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RECURRENT GRAVES’ THYROTOXICOSIS, AND POSSIBLE PREGNANCY

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RECURRENT GRAVES’ THYROTOXICOSIS, AND  POSSIB LE PREGNANCY

QUESTION-I have a question regarding a 35 y/o with Graves’ relapse and decision for RAI therapy.

She was diagnosed in 2009 and did not complete 18 months of anti-thyroid medication and took it intermittently.

Went to remission with pregnancy and only took PTU in first trimester. I don’t know her initial Ab titre.

Relapsed 7-8 months post partum in 2012 and started CBZ 10 mgB.D and1 month ago dose increased to 10 mg tds
TFT
12/13 Free T4 21 pmol/L
2/14 21
3/14 21
5/14 16
6/14 28
19/11/14 9, TSH still suppressed, Free T3 3.2. Her TSH RAb is 6.4 IU/L  now

Would you still go ahead for RAI therapy given the risk of increased titre and her plan for conception in 6-9 months?
Endotext discourage us to do it if titre is high. Dr Ali Sharafi, Australia

RESPONSE–Several questions remain about your case.  Does she have evident eye problems, and if so, how serious?
Does she take her pills consistently? I would guess not. She appears to have continuing borderline hyperthyroidism
while allegedly taking her CMZ. But 30 mg of CBZ daily during pregnancy sounds like an invitation for trouble.
She seems like a candidate for RAI  treatment to me, with steroid coverage if she has more than minimal eye problems.
It is wise to wait a year after treatment, before pregnancy, to be sure there is no need for a second treatment.
And during pregnancy she will  need close follow because of potential fetal thyroid stimulation, if her TRAbs are TSAbs.
L De Groot, MD