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Low iodine diet does not improve the efficacy of radioiodine for the treatment of Graves’ disease

Abstract

Objective

Consuming a low-iodine diet (LID) is a widely accepted practice before administering radioiodine (131I) to evaluate and to treat thyroid disease. Although this procedure is well established for the management of patients with differentiated thyroid cancer, its use in patients with benign disease is unclear. So, we aimed to evaluate the influence of a LID on the outcome in patients with Graves’ disease (GD) treated with131I.

Subjects and methods

We evaluated 67 patients with GD who were divided into 2 groups: one group (n = 31) consumed a LID for 1-2 weeks, and the second group (n = 36) was instructed to maintain a regular diet (RD).

Results

The LID group experienced a 23% decrease in urinary iodine after 1 week on the diet and a significant 42% decrease after 2 weeks on the diet. The majority (53%) of the patients in the LID group had urinary iodine levels that were consistent with deficient iodine intake. However, there was no difference in the rate of hyperthyroidism’s cure between the LID and the RD groups 6 months after 131I therapy. Furthermore, the therapeutic efficacy did not differ in patients with varying degrees of sufficient iodine intake (corresponding urinary iodine levels: < 10 μg/dL is deficient; 10-29.9 μg/dL is sufficient; and > 30 μg/dL is excessive).

Conclusion

In the present study, we demonstrated that although a LID decreased urinary iodine levels, those levels corresponding with sufficient or a mild excess in iodine intake did not compromise the therapeutic efficacy of131I for the treatment of GD.

Urinary iodine; iodine nutritional status; radioiodine; Graves’ disease


INTRODUCTION

Radioiodine (131I) represents one of the first-line therapies for Graves’ disease (GD) (11. Bahn Chair RS, Burch HB, Cooper DS, Garber JR, Greenlee MC, Klein I, et al. Hyperthyroidism and other causes of thyrotoxicosis: management guidelines of the American Thyroid Association and American Association of Clinical Endocrinologists. Thyroid. 2011;21(6):593-646.

2. Franklyn JA, Boelaert K. Thyrotoxicosis. Lancet. 2012;379(9821):1155-66.

3. Maia AL, Scheffel RS, Meyer EL, Mazeto GM, Carvalho GA, Graf H, et al.; Brazilian Society of Endocrinology and Metabolism. The Brazilian consensus for the diagnosis and treatment of hyperthyroidism: recommendations by the Thyroid Department of the Brazilian Society of Endocrinology and Metabolism. Arq Bras Endocrinol Metabol. 2013;57(3):205-32.
-44. Ross DS. Radioiodine therapy for hyperthyroidism. New Engl J Med. 2011;364:542-50.). In the majority of cases, a single dose of 131I is sufficient to restore the patient to euthyroidism or hypothyroidism within 6 to 12 months (44. Ross DS. Radioiodine therapy for hyperthyroidism. New Engl J Med. 2011;364:542-50.). Despite its efficacy, radioiodine therapy (RAIT) fails in 10-50% of cases (44. Ross DS. Radioiodine therapy for hyperthyroidism. New Engl J Med. 2011;364:542-50.). The success of RAIT is influenced by many variables, including gender, age, thyroid volume, prior use of antithyroid drugs and baseline free thyroxine (FT4) levels; however, none of these variables reliably predict the outcome after RAIT (55. Tuttle RM, Patience T, Budd S. Treatment with propylthiouracil before radioactive iodine therapy is associated with a higher treatment failure rate than therapy with radioactive iodine alone in Graves’ disease. Thyroid. 1995;5(4):243-7.

6. Imseis RE, Vanmiddlesworth L, Massie JD, Bush AJ, Vanmiddlesworth NR. Pretreatment with propylthiouracil but not methimazole reduces the therapeutic efficacy of iodine-131 in hyperthyroidism. J Clin Endocrinol Metab. 1998;83(2):685-7.

7. Allahabadia A, Daykin J, Holder RL, Sheppard MC, Gough SC, Franklyn JA. Age and gender predict the outcome of treatment for Graves’ hyperthyroidism. J Clin Endocrinol Metab. 2000;85(3):1038-42.

8. Alexander EK, Larsen PR. High dose of (131)I therapy for the treatment of hyperthyroidism caused by Graves’ disease. J Clin Endocrinol Metab. 2002;87(3):1073-7.

