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Effects of block-replace regimen in patients with autoimmune hypothyroidism converted to Graves’ disease

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Abstract

Purpose

We present two cases of autoimmune hypothyroidism converted to Graves’ disease (GD) and their medical management.

Methods

We tested thyroid function and thyroid antibodies and performed an ophthalmologic examination and neck ultrasound in two patients with autoimmune hypothyroidism converted to GD during a follow-up of several years.

Case reports

The first case is a 33 year-old woman with hypothyroidism due to Hashimoto’s thyroiditis (HT). She developed signs and symptoms of hyperthyroidism after 7 years of treatment with the same dose of levothyroxine (LT4). Even when LT4 therapy was discontinued, she remained thyrotoxic, with mild Graves’ ophthalmopathy (GO) and very high thyroid-stimulating hormone receptor antibodies (TRAb > 40 IU/L, reference range: <1.75 IU/L). Antithyroid medication was started on a titration regimen, without achievement of euthyroidism. She was switched to a block and replace regimen, using 20 mg of methimazole (MMI) and 75 mcg of LT4 daily, with normalization of thyroid hormones and improvement of GO without steroids. The second case is a 57 year-old man with a 2-year positive medical history of HT and 6 months of LT4 treatment. He developed hyperthyroidism and moderate-severe GO. Despite stopping LT4 and initiating antithyroid medication in a titration regimen, he did not achieve euthyroidism and had active GO. Pulse glucocorticoid therapy and switching to a block-replace regimen was required to achieve euthyroidism and reduce ocular proptosis and diplopia.

Conclusion

Spontaneous autoimmune conversion of hypothyroidism to hyperthyroidism can occur at any time: it is important to promptly identify these cases so as to manage them effectively.

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Data availability

Original data generated and analyzed during this study are available from the corresponding author on reasonable request.

Abbreviations

AST:

aspartate aminotransferase

BP:

blood pressure

CAS:

Clinical Activity Score

fT4 :

free thyroxine

GD:

Graves’ disease

GP:

general practitioner

HIV:

human immunodeficiency virus

HR:

heart rate

HT:

Hashimoto’s thyroiditis

IGF-1:

insulin-like growth factor 1

GO:

Graves’ ophthalmopathy

MMI:

methimazole

T3 :

triiodothyronine

LT4 :

levothyroxine

TBAb:

thyroid-blocking antibodies

TgAb:

thyroglobulin antibodies

TPOAb:

thyroid peroxidase antibodies

TRAb:

thyroid-stimulating hormone receptor antibodies

TSAb:

thyroid-stimulating antibodies

TSH:

thyroid-stimulating hormone

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Acknowledgements

The authors especially thank the medical staff of the “Thyroid correlation disorders” department for their involvement in the diagnosis and management of patients.

Funding

This work was co-financed by the European Social Fund through the Operational Programme, project number POCU/993/6/13/154722.

Author information

Authors and Affiliations

  1. “Carol Davila” University of Medicine and Pharmacy, Bucharest, Romania

    Ana-Maria Stancu & Corin Badiu

  2. “C.I.Parhon” National Institute of Endocrinology, Bd. Aviatorilor, no. 34-36, sector 1, 011863, Bucharest, Romania

    Ana-Maria Stancu, Daniela Alexandrescu & Corin Badiu

Authors
  1. Ana-Maria Stancu
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  2. Daniela Alexandrescu
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  3. Corin Badiu
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Contributions

AMS studied the literature and wrote the article. DA wrote the data related to Graves' ophthalmopathy. CB: supervised the writing of the article. All authors reviewed and approved the final draft.

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Correspondence to Ana-Maria Stancu.

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Stancu, AM., Alexandrescu, D. & Badiu, C. Effects of block-replace regimen in patients with autoimmune hypothyroidism converted to Graves’ disease. Hormones 23, 107–111 (2024). https://doi.org/10.1007/s42000-023-00496-w

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  • DOI: https://doi.org/10.1007/s42000-023-00496-w

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