RAI vs Surgery

[ar1281a]

Dear Dr Lupo,

Thanks so much for answering questions on this forum. I've found your answers to be extremely helpful in the past.

I was dx with Graves in 1999. Was hyper for about three years, then went hypo for a year, back to hyper until I achieved remission in 2005. Hyper came back in 2008 and had been taking tapazole since. in august this year, i started developing severe allergic reactions of questionable origin. I was switched to PTU just to rule out a tapazole allergy but the PTU triggered a severe allergic reaction that included a vasculitis-like rash. Stopped PTU and re-introduced tapazole one week later (about three weeks ago). After a few days on tapazole, I started showing allergy sx once again and the rash started to come back (not as bad as before). Stopped tapazole for three days last week, felt better and improved. Re-introduced it again last Friday, just to experience the same sx three days later. I was taken off the tapazole on Monday and have significantly improved. At this point, my allergist believes I have an allergy to both drugs and advice me to see my endo to discuss alternatives. I don't want to do RAI as I've read too many stories about it, so I'm leaning towards surgery. I saw my endo yesterday, but the problem is finding a good surgeon that's available. My questions are:

1) For how long can I be off tapazole before levels start raising and become of concern before surgery? my main concern is getting too hyper too fast.
2) How to know if a surgeon is good? what types of questions should I ask?
3) RAI vs surgery, based on yor experience, what have you seen are the cons of each procedure?
4) Are there any other alternatives to lower thryoid hormones?

Thanks in advance,
ar1281a

[Mark Lupo, M.D.]

1) This varies significantly from patient to patient.  Make sure you are on a beta blocker (atenolol or propanolol usually) to protect the heart while you are making these decisions and until after the treatment is complete

2) Surgeon should do at least 30 thyroid surgeries per year and have experience with Graves'.  Use of SSKI drops for at least 10 days pre-op decreases blood flow and helps control thyroid levels- this may be something to go ahead and start now if you are planning surgery (but NOT if you are doing RAI).

3) This is a huge debate - there is no right answer but common issues involve presence of eye disease, existence of thyroid nodules, availability of skilled surgeon...There may be a trend of increased use of surgery for Graves' patients who fail anti-thyroid drugs.

4) No -except recognize that some patients "burn-out" on their own (so you will see reports online of patients who were cured "naturally" but this is likely the normal disease progression/decline and not a result of alternative treatments).  

Your history makes definitive treatment with surgery or RAI the next logical step.

If you smoke, stop - this makes Graves' worse.

[ar1281a]

Thank you so much Dr Lupo! will ask about BB. One last question, typically, how long does it take after surgery for reaching an optimal thyroid hormone replacement level?