9. Leslie WD, Ward L, Salamon EA, Ludwig S, Rowe RC, Cowden EA. A randomized comparison of radioiodine doses in Graves’ hyperthyroidism. J Clin Endocrinol Metab. 2003;88(3):978-83.

10. Erem C, Kandemir N, Hacihasanoglu A, Ersöz HO, Ukinc K, Kocak M. Radioiodine treatment of hyperthyroidism: prognostic factors affecting outcome. Endocrine. 2004;25(1):55-60.

11. Boelaert K, Syed AA, Manji N, Sheppard MC, Holder RL, Gough SC, et al. Prediction of cure and risk of hypothyroidism in patients receiving 131I for hyperthyroidism. Clin Endocrinol (Oxf). 2009;70(1):129-38.
-1212. Bonnema SJ, Hegedüs L. Radioiodine therapy in benign thyroid diseases: effects, side effects, and factors affecting therapeutic outcome. Endocr Rev. 2012;33(6):920-80.).

The effect of RAIT is directly correlated to the dose of 131I as well as to the dose absorbed by the thyroid tissue (1212. Bonnema SJ, Hegedüs L. Radioiodine therapy in benign thyroid diseases: effects, side effects, and factors affecting therapeutic outcome. Endocr Rev. 2012;33(6):920-80.) although one study showed no difference in this respect (1313. Ruchała M, Sowin8ski J, Dolata M, Junik R, Gembicki M, Skiba A. Radioiodine treatment of hyperthyroidism in patients with low thyroid uptake. Nucl Med Rev Cent East Eur. 2005;8(1):28-32.). It is known that thyroid uptake varies based on the availability of dietary iodine. A decline in radioiodine uptake has been observed over time in populations with benign thyroid disease who are exposed to high amounts of iodine in accordance with public policies of iodine supplementation (1414. Vej-Hansen A, Nygaard B. [Iodine uptake and the effect of radioiodine treatment--status after the addition of iodine to salt]. Ugeskr Laeger. 2005;167(39):3684-7.,1515. Baczyk M, Junik R, Ziemnicka K, Sowin8ski J. Iodine prophylaxis intensification. Influence on radioiodine uptake and activity of 131I used in the treatment of hyperthyroid patients with Graves’ disease. Nuklearmedizin. 2005;44(5):197-9.). Moreover, previous studies have reported that a 25% decline in iodine uptake occurs when iodine excretion is increased by 2-fold (1212. Bonnema SJ, Hegedüs L. Radioiodine therapy in benign thyroid diseases: effects, side effects, and factors affecting therapeutic outcome. Endocr Rev. 2012;33(6):920-80.,1616. Meller B, Haase A, Seyfarth M, Wenzel BE, Richter E, Baehre M. [Reduced radioiodine uptake at increased iodine intake and 131I-induced release of “cold” iodine stored in the thyroid]. Nuklearmedizin. 2005;44(4):137-42.).

To increase 131I uptake, a stringent low-iodine diet (LID) is recommended and its efficacy is easily monitored by measuring urinary iodine levels (1717. Morsch EP, Vanacor R, Furlanetto TW, Schmid H. Two weeks of a low-iodine diet are equivalent to 3 weeks for lowering urinary iodine and increasing thyroid radioactive iodine uptake. Thyroid. 2011;21(1):61-7.,1818. Sawka AM, Ibrahim-Zada I, Galacgac P, Tsang RW, Brierley JD, Ezzat S, et al. Dietary iodine restriction in preparation for radioactive iodine treatment or scanning in well-differentiated thyroid cancer: a systematic review. Thyroid. 2010;20(10):1129-38.). A LID reduces plasma iodine levels, leading to increased expression of sodium-iodide symporter (NIS), thereby increasing 131I uptake (1919. Uyttersprot N, Pelgrims N, Carrasco N, Gervy C, Maenhaut C, Dumont JE, et al. Moderate doses of iodide in vivo inhibit cell proliferation and the expression of thyroperoxidase and Na+/I- symporter mRNAs in dog thyroid. Mol Cell Endocrinol. 1997;131(2):195-203.,2020. De La Vieja A, Dohan O, Levy O, Carrasco N. Molecular analysis of the sodium/iodide symporter: impact on thyroid and extrathyroid pathophysiology. Physiol Rev. 2000;80(3):1083-105.). Although this practice has been widely accepted for the management of differentiated thyroid cancer (DTC), its use in evaluating and treating benign thyroid diseases, particularly GD, has not been demonstrated. In fact, recent guidelines and reviews have suggested that high plasma iodine levels rarely compromise RAIT for thyrotoxicosis and that a LID is only indicated in cases of DTC or nontoxic goiters (11. Bahn Chair RS, Burch HB, Cooper DS, Garber JR, Greenlee MC, Klein I, et al. Hyperthyroidism and other causes of thyrotoxicosis: management guidelines of the American Thyroid Association and American Association of Clinical Endocrinologists. Thyroid. 2011;21(6):593-646.,33. Maia AL, Scheffel RS, Meyer EL, Mazeto GM, Carvalho GA, Graf H, et al.; Brazilian Society of Endocrinology and Metabolism. The Brazilian consensus for the diagnosis and treatment of hyperthyroidism: recommendations by the Thyroid Department of the Brazilian Society of Endocrinology and Metabolism. Arq Bras Endocrinol Metabol. 2013;57(3):205-32.,1212. Bonnema SJ, Hegedüs L. Radioiodine therapy in benign thyroid diseases: effects, side effects, and factors affecting therapeutic outcome. Endocr Rev. 2012;33(6):920-80.). However, information regarding the effects of LID on the therapeutic efficacy of 131I on GD is lacking.

