RADIOACTIVE IODINE THERAPY (RAI)

Radioactive iodine (I-131) or RAI as it shall now be referred to, has been commonly used for
the treatment of both benign and malignant thyroid conditions since the 1940s.
GOALS : to treat hyperthyroidism by destroying sufficient thyroid tissue to render the patient
either euthyroid or hypothyroid.

WHAT IS I-131?
Iodine-131 is a beta-emitting radionuclide with a maximum energy of 0.61 MeV, an average
energy of 0.192 MeV, and a range in tissue of 0.8 mm. It remains the radionuclide of choice
for therapy because of its long half-life of just over 8 days.
MoA
Iodine is the precursor of thyroxine.
The radioactive form of iodine is taken up by iodide transporter of the thyroid the same way
as natural iodine and is similarly processed  The beta particle destroys the follicular cell  Commented [HNP1]: Beta particles are high energy
gradually leading to volume reduction and control of the thyrotoxicosis. electrons in unstable nuclei. Tersusun bukan dari electron
yang di cangkang nucleus, tapi dari neutron yang terpecah
jadi proton. Beta particles  (-)
Indications and contraindications for RAI therapy

The main indications for RAI therapy include the following conditions

1. Hyperthyroidism due to:

a. Grave’s disease

b. Toxic multinodular giotre or

c. Hyperfunctioning thyroid nodules

2. Non-toxic multinodular goitre

3. Thyroid cancer.

Contra-indications for RAI therapy

1. Pregnancy

2. Breast feeding

3. Severe uncontrolled thyrotoxicosis

 Indications for radioactive iodine over antithyroid agents include
- a large thyroid gland,
- multiple symptoms of thyrotoxicosis,
- high levels of thyroxine,
- high titers of TSI.
 Many physicians in the United States prefer to use radioactive iodine as first-line
therapy, especially in younger patients  karena kalo pake antithyroid drugs biasanya
tingkat relapse nya >50%
 Usual dose ranges from 5-15 mCi, , ditentukan dengan menggunakan berbagai Commented [HNP2]: Ci = curie (mCi = millicurie) 
satuan zat radioaktif
formula yang memperhitungkan taksiran berat tiroid dan serapan radioiodine atau
dengan menggunakan dosis tetap iodium I 131.
A fixed dose of 7 mCi has been advocated by some researchers as the first
empirical dose in the treatment of hyperthyroidism.
In general, higher dosages are required for patients who have
- large goiters,
- have low radioiodine uptake,
- or who have been pretreated with antithyroid drugs.
 Patients currently taking antithyroid drugs must discontinue the medication at least
2 days prior to taking the radiopharmaceutical
 Thyroid function test results generally improve within 6-8 weeks of therapy
 The desired result is hypothyroidism due to destruction of the gland, which usually
occurs 2-3 months after administration. Approximately one third of patients develop
transient hypothyroidism. Unless a patient is highly symptomatic, thyroxine
replacement may be withheld if hypothyroidism occurs within the first 2 months of
therapy. If it persists for longer than 2 months, permanent hypothyroidism is likely
and replacement with T4 should be initiated.
 Following up with the patient and monitoring thyroid function monthly or as the
clinical condition dictates
 The possibility exists that radioactive iodine can precipitate thyroid storm by
releasing thyroid hormones. This risk is higher in elderly and debilitated patients.
This problem can be addressed by pretherapy administration with antithyroidal
medication such as propylthiouracil (PTU) or methimazole, but antithyroid
medication also may decrease the effectiveness of radioiodine
 If thyroid function does not normalize within 6-12 months of treatment, a second
course at a similar or higher dose can be given. Third courses are rarely needed.
 Radiation thyroiditis is rare, but it may occur and exacerbate thyrotoxicosis
 Long-term follow-up is mandatory for all patients
 If possible in patients with mild progressive ophthalmopathy, institute a course of
steroids (prednisone up to 1 mg/kg) for 2-3 months, tapering a few days before
radioiodine therapy.  RAI bias memperparah
 CONTRAINDICATION : pregnancy  there is a very small increased risk that the baby may
go on to develop cancer in childhood

SURGICAL CARE
a) THYROIDECTOMY
 Not the recommended first-line therapy for hyperthyroid Graves disease in the
United States.
 Surgery is a safe alternative therapeutic option in patients who are
- noncompliant with or cannot tolerate antithyroid drugs,
- have moderate-to-severe ophthalmopathy,
- have large goiters,  Abnormal enlargement of the butterfly-shaped gland below the
Adam's apple (thyroid)
- or refuse or cannot undergo radioiodine therapy.
 more effective than radioiodine therapy to achieve cure and reduce recurrence
 may be appropriate in the presence of a thyroid nodule that is suggestive of
carcinoma
 In certain cases (e.g. in pregnant patients with severe hyperthyroidism), may be
indicated because radioactive iodine and antithyroid medications may be
contraindicated
Procedure & Preparations :

