RAI or drugs? It depends on where you live.

These tables summarize surveys dated 1997 and 1998 and Oct 2000 provided in the abstracts below.

Differences and similarities in the diagnosis and treatment of Graves' disease in Europe, Japan, and the United States.
Wartofsky L, Glinoer D, Solomon B, Nagataki S, Lagasse R, Nagayama Y, Izumi M -- Walter Reed Army Medical Center, Washington, DC.

In three separate studies, members of the American Thyroid Association (ATA), the European Thyroid Association (ETA), and the Japan Thyroid Association (JTA) were surveyed by questionnaire on their management of Graves' disease.

The aim was to determine how expert clinical thyroidologists employ diagnostic procedures and the three different therapies that are available for this disorder.

In this report, we identify, summarize, compare, and contrast similarities and differences in the results of these surveys in these three different regions of the world.

In general, ATA members used fewer diagnostic tests than did their European or Japanese colleagues.

For the index patient, radioiodine was the therapy of choice for 69% of ATA respondents but only 22% and 11% of ETA and JTA respondents, respectively.

In contrast, only 30.5% of ATA respondents chose antithyroid drugs as first-line therapy compared to 77% of ETA and 88% of JTA respondents.

There was consensus on the relative lack of a role for thyroidectomy except for narrow indications.

The implications of these differing approaches for the diagnosis and treatment of hyperthyroidism due to Graves' disease are discussed.

PMID: 1688014, UI: 92346055
Thyroid 1997 Apr;7(2):217-20

International differences in approaches to 131I therapy for Graves' disease: case selection and restrictions recommended to patients in Japan, Korea, and China.
Tominaga T, Yokoyama N, Nagataki S, Cho BY, Koh CS, Chen JL, Shi Y -- First Department of Internal Medicine, Nagasaki University School of Medicine, Japan.

Members of the American Thyroid Association (ATA), European Thyroid Association (ETA), Japan Thyroid Association (JTA), Korean Thyroid Association (KTA), and Chinese Thyroid Association (CTA) were surveyed independently through an identical questionnaire on their management of Graves' disease.

One of the major purposes of the survey was to determine how expert thyroidologists in different regions of the world use three different therapies available for a typical Graves' patient as well as for clinical variations provided.

In this report, we summarized, contrasted, and interpreted the results of the surveys in three Asian countries by focusing on therapeutic preference of radioiodine.

Clin Endocrinol (Oxf) 1998 Jul;49(1):21-8

Case selection and restrictions recommended to patients with hyperthyroidism in South America.
Romaldini JH Department of Endocrinology, Hospital Servidor Publico Estadual-IAMSPE, Sao, Paulo, Brazil.

Data from South America related to the use of radioiodine therapy indicate that radioiodine is prescribed only by physicians with special training and a license.

A thyroid dose of 131-I higher than 29 mCi requires hospitalization of the patient.

Members of the Latin American Thyroid Society (LATS) (235 physicians) were surveyed by a questionnaire on their management of Graves' disease, and the survey procedure was the same used by the other thyroid societies.

Thyroid uptake/scintigraphy was carried out by 60% of respondents and 131I was the isotope most used (chosen by 95% of respondents).

Serum total T4 and T3 were requested by 97%, of LATS members whereas measurement of free T4 and TSH was employed less frequently (27% and 46.3%, respectively).

The therapy of choice for 83% of responding members was antithyroid drugs.

Radioiodine was chosen by 15.3% of respondents.

For most respondents, the aim of 131I therapy was to restore euthyroidism. It was based on goiter size and thyroid uptake and administered in a single dose.

For the radioiodine therapy, 55.5% of the respondents did not add any other medical treatment.

The remaining group used antithyroid drugs before 131I (50%), and 77% employed it after the dose.

There is a general consensus to provide the 131I treatment only to patients elder than 18 years of age.

131I was overwhelmingly (64.2% versus 34% of drug therapy) the therapy seen as most appropriate for patients with recurrence or old age.

The predominant use of antithyroid drugs for therapy of Graves' disease in South America was similar to that in Europe and Japan but different from the practice in North America.

PMID: 9133690, UI: 97279182

Management of Graves' disease in Australia.
Walsh JP - Department of Endocrinology and Diabetes, Sir Charles Gairdner Hospital, Perth, WA, USA. john.walsh@health.wa.gov.au

BACKGROUND:
Surveys of physicians in Europe, the USA and elsewhere have shown marked international differences in the management of Graves' disease. There are no comparable data on clinical practice in Australia.

AIMS:
To examine the current management of Graves' disease by Australian endocrinologists, particularly controversial aspects of management.

METHODS:
A questionnaire, modified from previous studies, was sent to members of the Endocrine Society of Australia, asking how they would manage a 43-year-old female with a first episode of Graves' disease.

Eight variations on this index case (goitre size, age, sex, severity, recurrent disease) were then introduced.

A novel ninth variation, recurrent Graves' disease accompanied by moderate ophthalmopathy, was added.

RESULTS:
Responses from 130 endocrinologists who regularly managed Graves' disease in adults were analysed.

For the index case, medical treatment with antithyroid drugs was recommended by 81% of respondents and radioiodine by 19%.

Most respondents also recommended medical treatment for a patient aged 19 years, a patient with a large goitre, no goitre or severe hyperthyroidism.

For an older patient aged 71 years, however, 57% of endocrinologists recommended radioiodine, and the remainder medical treatment.

For recurrent Graves' disease after previous medical treatment, 76% of respondents recommended radioiodine, 22% medical treatment and 2% surgery.

By contrast, for an identical case accompanied by moderate ophthalmopathy, 54% recommended medical treatment, 27% surgery and only 19% radioiodine.

CONCLUSIONS:
Most endocrinologists in Australia recommend medical treatment for a first episode of Graves' disease.

Radioiodine is used mainly in older patients and for recurrent disease.

In the presence of significant ophthalmopathy, most endocrinologists avoid the use of radioiodine.

Aust N Z J Med 2000 Oct;30(5):559-66
PMID: 11108065, UI: 20557413