In the present study, we aimed to evaluate the effectiveness of a LID at achieving a nutritionally deficient state and to determine the impact of this condition on the response to 131I treatment.

SUBJECTS AND METHODS

Patients

We enrolled consecutively 67 patients with GD (59 women and 8 men; age range, 16-76 years) who were referred to our Thyroid Outpatient Clinic. GD was diagnosed based on the presence of signs and symptoms of hyperthyroidism, diffuse goiter and laboratory tests consistent with thyrotoxicosis. The Ethical Committee of our institution approved the protocol (CAAE: 02584112.5.0000.5505) and all the patients signed an informed consent.

Laboratory analyses

Patients were followed for 2 weeks before RAIT and were examined weekly to determine thyroid function and to measure urinary iodine levels. Serum free thyroxine (FT4) and thyroid-stimulating hormone (TSH) levels were determined by electrochemiluminescence using commercially available kits (Roche Diagnostics, Mannheim, Germany). The reference values were as follows: TSH = 0.3-4.0 mU/L and FT4 = 0.6-1.5 ng/dL. Thyroid ultrasound was performed in all patients using an ENVISOR Doppler Duplex (Philips, Andover, MA, USA), with a 12-MHz linear array transducer. The same examiner, who was blinded to the patients’ clinical conditions, performed all of the thyroid measurements.

Urinary iodine from spot samples was quantified by a semi-automatic spectrophotometric method using the Sandell-Kolthoff reaction (2121. Esteves RZ, Kasamatsu TS, Kunii IS, Furuzawa GK, Vieira JG, Maciel RM. [Development of a semi-automated method for measuring urinary iodine and its application in epidemiological studies in Brazilian schoolchildren]. Arq Bras Endocrinol Metabol. 2007;51(9):1477-84.). Each sample was digested with 0.1 M ammonium persulfate for 60 minutes at 95°C. After cooling, the samples were incubated with 0.02 M arsenious acid for 15 minutes and with 0.02 M ceric sulfate for 40 minutes, and the absorbance was measured at 405 nm. The amount of iodine present in each sample was determined by comparing the absorbance with a standard curve. This technique has an analytical sensitivity of 1.0 µg/dL.

Low-iodine diet

Two weeks before RAIT, the patients were allocated alternately into 2 groups: one group consumed a LID (n = 31), corresponding to a maximum amount of 50 µg iodine/day (2222. Sapienza MT, Endo IS, Campos Neto GC, Tavares MG, Marone MM. [Radioiodine therapy for differentiated thyroid carcinoma: methods used to increase the radiation absorbed dose]. Arq Bras Endocrinol Metabol. 2005;49(3):341-9.), and the other group (n = 36) was instructed to maintain a regular diet (RD). We monitored patient compliance to their diet each week and emphasized its importance. Considering that a restrictive diet would result in urinary iodine excretion levels consistent with iodine nutritional deficiency, dietary efficacy was also interpreted based on the iodine nutritional status criteria developed by the International Council for Control of Iodine Deficiency Disorders (ICCIDD) and the World Health Organization (WHO). Urinary iodine excretion < 10 µg/dL indicates deficient intake; urinary iodine between 10 µg/dL and 29.9 µg/dL denotes a sufficient nutritional status; and urinary iodine ≥ 30 µg/dL corresponds to excessive iodine ingestion.

