• 廣西醫(yī)科大學(xué)內(nèi)分泌科（南寧 530021）;

目的 　探討1例彌漫性甲狀腺腫合并甲狀腺機能亢進(jìn)癥（Graves’ disease）患者的最佳治療方案。
方法 　針對患者問題，計算機檢索Cochrane圖書館（2006年第1期）、SUMsearch（1980.1～2006.3）、 PubMed網(wǎng)站（1980.1～2006.3）,中國期刊網(wǎng)全文數(shù)據(jù)庫（1980.1～2006.3）、中文科技期刊全文數(shù)據(jù)庫（1980.1～2006.3），收集關(guān)于Graves’ disease治療的藥物、131I和手術(shù)治療的系統(tǒng)評價、臨床對照試驗，并評價所獲得的證據(jù)質(zhì)量。
結(jié)果　 共檢索到1篇指南，1篇Cochrane系統(tǒng)評價，1篇Meta分析和15個RCT。分析結(jié)果表明，恰當(dāng)劑量（小劑量）和阻斷-替代劑量（大劑量）治療，對甲亢的復(fù)發(fā)率影響無顯著差異，而阻斷-替代劑量療法引起的副作用較多。藥物治療過程中或治療結(jié)束后，甲狀腺素替代治療對甲亢復(fù)發(fā)率無明顯影響。在促進(jìn)誘導(dǎo)甲狀腺功能正常方面，甲基硫氧咪唑優(yōu)于丙基硫氧嘧啶。治療Graves’ disease的三個方案，即藥物、131I及手術(shù)治療對生活質(zhì)量影響無差異，手術(shù)治療甲亢復(fù)發(fā)率最低，但成本最高。根據(jù)自己的臨床經(jīng)驗并參考患者及其家屬的意見后，為患者制定的治療方案為繼續(xù)甲基硫氧咪唑10 mg tid，1個月后復(fù)查甲狀腺功能正常，且無明顯不良反應(yīng)發(fā)生，然后逐漸減量。經(jīng)4個月的治療隨訪，證實該方案適合該患者。
結(jié)論 　藥物、131I和手術(shù)都是治療Graves’ disease的有效方法。甲基硫氧咪唑是治療Graves’ disease的有效藥物，其粒細(xì)胞減少的副作用有待進(jìn)一步評價。補充甲狀腺素對甲亢復(fù)發(fā)無明顯影響。

引用本文： 朱汝霞,歐陽玲莉,陳俊強,莫增南. 1例彌漫性甲狀腺腫合并甲狀腺機能亢進(jìn)癥患者的循證治療. 中國循證醫(yī)學(xué)雜志, 2006, 06(5): 380-384. doi: 復(fù)制

1. minimum radioiodine dose in patients with Graves’ disease: a clinical outcome study. European Journal of Nuclear Medicine, 2001; 28: 1489-1495.
2. 李雪鋒, 李艷, 朱大菊. 兩種劑量131I治療甲狀腺機能亢進(jìn)癥臨床研究. 臨床薈萃, 2002; 17(4): 191-192.
3. 胡廷輝, 馬永源. 甲狀腺一葉全切加對側(cè)大部切除術(shù)治療甲狀腺功能亢進(jìn)的臨床評價. 中國普通外科雜志, 2004; 13(5): 346-347.
4. 李雪鋒, 李艷, 朱大菊. 兩種劑量131I治療甲狀腺機能亢進(jìn)癥臨床研究. 臨床薈萃, 2002; 17(4): 191-192.
5. 胡廷輝, 馬永源. 甲狀腺一葉全切加對側(cè)大部切除術(shù)治療甲狀腺功能亢進(jìn)的臨床評價. 中國普通外科雜志, 2004; 13(5): 346-347.
6. AACE Thyroid Task Force. American Association of Clinical Endocrinologists Medical Guidelines for Clinical practice for the Evaluation and treatment of the hyperthyroidism and hypothyroidism. AACE Thyroid Guidelines, Endocr Pract, 2002; 8(6): 457-469.
