Table 1 Summary of ETD for Recommendation # 8

Original Recommendation

Sufficient activity of RAI should be administered in a single application, typically a mean dose of 10–15 mCi (370–555 MBq), to render the patient with GD hypothyroid (Strong Recommendation; Moderate Quality Evidence)

Modified Recommendation

As a substitute for RAI, ATD treatment (with routine thyroid function test monitoring) may be continued or surgery may be performed, to render the patient with GD hypothyroid

Overall Conclusion

☐Strong recommendation for Modification

☐Conditional recommendation for Proposed Modification

☐Conditional recommendation for either Original Recommendation or Proposed Modification

☐Conditional recommendation for Original Recommendation

☒Strong recommendation for Original Recommendation

Additional Suggestions:

• If no major financial concerns, RAI therapy is a feasible option as a definitive treatment in patients on high doses of ATDs for GD.

• RAI therapy should be preferred over surgical treatment in GD patients not responding to medical treatment.

• Patients with uncontrolled GD without orbitopathy, relapsed cases, and those requiring ATD for more than 2 years should also be considered for RAI therapy

Justification:

• Long-term follow up is reduced as once the patient becomes hypothyroid thyroxine dosage usually remains static.

• Expertise for ATD calculation is usually lacking in LMICs, with dose calculation increasing patient-borne costs

• ATDs result in a longer time taken to achieve euthyroid status and treatment failure rates are higher compared to RAI therapy.

• It is easier to manage primary hypothyroidism as opposed to GD, particularly in the case of non-compliance or potentially deadly thyroid storm.

• RAI therapy is more cost-effective than surgical treatment and usually leads to definitive cure.