Radioiodine therapy and follow-up

All of the patients discontinued antithyroid drugs 5 days before RAIT. All patients received a fixed dose of 555 MBq (15 mCi) of 131I. Antithyroid medication was reintroduced in the follow up to the symptomatic patients with persistent low TSH and increased FT4.

After treatment, the patients were examined at 1, 2, 3 and 6 months for clinical and laboratory evaluations. At 6 months of follow-up, patients were classified as “cured” if: a) they developed hypothyroidism and were receiving levothyroxine (LT4) replacement; or b) the FT4 levels were within the reference range with no use of antithyroid medication.

Statistical analysis

We utilized the Mann-Whitney test to compare the quantitative variables (age, TSH levels, T4L levels, urinary iodine concentration and thyroid volume). We analyzed gender and treatment response using Fisher’s exact test. We utilized ANOVA to compare the temporal progression of urinary iodine levels from baseline to 1 week to 2 weeks on a LID. Statistical significance was established at p < 0.05. We performed all of the analyses using GraphPad Prism 5.0 (GraphPad Software, Inc., La Jolla, CA, USA).

RESULTS

The impact of a LID on urinary iodine excretion

Table 1 presents the clinical and laboratory characteristics of the patients included in the study. At baseline, there were no significant differences between the LID and the RD groups in terms of gender, age, duration of disease, thyroid volume or TSH, FT4 or urinary iodine levels.

Table 1
Clinical and laboratory characteristics of patients who were maintained on low-iodine diet (LID) or in regular diet (RD)

After a restrictive diet, the urinary iodine levels in the LID group decreased by 23% after the first week (p = 0.054) followed by a significant 42% decline after 2 weeks (Figure 1A). However, there was no significant difference in the reduction in urinary iodine levels between 1 week and 2 weeks on a LID. In the RD group, there was no difference in urinary iodine excretion after 1 or 2 weeks compared with baseline (Figure 1B).

Figure 1
Effect of low-iodine diet in the urinary iodine excretion. LID, low-iodine diet (A). RD, regular diet (B). * p < 0.05 if compared to baseline. ** Not significant in the comparison with baseline and 1 week.

The proportion of patients in the LID and RD groups whose iodine urinary excretion indicated deficient, sufficient or excessive iodine intake did not differ at baseline (Table 2); nevertheless, more than 80% of the patients in both groups presented with urinary iodine levels compatible with sufficient or excessive iodine intake. However, in the LID group, the proportion of patients who exhibited levels consistent with deficient iodine intake after 2 weeks on the restrictive diet increased from 16% to more than 53% (p < 0.05). Further, the percentage of patients with urinary iodine levels corresponding to excessive iodine intake decreased significantly from 26% to less than 7%. Nevertheless, approximately 40% of the patients who consumed a LID had urinary iodine levels that were compatible with sufficient or excessive iodine intake. In the RD group, the percentage of patients with urinary iodine levels corresponding to deficient iodine intake increased from 8.3% to 30.5%. However, in this group, those patients with urinary iodine levels indicative of sufficient or excessive iodine intake remained nearly constant throughout the study (Table 2).

Table 2
Distribution of patients according to the adequacy of iodine intake as recommended by ICCIDD/WHO

The impact of LID on the response to radioiodine

Patients who progressed to hypothyroidism or maintained their FT4 levels within the reference values were considered to be cured. We compared the proportion of cured patients in the LID and the RD groups and did not identify a statistical difference between them during the follow-up period (Table 3). In the low iodine diet (LID) group, there were 0, 7, 17 and 21 patients in hypothyroidism at 1th, 2nd, 3rd and 6th months after131I, respectively; while 9, 11, 7 and 5 patients were in euthyroidism at the same period of times. On the other hand, in the regular diet (RD) group, there were 0, 9, 21 and 23 patients in hypothyroidism at 1th, 2nd, 3rd and 6th months after 131I, respectively; while 10, 10, 8 and 6 patients were in euthyroidism at that times. In this analysis, one patient in each group was excluded due to loss of follow-up. At six month, only one patient from each group was on antithyroid drug treatment.

