Episode - 3 Reasons To Avoid Radioactive Iodine


Three Reasons to Avoid Radioactive Iodine

Radioactive iodine is commonly recommended by endocrinologists as a treatment for hyperthyroidism.  While conventional treatment methods are sometimes necessary, options such as radioactive iodine and thyroid surgery should be avoided whenever possible, as the goal should be to address the underlying cause of the condition.  That being said, for those who are thinking about radioactive iodine but need further convincing as to why they should avoid it, during this episode I’ll discuss three reasons why you’ll want to avoid it.

During this episode you’ll learn:

  • The risks of receiving radioactive iodine in Graves’ disease patients
  • The risks of receiving radioactive iodine in those with toxic multinodular goiter
  • What the research shows regarding the quality of life when comparing radioactive iodine, thyroid surgery, and antithyroid medication
  • Whether thyroid surgery is a better option
  • My thoughts on long-term antithyroid medication

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Here is the transcript for this episode:

Welcome back to the Save My Thyroid podcast. This is Dr. Eric Osansky. And in this episode, I will discuss three reasons why you should avoid radioactive iodine. Before I begin, I want to let you know that I am not completely opposed to conventional medical treatment. I realize that there is a time and place for thyroid surgery. Many of my patients do take antithyroid medication, such as methimazole. However, when it comes to radioactive iodine, in most cases, perhaps even in all cases, I think this should be avoided. During this episode, I will tell you why. Let’s get started.

The first reason is because radioactive iodine obviously does not do anything to address the cause of the condition. Endocrinologists don’t do anything for the underlying cause. By not addressing the underlying cause of the condition, this could lead to other health issues in the future. For example, someone with Graves’ Disease is more likely to develop other autoimmune conditions in the future if the autoimmune component isn’t addressed. For those with toxic multinodular goiter, some of the common causes include insulin resistance and problems with estrogen metabolism. Ideally, these need to be addressed as well.

A second reason why you should not receive radioactive iodine is because the quality of life is worse for those who receive radioactive iodine. This isn’t me just saying this; this is according to the research. Although earlier studies show that quality of life is similar among patients treated by antithyroid drugs, radioactive iodine, or thyroid surgery, a more recent study didn’t confirm this.

This study involved 1,186 patients with Graves’ Disease. 347 patients were treated with antithyroid drugs only, 395 patients treated with radioactive iodine, and 233 patients treated with surgery. Quality of life was assessed using two different questionnaires on an average of eight years after the diagnosis of Graves’ Disease.

Among the three treatment groups, patients who received radioactive iodine treatment had worse thyroid-specific quality of life scores than patients treated with antithyroid drugs or surgery. The radioactive iodine therapy group had worse scores for the following: hyperthyroid symptoms, goiter symptoms, fatigue, anxiety, depression, emotional susceptibility, impaired social life, impaired daily life, and impaired sex life. In addition, the study also showed that those who received radioactive iodine had worse scores in hypothyroid symptoms as well as eye symptoms and appearance than the antithyroid drug group.

It’s important to mention that both the patients in the surgery group and the antithyroid drug group were younger than those in the radioactive iodine group, 54 years compared to those of 35 years in the surgery group and 43 for the antithyroid drug group. More patients in the radioactive iodine therapy group had other medical conditions that may affect quality of life. But these factors alone didn’t explain the decreased quality of life.

A third reason why you should consider avoiding radioactive iodine is because radioactive iodine might cause or exacerbate thyroid eye disease. Not only do studies show this, but I have also seen people receive radioactive iodine and develop thyroid eye disease or experience an exacerbation of their existing thyroid eye disease condition.

In the former case, the people probably had mild thyroid eye disease without symptoms, and then when they received radioactive iodine, they developed overt eye symptoms. While many endocrinologists won’t recommend radioactive iodine treatment for those with active thyroid eye disease, this doesn’t mean that radioactive iodine can’t cause overt thyroid eye disease in those without eye symptoms. So you want to be very cautious.

How does radioactive iodine cause or exacerbate thyroid eye disease? Apparently, radioactive iodine leads to prolonged worsening of autoimmunity against the TSH receptor. Taking steroids after receiving radioactive iodine might prevent an exacerbation of thyroid eye disease, so this is something to consider. This is especially true for someone who has had Graves’ Disease for less than five years, as there is an increased risk for new reactivated thyroid eye disease.

