How should hyperthyroidism be managed in the setting of ICPI therapy?
Patients with destructive thyroiditis who are asymptomatic can be monitored, and those with significant symptoms (palpitations, tremors) can be treated with beta-blockers and, if necessary, steroids. If and when patients convert to a hypothyroid phase, asymptomatic patients can be monitored with serial thyroid laboratory evaluations every 4 to 6 weeks, and symptomatic patients can be placed on thyroid hormone replacement with dose titration until the serum TSH is within the reference range. After 4 to 8 months, patients can be taken off medication to determine if they still require treatment. Patients with clinical autoimmune hyperthyroidism can be treated with antithyroid medications, such as methimazole (MMI) or propylthiouracil (PTU), and with beta-blockers, as necessary. If a patient is experiencing grade 3 or 4 toxicity, ICPIs should be withheld and the patient hospitalized, as necessary, until stabilized. In addition, avoidance of interventions that may exacerbate thyroid disease, such as iodinated contrast administration, is recommended until the patient is placed on medications that will control the thyroid disease. Treatment with RAI ( 131 I) or thyroidectomy can also be considered.