Table 3
Effect of low-iodine diet in the proportion of cure after radioiodine

We also evaluated whether urinary iodine levels at the time of treatment, regardless of whether the patients adhered to a restrictive diet, affected the response to radioiodine. We regrouped the patients according to their urinary iodine levels indicative of deficient, sufficient or excessive iodine intake and determined whether their hyperthyroidism was controlled. As presented in table 4, there were no differences among these 3 groups with regard to clinical or laboratory parameters, with the exception of urinary iodine. Among these 3 groups, the proportion of cured patients did not differ after 6 months of follow-up (Table 4). In fact, approximately 80% of the patients achieved a cure 3 months after 131I treatment; this percentage was maintained throughout the 6-month follow-up.

Table 4
Baseline laboratory and clinical characteristics according to the degree of iodine nutritional intake and proportion of cure at 6th month after radioiodine

DISCUSSION

In the present study, we demonstrated that although a LID efficiently decreased urinary iodine excretion, this reduction did not affect the therapeutic response to131I. The results indicated that even at urinary iodine levels compatible with sufficient or slightly excessive endogenous iodine, there was no reduction in the cure rate for hyperthyroidism compared with patients with a clear iodine deficiency who received 131I.

A LID is routinely prescribed before RAIT, especially in patients with DTC (1818. Sawka AM, Ibrahim-Zada I, Galacgac P, Tsang RW, Brierley JD, Ezzat S, et al. Dietary iodine restriction in preparation for radioactive iodine treatment or scanning in well-differentiated thyroid cancer: a systematic review. Thyroid. 2010;20(10):1129-38.,2323. Pacini F, Schlumberger M, Dralle H, Elisei R, Smit JW, Wiersinga W; European Thyroid Cancer Taskforce. European consensus for the management of patients with differentiated thyroid carcinoma of the follicular epithelium. Eur J Endocrinol. 2006;154(6):787-803.

24. Luster M, Clarke SE, Dietlein M, Lassmann M, Lind P, Oyen WJ, et al.; European Association of Nuclear Medicine (EANM). Guidelines for radioiodine therapy of differentiated thyroid cancer. Eur J Nucl Med Mol Imaging. 2008;35(10):1941-59.
-2525. American Thyroid Association (ATA) Guidelines Taskforce on Thyroid Nodules and Differentiated Thyroid Cancer; Cooper DS, Doherty GM, Haugen BR, Kloos RT, Lee SL, Mandel SJ, et al. Revised American Thyroid Association management guidelines for patients with thyroid nodules and differentiated thyroid cancer. Thyroid. 2009;19(11):1167-214.). Such a diet reduces the endogenous pool of iodine, thereby contributing to the increased uptake and half-life of 131I in the thyroid remnant. This enhanced uptake might result from increased NIS gene expression, a higher specific activity of131I or the increased sensitivity of the remaining thyroid tissue to TSH (1919. Uyttersprot N, Pelgrims N, Carrasco N, Gervy C, Maenhaut C, Dumont JE, et al. Moderate doses of iodide in vivo inhibit cell proliferation and the expression of thyroperoxidase and Na+/I- symporter mRNAs in dog thyroid. Mol Cell Endocrinol. 1997;131(2):195-203.,2020. De La Vieja A, Dohan O, Levy O, Carrasco N. Molecular analysis of the sodium/iodide symporter: impact on thyroid and extrathyroid pathophysiology. Physiol Rev. 2000;80(3):1083-105.). Despite the controversy regarding the appropriate degree and duration of a LID (2626. Hinds SR 2nd, Stack AL, Stocker DJ. Low-iodine diet revisited: importance in nuclear medicine imaging and management. Clin Nucl Med. 2008;33(4):247-50.,2727. Tomoda C, Uruno T, Takamura Y, Ito Y, Miya A, Kobayashi K, et al. Reevaluation of stringent low iodine diet in outpatient preparation for radioiodine examination and therapy. Endocr J. 2005;52(2):237-40.), the general recommendation is that patients should consume a LID, generally consisting of less than 50 μg iodine/day, for 1 to 4 weeks (1818. Sawka AM, Ibrahim-Zada I, Galacgac P, Tsang RW, Brierley JD, Ezzat S, et al. Dietary iodine restriction in preparation for radioactive iodine treatment or scanning in well-differentiated thyroid cancer: a systematic review. Thyroid. 2010;20(10):1129-38.,2222. Sapienza MT, Endo IS, Campos Neto GC, Tavares MG, Marone MM. [Radioiodine therapy for differentiated thyroid carcinoma: methods used to increase the radiation absorbed dose]. Arq Bras Endocrinol Metabol. 2005;49(3):341-9.). This stringent diet results in a significant decrease in urinary iodine excretion, ranging from 50% to 80%; more than 80% of the patients develop iodine deficiency. Consequently, this diet increases treatment effectiveness by more than 65% (2727. Tomoda C, Uruno T, Takamura Y, Ito Y, Miya A, Kobayashi K, et al. Reevaluation of stringent low iodine diet in outpatient preparation for radioiodine examination and therapy. Endocr J. 2005;52(2):237-40.,2828. Pluijmen MJ, Eustatia-Rutten C, Goslings BM, Stokkel MP, Arias AM, Diamant M, et al. Effects of low-iodide diet on postsurgical radioiodide ablation therapy in patients with differentiated thyroid carcinoma. Clin Endocrinol (Oxf). 2003;58(4):428-35.).