7. Abraham P, Avenell A, Watson WA, et al. Antithyroid drug regimen for treating Graves’ hyperthyroidism. The Cochrane Database of Systematic Reviews, 2005; (2): CD003420.
8. Palit TK, Miller CC, Miltenburg DM. The Efficacy of Thyroidectomy for Graves’ Disease: A Meta-analysis. Journal of Surgical Research, 2000; 90(2): 161-165.
9. Benker G, Reinwein D, Kahaly G, et al. Herbert Hirche and The European Multicentre Trial Group of the Treatment of Hyperthyroidism with Antithyroid Drugs. Is there a methimazole dose effect on remission rate in Graves’ disease? Results from a long-term prospective study. Clinical Endocrinology, 1998; 49: 451-457.
10. Raber W, Kmen E, Waldha¨usl W, et al. Medical therapy of Graves’ hyperthyroidism: effect on remission rates of methimazole alone and in combination with triiodothyronine. European Journal of Endocrinology, 2000; 142(2): 117-124.
11. Nedrebø BG, Holm PI, Uhlving S, et al. Predictors of outcome and comparison of different drug regimens for the prevention of relapse in patients with Graves’ disease. European Journal of Endocrinology, 2002; 147(5): 583-589.
12. Hoermann R, Quadbeck B, Roggenhuck U, et al. Basedow Study Group. Relapse of Graves’ hyperthyroidism after successful outcome of antithyroid drug therapy: results of a prospective randomized study on the use of levothyroxine. Thyroid, 2002; 12(12): 1119-1128.
13. He CT, Hsieh AT, Pei D, et al. Comparison of single daily dose of methimazole and propylthiouracil in the treatment of Graves’ hyperthyroidism. Clin Endocrinol (Oxf), 2004; 60(6): 676-681.
14. Leslie WD, Ward L , Salamon EA, et al. A Randomized Comparison of Radioiodine Doses in Graves’ Hyperthyroidism. The Journal of Clinical Endocrinology & Metabolism, 2003; 88(3): 978-983.
15. Müller PE, Bein B, Robens E, et al. Thyroid surgery according to Enderlen-Hotz or Dunhill: a comparison of two surgical methods for the treatment of Graves’ hyperthyroidism. International surgery, 2001; 86(2): 112-116.
16. Palestini N , Grivon M , Carbonaro G, et al. A Surgical treatment of Graves’s disease: results in 108 patients. Ann Ital Chir, 2005; 76(1): 13-18.
17. Ljunggren JG, Törring O, Wallin G, et al. Quality of life aspects and costs in treatment of Graves’ hyperthyroidism with antithyroid drugs, surgery, or radioiodine: results from a prospective, randomized study. Thyroid, 1998; 8(8): 653-659.
18. Mastorakos G, Doufas AG, Mantzos E, et al. T4 but not T3 administration is associated with increased recurrence of Graves’ disease after successful medical therapy. J Endocrinol Invest, 2003; 26(10): 979-984.
19. Howarth D, Epstein M, Lan L, et al. Determination of the optimal minimum radioiodine dose in patients with Graves’ disease: a clinical outcome study. European Journal of Nuclear Medicine, 2001; 28: 1489-1495.
20. Chi SY, Hsei KC, Sheen-Chen SM, et al. A Prospective Randomized Comparison of Bilateral Subtotal Thyroidectomy versus Unilateral Total and Contralateral Subtotal Thyroidectomy for Graves’ disease. World J. Surg, 2005; 29: 160–163.
21. Chi SY, Hsei KC, Sheen-Chen SM, et al. A Prospective Randomized Comparison of Bilateral Subtotal Thyroidectomy versus Unilateral Total and Contralateral Subtotal Thyroidectomy for Graves’ disease. World J. Surg, 2005; 29: 160–163.
