Post-radioiodine Graves’ management: the PRAGMA study

Petros Perros, Ansu Basu, Kristien Boelaert, Colin Dayan, Bijay Vaidya, Graham R. Williams, John H Lazarus, Janis Hickey, William M Drake, Anna Crown, Stephen M Orme, Andrew Johnson, David W. Ray, Graham P. Leese, T Hugh Jones, Prakash Abraham, Ashley Grossman, Aled Rees, Salman Razvi, Fraser W GibbCarla Moran, Asgar Madathil, Miloš P. Žarković, Zoe Plummer, Sheba Jarvis, Agnieszka Falinska, Anand Velusamy, Violet Sanderson, Nadia Parian, Stephen L Atkin, Akheel A Syed, Thozhukat Sathyapalan, Sath Nag, Jackie Gilbert, Helena Gleeson, Miles J. Levy, Colin Johnston, Nigel Sturrock, Stuart Bennett, Biswa Mishra, Isha Malik, Niki Karavitaki

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Retrospective, multi-centre, observational study.

Adult patients with Graves’ disease treated with radioiodine with 12 months’ follow-up.

Euthyroidism was defined as both serum thyrotropin (TSH) and free thyroxine (FT4) within their reference ranges or, when only one was available, it was within its reference range; hypothyroidism as TSH ≥ 10 mu/L, or subnormal FT4 regardless of TSH; hyperthyroidism as TSH below and FT4 above their reference ranges; dysthyroidism as the sum of hypo- and hyperthyroidism; subclinical hypothyroidism as normal FT4 and TSH between the upper limit of normal and <10 mu/L; subclinical hyperthyroidism as low TSH and normal FT4

Of 812 patients studied post-radioiodine, hypothyroidism occurred in 80.7% and hyperthyroidism in 48.6% of patients. Three principal post-radioiodine management strategies were employed: (a) anti-thyroid drugs alone, (b) levothyroxine alone and (c) combination of the two. Differences among these were small. Adherence to national guidelines regarding monitoring thyroid function in the first 6 months was low (21.4–28.7%). No negative outcomes (new-onset/exacerbation of Graves’ orbitopathy, weight gain, cardiovascular events), were associated with dysthyroidism. There were significant differences in demographics, clinical practice, and thyroid status post-radioiodine between centres.

Dysthyroidism in the 12 months post-radioiodine was common. Differences between post-radioiodine strategies were small, suggesting these interventions alone are unlikely to address the high frequency of dysthyroidism.

Original languageEnglish
Pages (from-to)664-675
JournalClinical Endocrinology
Issue number5
Early online date11 Mar 2022
Publication statusE-pub ahead of print - 11 Mar 2022


  • Graves' disease
  • hyperthyroidism
  • hypothyroidism
  • radioiodine
  • thyroid


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