In the present study, urinary iodine excretion decreased by 23% in the first week and by more than 40% in the second week of a LID; this rate was lower than those reported in previous studies (2929. Lakshmanan M, Schaffer A, Robbins J, Reynolds J, Norton J. A simplified low iodine diet in I-131 scanning and therapy of thyroid cancer. Clin Nucl Med. 1988;13(12):866-8.

30. Park 2nd JT, Hennessey JV. Two-week low iodine diet is necessary for adequate outpatient preparation for radioiodine rhTSH scanning in patients taking levothyroxine. Thyroid. 2004;14(1):57-63.
-3131. Prestwich RJ, Gerrard GE. Low-iodine diet before radioiodine uptake scans or therapy – flawed advice to U.K. patients. Clin Oncol (R Coll Radiol). 2005;17(2):73-4.). Moreover, only 53% of the patients achieved iodine deficiency after a 2-week diet. However, previous reports (2929. Lakshmanan M, Schaffer A, Robbins J, Reynolds J, Norton J. A simplified low iodine diet in I-131 scanning and therapy of thyroid cancer. Clin Nucl Med. 1988;13(12):866-8.

30. Park 2nd JT, Hennessey JV. Two-week low iodine diet is necessary for adequate outpatient preparation for radioiodine rhTSH scanning in patients taking levothyroxine. Thyroid. 2004;14(1):57-63.
-3131. Prestwich RJ, Gerrard GE. Low-iodine diet before radioiodine uptake scans or therapy – flawed advice to U.K. patients. Clin Oncol (R Coll Radiol). 2005;17(2):73-4.) evaluated patients with DTC who underwent a thyroidectomy, which could explain this discrepancy because iodine clearance is faster in the absence of the thyroid. A recent study demonstrated that patients with DTC who underwent thyroid surgery and were subsequently exposed to iodine contrast exhibited normal urinary iodine levels 4 weeks after a LID (3232. Padovani RP, Kasamatsu TS, Nakabashi CC, Camacho CP, Andreoni DM, Malouf EZ, et al. One month is sufficient for urinary iodine to return to its baseline value after the use of water-soluble iodinated contrast agents in post-thyroidectomy patients requiring radioiodine therapy. Thyroid. 2012;22(9):926-30.). Another recent study reported that patients with an intact thyroid who underwent intravenous iodinated contrast procedures required approximately 75 days to achieve baseline urinary iodine levels (3333. Nimmons GL, Funk GF, Graham MM, Pagedar NA. Urinary iodine excretion after contrast computed tomography scan: implications for radioactive iodine use. JAMA Otolaryngol Head Neck Surg. 2013;139(5):479-82.).