22. braham-Nordling M, Törring O, Hamberger B, et al. Graves’ disease: a long-term quality-of-life follow up of patients randomized to treatment with antithyroid drugs, radioiodine, or surgery. Thyroid, 2005; 15(11): 1279-86.
23. braham-Nordling M, Törring O, Hamberger B, et al. Graves’ disease: a long-term quality-of-life follow up of patients randomized to treatment with antithyroid drugs, radioiodine, or surgery. Thyroid, 2005; 15(11): 1279-86.
24. Li XF, Li Y, Zhu DJ. Clinical research of two dosages of 131I for Graves ‘disease. Clinical Focus, 2002; 17(4): 191-192.
25. Li XF, Li Y, Zhu DJ. Clinical research of two dosages of 131I for Graves ‘disease. Clinical Focus, 2002; 17(4): 191-192.
26. Hu TH, Ma YY. Evaluation of the effect of one side lobectomy plus opposite side partial lobectomy in the treatment of hyperthyroidism. Chinese Journal of General Surgery, 2004; 13(5): 346-347.
27. Hu TH, Ma YY. Evaluation of the effect of one side lobectomy plus opposite side partial lobectomy in the treatment of hyperthyroidism. Chinese Journal of General Surgery, 2004; 13(5): 346-347.
  1. 1. minimum radioiodine dose in patients with Graves’ disease: a clinical outcome study. European Journal of Nuclear Medicine, 2001; 28: 1489-1495.
  2. 2. 李雪鋒, 李艷, 朱大菊. 兩種劑量131I治療甲狀腺機能亢進(jìn)癥臨床研究. 臨床薈萃, 2002; 17(4): 191-192.
  3. 3. 胡廷輝, 馬永源. 甲狀腺一葉全切加對側(cè)大部切除術(shù)治療甲狀腺功能亢進(jìn)的臨床評價. 中國普通外科雜志, 2004; 13(5): 346-347.
  4. 4. 李雪鋒, 李艷, 朱大菊. 兩種劑量131I治療甲狀腺機能亢進(jìn)癥臨床研究. 臨床薈萃, 2002; 17(4): 191-192.
  5. 5. 胡廷輝, 馬永源. 甲狀腺一葉全切加對側(cè)大部切除術(shù)治療甲狀腺功能亢進(jìn)的臨床評價. 中國普通外科雜志, 2004; 13(5): 346-347.
  6. 6. AACE Thyroid Task Force. American Association of Clinical Endocrinologists Medical Guidelines for Clinical practice for the Evaluation and treatment of the hyperthyroidism and hypothyroidism. AACE Thyroid Guidelines, Endocr Pract, 2002; 8(6): 457-469.
  7. 7. Abraham P, Avenell A, Watson WA, et al. Antithyroid drug regimen for treating Graves’ hyperthyroidism. The Cochrane Database of Systematic Reviews, 2005; (2): CD003420.
  8. 8. Palit TK, Miller CC, Miltenburg DM. The Efficacy of Thyroidectomy for Graves’ Disease: A Meta-analysis. Journal of Surgical Research, 2000; 90(2): 161-165.
  9. 9. Benker G, Reinwein D, Kahaly G, et al. Herbert Hirche and The European Multicentre Trial Group of the Treatment of Hyperthyroidism with Antithyroid Drugs. Is there a methimazole dose effect on remission rate in Graves’ disease? Results from a long-term prospective study. Clinical Endocrinology, 1998; 49: 451-457.
  10. 10. Raber W, Kmen E, Waldha¨usl W, et al. Medical therapy of Graves’ hyperthyroidism: effect on remission rates of methimazole alone and in combination with triiodothyronine. European Journal of Endocrinology, 2000; 142(2): 117-124.
  11. 11. Nedrebø BG, Holm PI, Uhlving S, et al. Predictors of outcome and comparison of different drug regimens for the prevention of relapse in patients with Graves’ disease. European Journal of Endocrinology, 2002; 147(5): 583-589.