 Preoperative preparation to render the patient euthyroid is essential in order to Commented [HNP3]: Keadaan thyroid normal
prevent thyrotoxic crisis (thyroid storm)  USE PHARMACOLOGICAL TREATMENT Commented [HNP4]: an acute, life-threatening,
(e.g combination of iopanoic acid, dexamethasone, beta-blockers, and thioamides). hypermetabolic state induced by excessive release of
thyroid hormones (THs) in individuals with thyrotoxicosis.
This can be accomplished with the use of antithyroid drugs for approximately 6
Commented [HNP5]: potent inhibitors of thyroid
weeks, with or without concomitant beta-blockade. hormone release from thyroid gland
 Most surgeons administer iodine (as Lugol solution or saturated solution of Commented [HNP6]: corticosteroid
potassium iodide to provide ≥30 mg of iodine/d) for 10 days before surgery to Commented [HNP7]: e.g prophyltiourasil  blocking the
- decrease thyroid gland vascularity, synthesis of T4 by preventing iodination of tyrosine residues

- decrease the rate of blood flow, and

- decrease intraoperative blood loss during thyroidectomy
 COMPLICATIONS :
- Injury to recurrent or superior laryngeal nerve
 can yield vocal fold paresis or paralysis
 the patient usually presents with postoperative persistent hoarseness.
 Patients with suspected recurrent laryngeal nerve injury should be evaluated
with flexible laryngoscopy or videostroboscopy to confirm the position and
movement of the vocal folds
- Vocal cord paralysis due to superior or recurrent laryngeal nerve injury
- Hypoparathyroidism
- Hypocalcemia secondary to hypoparathyroidism
 related to a transient ischemia to the parathyroid glands.
 Patients who are noted to have postoperative hypocalcemia should be
managed with calcium supplementation.
- Recurrent hyperthyroidism
 - Thyrotoxic storm
 precipitation of a thyroid storm, which can occur intraoperatively or
postoperatively
 Manifestations include tachycardia, hyperthermia, cardiac arrhythmias, and
increased sympathetic output. Awake patients also present with nausea and
altered mental status. If untreated, it may precipitate coma and death
 Intraoperatively : case needs to be halted and the patient needs to be
medically managed to reduce sympathetic output. Cooling blankets, beta-
blockers, PTU, and iodine should be administered.
 Postoperatively : should be continued on preventative medication.
Medications can be weaned as thyroid hormone levels decrease.
 Subtotal thyroidectomy is usually used with the intention of leaving enough thyroid
remnants behind to avoid hypothyroidism  the risk of recurrent hyperthyroidism
potentially increases with larger remnant sizes
 If the goal of surgery is to avoid recurrent hyperthyroidism, near-total
thyroidectomy has been advocated as the procedure of choice.
 all patients require long-term follow-up
 TYPES :
- Total thyroidectomy is an operation that involves the surgical removal of the
whole thyroid gland.
- Near-total thyroidectomy is an operation that involves the surgical removal of
both thyroid lobes except for a small amount of thyroid tissue (on one or
both sides less than 1.0 mL).
- Subtotal thyroidectomy leaves 3 g to 5 g on the less affected side of the
thyroid gland.
 PROCEDURE :
- Incision and exposure of the thyroid gland
- Releasing the superior pole
 dissect the overlying strap muscles off of the thyroid gland without
injuring the subcapsular vessels. Next, the cricothyroid space should be
identified and dissected
 Care should be taken to avoid injuring the external branch of the superior
thyroid nerve
- Identifying the parathyroid glands
 After identifying the glands, they should be carefully dissected from the
thyroid and left in the thyroid bed.
- Identifying the recurrent laryngeal nerve
 Once the nerve is identified anatomically, its identity and integrity may be
confirmed with nerve stimulation.
 The course of the nerve should be bluntly dissected using the Reinhoff or a
right angle clamp
 - Removing the thyroid gland
- Closure

b) OPTHALMOPATHY
 If ophthalmopathy is severe but inactive,
- orbital decompression may be performed  Reducing proptosis and
decompressing the optic nerve can be achieved by transantral orbital
decompression
 The major adverse effect is postoperative diplopia, which may necessitate a second Commented [HNP8]: the subjective complaint of seeing
2 images instead of one
surgery on the extraocular muscles to correct the problem
 Rehabilitative (extraocular muscle or eyelid) surgery is often needed. Eyelid surgery
(eg, severance of the Müller muscle, scleral or palatal graft insertion) can be
performed to improve exposure keratitis.
SUMBER :

 https://emedicine.medscape.com/article/120619-treatment
 https://www.thyroid.org/graves-disease/
 https://www.ncbi.nlm.nih.gov/pubmed/26670972
 Greenspan’s 9th Edition Chapter 7 Page 198
 https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3336179/
 http://www.passmyexams.co.uk/GCSE/physics/alpha-beta-gamma-rays.html
 https://www.cochrane.org/CD010370/ENDOC_total-or-near-total-thyroidectomy-versus-
subtotal-thyroidectomy-multinodular-non-toxic-goitre-adults
 https://emedicine.medscape.com/article/1891109-overview#a5