You might wonder if thyroid surgery a better option? While you want to do everything you can to avoid radioactive iodine, there is no denying that there are also risks of getting thyroid surgery, of getting a thyroidectomy. There are increased complications with patients 70 and older. The history suggests a risk of congestive heart failure, smoking history, bleeding disorder, and other health conditions. However, complications can occur in those without these risk factors mentioned.

One of the most concerning complications of thyroid surgery is injury to the recurrent laryngeal nerve. This in turn can cause unilateral vocal cord paralysis, thus causing hoarseness and changes in vocal pitch as well as noisy breathing. One study involving 11,370 patients showed that recurrent laryngeal nerve injury occurred in nearly 6% of thyroid surgeries. There are other risks of thyroid surgery as well, such as damage to the parathyroid glands.

As I mentioned earlier, neither radioactive iodine nor thyroid surgery is desirable, as there are risks to both procedures, which is why for most people with hyperthyroidism, I recommend trying to address the underlying cause of the problem. If someone has a non-autoimmune hyperthyroid condition such as toxic multinodular goiter, while you also want to try to address the cause of the condition, there obviously isn’t a risk of developing or exacerbating thyroid eye disease after radioactive iodine.

How about long-term antithyroid medication? This is also an option to consider. Maybe not so much in the United States, even though there are some endocrinologists who may be open to this. But you see it more commonly in other countries. While taking antithyroid medication doesn’t do anything to address the cause of the condition, there are some people who do find taking lower doses of antithyroid medication for many years to be helpful. When I say lower doses, if they take low dose methimazole for example, maybe 5mg a day or even sometimes half a tablet, 2.5mg a day, and so this is an option to consider to manage the symptoms for those who struggle to get in remission. Obviously if you are not struggling to get in remission, if everything is going smoothly, you probably don’t need any of these treatments.

According to the research, long-term treatment with antithyroid medication is safe in low doses in adults, indicating that it should be considered an alternative treatment to radioactive iodine and thyroid surgery. Ultimately, your goal should be to do everything you can to restore your health, but if for any reason you’re unsuccessful in doing this, there might be other options than resorting to radioactive iodine or thyroid surgery. That is why I’m bringing it up.

I am not encouraging people to stay on long-term, low dose antithyroid medication. But if someone is unable to get into remission, and most people who are unable to get on remission haven’t tried doing anything else to address the cause of the problem, but if you happen to do something to address the cause of the problem, took a natural approach to find your triggers, underlying imbalances, and that is not helping, and an endocrinologist is pressuring you to receive radioactive iodine or get thyroid surgery, you might want to discuss low dose antithyroid medication on a long-term basis.

Let’s summarize everything. Radioactive iodine should be avoided in most, if not all, cases of hyperthyroidism. One reason is because it does not address the underlying cause of the condition. The second reason is because quality of life is worse in those who receive it. Again, this is according to the research. The third reason is because radioactive iodine can cause or exacerbate thyroid eye disease. If someone has thyroid eye disease, it can exacerbate this, but if someone doesn’t have eye symptoms, maybe they have an underlying thyroid eye disease condition that they are not aware of, and then when they receive the radioactive iodine, all of a sudden, they are experiencing thyroid eye disease.

Also, there are risks of receiving thyroid surgery. Thyroid surgery is an option to consider for those who don’t receive radioactive iodine, but of course there are risks associated with it as well.

I also discussed how low dose antithyroid medication such as methimazole might also be an option to consider in cases where someone is struggling to get into remission. But of course, overall, the goal should be to do everything you can to address the root cause, to find your triggers, correct the underlying imbalances.

That’s all I wanted to discuss regarding why you should avoid radioactive iodine. If you are thinking about receiving radioactive iodine, again, my goal is not to try to talk you out of getting radioactive iodine, but to educate you as to reasons why you might want to think twice about getting radioactive iodine. Maybe you will decide to get surgery instead, or low dose antithyroid medication. Hopefully you have also done things to address the cause of the problem. If not, I would start there.

Thanks for tuning in, and I look forward to seeing you on the next episode.