  12. 12. Hoermann R, Quadbeck B, Roggenhuck U, et al. Basedow Study Group. Relapse of Graves’ hyperthyroidism after successful outcome of antithyroid drug therapy: results of a prospective randomized study on the use of levothyroxine. Thyroid, 2002; 12(12): 1119-1128.
  13. 13. He CT, Hsieh AT, Pei D, et al. Comparison of single daily dose of methimazole and propylthiouracil in the treatment of Graves’ hyperthyroidism. Clin Endocrinol (Oxf), 2004; 60(6): 676-681.
  14. 14. Leslie WD, Ward L , Salamon EA, et al. A Randomized Comparison of Radioiodine Doses in Graves’ Hyperthyroidism. The Journal of Clinical Endocrinology & Metabolism, 2003; 88(3): 978-983.
  15. 15. Müller PE, Bein B, Robens E, et al. Thyroid surgery according to Enderlen-Hotz or Dunhill: a comparison of two surgical methods for the treatment of Graves’ hyperthyroidism. International surgery, 2001; 86(2): 112-116.
  16. 16. Palestini N , Grivon M , Carbonaro G, et al. A Surgical treatment of Graves’s disease: results in 108 patients. Ann Ital Chir, 2005; 76(1): 13-18.
  17. 17. Ljunggren JG, Törring O, Wallin G, et al. Quality of life aspects and costs in treatment of Graves’ hyperthyroidism with antithyroid drugs, surgery, or radioiodine: results from a prospective, randomized study. Thyroid, 1998; 8(8): 653-659.
  18. 18. Mastorakos G, Doufas AG, Mantzos E, et al. T4 but not T3 administration is associated with increased recurrence of Graves’ disease after successful medical therapy. J Endocrinol Invest, 2003; 26(10): 979-984.
  19. 19. Howarth D, Epstein M, Lan L, et al. Determination of the optimal minimum radioiodine dose in patients with Graves’ disease: a clinical outcome study. European Journal of Nuclear Medicine, 2001; 28: 1489-1495.
  20. 20. Chi SY, Hsei KC, Sheen-Chen SM, et al. A Prospective Randomized Comparison of Bilateral Subtotal Thyroidectomy versus Unilateral Total and Contralateral Subtotal Thyroidectomy for Graves’ disease. World J. Surg, 2005; 29: 160–163.
  21. 21. Chi SY, Hsei KC, Sheen-Chen SM, et al. A Prospective Randomized Comparison of Bilateral Subtotal Thyroidectomy versus Unilateral Total and Contralateral Subtotal Thyroidectomy for Graves’ disease. World J. Surg, 2005; 29: 160–163.
  22. 22. braham-Nordling M, Törring O, Hamberger B, et al. Graves’ disease: a long-term quality-of-life follow up of patients randomized to treatment with antithyroid drugs, radioiodine, or surgery. Thyroid, 2005; 15(11): 1279-86.
  23. 23. braham-Nordling M, Törring O, Hamberger B, et al. Graves’ disease: a long-term quality-of-life follow up of patients randomized to treatment with antithyroid drugs, radioiodine, or surgery. Thyroid, 2005; 15(11): 1279-86.
  24. 24. Li XF, Li Y, Zhu DJ. Clinical research of two dosages of 131I for Graves ‘disease. Clinical Focus, 2002; 17(4): 191-192.
  25. 25. Li XF, Li Y, Zhu DJ. Clinical research of two dosages of 131I for Graves ‘disease. Clinical Focus, 2002; 17(4): 191-192.
  26. 26. Hu TH, Ma YY. Evaluation of the effect of one side lobectomy plus opposite side partial lobectomy in the treatment of hyperthyroidism. Chinese Journal of General Surgery, 2004; 13(5): 346-347.
  27. 27. Hu TH, Ma YY. Evaluation of the effect of one side lobectomy plus opposite side partial lobectomy in the treatment of hyperthyroidism. Chinese Journal of General Surgery, 2004; 13(5): 346-347.