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Comparative effectiveness of therapies for graves’ hyperthyroidism: a systematic review and network meta-analysis

Journal of Clinical Endocrinology and Metabolism, 07/05/2013

Sundaresh V et al. – The primary outcome was to determine the relapse rates of various treatment options. The secondary outcome was to present data regarding adverse effects of antithyroid drugs (ATDs). The authors confirm the relatively high relapse rate of ATD therapy in comparison with radioactive iodine (RAI) or surgery, along with a significant side–effect profile for these drugs. These data can inform discussion between physician and patients regarding choice of therapy for Graves' disease (GD). The limited quality of the evidence in the literature underlines the need for future RCTs in this area.


  • The authors searched multiple databases through March 2012.
  • Eligible studies were randomized clinical trials (RCTs) and comparative cohort studies in adults that included two or more treatment options for GD.
  • Two reviewers independently selected studies, appraised study quality, extracted outcome data, and determined adverse effect profiles.


  • They found 8 studies with 1402 patients from 5 continents.
  • Mean follow up duration in months was: ATDs: 57, RAI: 64, Surgery: 59.
  • Studies were at moderate to high risk of bias.
  • Network meta–analysis suggested higher relapse rates with ATDs (52.7%, 352/667) than RAI (15%, 46/304) [odds ratio (OR) =6.25; 95 % confidence interval (CI), 2.40–16.67] and with ATDs than surgery (10%, 39/387) [OR=9.09; 95% CI, 4.65–19.23].
  • There was no significant difference in relapse between RAI and surgery.
  • Examination of 31 cohort studies identified adverse effects of ATDs in 692/5136 (13%) patients.
  • These were more common with methimazole, mainly owing to dermatologic complications, while hepatic effects were more common with propylthiouracil use.


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