Recommendations for the Use of Thyroxine in the Nontoxic Multinodular Goiter

In practical terms, if TSH suppressive treatment is to be tried, it would be logical to give enough levothyroxine to reduce the TSH consistently to 0.5 mU/L. If the goiter decreases in overall size or remains static (both clinically and by ultrasonography), treatment may be continued indefinitely in a low dose (perhaps in patients younger than 60 years), with periodic monitoring of TSH and thyroglobulin levels to assess the patient for the likelihood of functional anatomy.

If the goiter clinically enlarges, further evaluation for underlying carcinoma is necessary. If the serum TSH concentration is low in the clinically euthyroid case to begin with, levothyroxine is contraindicated because of the likelihood of subclinical incipient functional autonomy. The natural history of these glands is toward hyperthyroidism over a 15- to 25-year period of goiter follow-up.

Goiters that respond usually do so within a period of 6 months of commencement of therapy, so there is little point in continuing treatment if an effect is not observed within this time.

It should also be noted that after surgery for nodular nontoxic goiter, only 15% of patients experience recurrence; hence, potentially lifelong treatment is unnecessary in 85%. One randomized trial comparing levothyroxine therapy versus no therapy after thyroid lobectomy showed no difference in thyroid size after a follow-up of 1 year when the thyroid remnant size was recorded ultrasonographically.127 Several large retrospective studies, including a total of 656 patients and mean follow-up of 5 to 8 years, showed that postoperative levothyroxine therapy did not decrease the frequency of goiter recurrence, which on average was 10% at 8 years.128 In many patients older than 50 years, dominant nodules never change in size after discovery. Because of the logistic difficulty in assessing response to suppressive treatment in multinodular goiter, we do not recommend its use, although other clinicians do.

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