What is the most effective method for the treatment of Graves’ disease with radioiodine, dosimetric or empirical approach? : a PRISMA guided review

Abstract

Background: The effectiveness of empirical versus dosimetric radioiodine therapy (RIT) for achieving euthyroidism in Graves’ Disease (GD) remains a topic of ongoing debate. The 2023 EANM guidelines advocate for dosimetry due to its individualised-dosing based on patient-specific uptake. Objective: To compare the effectiveness of empirical and dosimetric RIT in achieving euthyroidism rather than hypothyroidism in GD, and to identify which approach is more effective in eradicating hyperthyroidism. Research Methodology: A PRISMA review was conducted across electronic databases including PubMed, HyDi, ScienceDirect, the Journal of American Association of Physicists in Medicine, and the European Journal of Medical Physics. Studies involving empirical or dosimetric RIT for GD were selected, focusing on thyroid function outcomes (euthyroidism, hypothyroidism, hyperthyroidism) and cure rates for GD. Selected research was resricted between 2019 and 2023. Results: Ten studies on dosimetric RIT and seven on empirical RIT were included. Proportion forest plots for each thyroid outcome were generated. For empirical versus dosimetric RIT, euthyroidism proportions were 0.15, 95% CI [ 0.09 – 0.23] and 0.14, 95% CI [ 0.08 – 0.24]; hypothyroidism proportions were 0.68, 95% CI [0.47 – 0.83] and 0.60, 95% CI [ 0.46 – 0.72]; and hyperthyroidism proportions were 0.14, 95% CI [0.06 – 0.29] and 0.22, 95% CI [0.16 – 0.30], respectively. Risk Ratio (RR) forest plots showed the likelihood of GD cure with empirical RIT as RR = 5.60, 95 % CI [2.22 – 14.16] and with dosimetric RIT as RR = 3.40 95% CI [2.22 – 5.22]. Conclusion: Both approaches were similarly effective in achieving euthyroidism. However, dosimetric RIT showed a slight increase in persistent hyperthyroidism, while empirical RIT had slightly higher rates of hypothyroidism. Significant heterogeneity across studies was a major limitation, precluding a definitive conclusion from this meta-analysis. For future research, a large randomised controlled trial is recommended to minimise heterogeneity and maintain greater experimental control, avoiding the complexities of varied methodologies and patient demographics.