or infection requiring intervention.

The researchers concluded that total thyroidectomy yielded benefit for up to five years in patients with Hashimoto disease and persistent symptoms but called the 14% rate of long-term complications “unacceptably high.” They noted that medication and compensatory mechanisms alleviated symptoms among those with hypoparathyroidism and unilateral recurrent nerve injury, respectively. “In Hashimoto disease with persistent symptoms, we still lack a pathophysiologic model to explain the range of patient-reported symptoms,” the authors wrote. Potential causes could include extrathyroidal autoimmunity or reaction to unspecified inflammation, they said.