Recent guidelines for and reviews of the treatment of hyperthyroidism do not recommend a special diet before RAIT, except in cases where the patients have been exposed to excessive amounts of iodine via iodinated contrast or amiodarone (11. Bahn Chair RS, Burch HB, Cooper DS, Garber JR, Greenlee MC, Klein I, et al. Hyperthyroidism and other causes of thyrotoxicosis: management guidelines of the American Thyroid Association and American Association of Clinical Endocrinologists. Thyroid. 2011;21(6):593-646.,33. Maia AL, Scheffel RS, Meyer EL, Mazeto GM, Carvalho GA, Graf H, et al.; Brazilian Society of Endocrinology and Metabolism. The Brazilian consensus for the diagnosis and treatment of hyperthyroidism: recommendations by the Thyroid Department of the Brazilian Society of Endocrinology and Metabolism. Arq Bras Endocrinol Metabol. 2013;57(3):205-32.). However, no studies have convincingly demonstrated whether an adequate or slightly elevated iodine nutritional status has a negative impact on the treatment of hyperthyroidism. A single recent study compared the impact of an iodine-restrictive diet for 2 or 3 weeks on patients referred for investigation based on suppressed TSH levels associated with thyroid nodules and goiters (1717. Morsch EP, Vanacor R, Furlanetto TW, Schmid H. Two weeks of a low-iodine diet are equivalent to 3 weeks for lowering urinary iodine and increasing thyroid radioactive iodine uptake. Thyroid. 2011;21(1):61-7.). In this study, 2 and 3 weeks of a LID similarly decreased urinary iodine levels by 60%, which was accompanied by an approximately 40% increase in131I uptake by the thyroid. However, in that study, the outcome after RAIT was not evaluated. In our study, we do not analyze 131I uptake only the impact of RD. In this respect, we showed that there was a smaller decline in urinary iodine after 2 weeks on a LID (43%) compared with previous reports. Several factors might explain this difference in the percent urinary iodine decrease after a LID, such as distinct etiologies of thyroid diseases, patient compliance to the strict diet and differences in the basal nutritional status of the patients in the 2 studies. In the present report, we demonstrated that the efficacy of RAIT for GD was not compromised by the iodine nutritional status, even when patients presented with urinary iodine excretion compatible with mildly excessive iodine ingestion. The study has some limitations and the main one is a limited number of patients. These findings will need to be confirmed in a larger cohort.

In summary, our study revealed that the corporal iodine pool did not compromise the therapeutic response to 131I in patients with GD; in fact, the majority of patients exhibited the criteria for being cured after 6 months of RAIT, regardless of the urinary iodine levels. Then, for the management of patients with GD, we recommend a less stringent diet for a shorter time, along with the determination of urinary iodine levels to exclude exogenous and extreme iodine contamination, which will likely be sufficient before undergoing RAIT.

Acknowledgments

we are grateful for Yeda Queiroga Confessor and Ângela Maria Faria for their administrative assistance and The Federal Agency of Support and Evaluation of Postgraduate Education (Coordenação de Aperfeiçoamento de Pessoal de Nível Superior – Capes) and the São Paulo Research Foundation (Fundação de Amparo à Pesquisa do Estado de São Paulo – Fapesp) for financial support.

REFERENCES

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    Ross DS. Radioiodine therapy for hyperthyroidism. New Engl J Med. 2011;364:542-50.
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    Tuttle RM, Patience T, Budd S. Treatment with propylthiouracil before radioactive iodine therapy is associated with a higher treatment failure rate than therapy with radioactive iodine alone in Graves’ disease. Thyroid. 1995;5(4):243-7.
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    Imseis RE, Vanmiddlesworth L, Massie JD, Bush AJ, Vanmiddlesworth NR. Pretreatment with propylthiouracil but not methimazole reduces the therapeutic efficacy of iodine-131 in hyperthyroidism. J Clin Endocrinol Metab. 1998;83(2):685-7.
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    Ruchała M, Sowin8ski J, Dolata M, Junik R, Gembicki M, Skiba A. Radioiodine treatment of hyperthyroidism in patients with low thyroid uptake. Nucl Med Rev Cent East Eur. 2005;8(1):28-32.
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    Vej-Hansen A, Nygaard B. [Iodine uptake and the effect of radioiodine treatment--status after the addition of iodine to salt]. Ugeskr Laeger. 2005;167(39):3684-7.
  • 15
    Baczyk M, Junik R, Ziemnicka K, Sowin8ski J. Iodine prophylaxis intensification. Influence on radioiodine uptake and activity of 131I used in the treatment of hyperthyroid patients with Graves’ disease. Nuklearmedizin. 2005;44(5):197-9.
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    Meller B, Haase A, Seyfarth M, Wenzel BE, Richter E, Baehre M. [Reduced radioiodine uptake at increased iodine intake and 131I-induced release of “cold” iodine stored in the thyroid]. Nuklearmedizin. 2005;44(4):137-42.
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Publication Dates

  • Publication in this collection
    25 Sept 2015
  • Date of issue
    Dec 2015

History

  • Received
    5 May 2015
  • Accepted
    18 June 2015
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