The article by Burch and colleagues [1] creates a dilemma for physicians treating elderly patients with hyperthyroidism. The authors show a temporary elevation in thyroid hormone levels in patients with Graves disease who were pretreated with antithyroid drugs before Iodine-131 was administered. They further conclude that this effect occurs because the antithyroid drugs were withdrawn. The clinical significance of a transient increase in thyroxine and triiodothyronine levels is not addressed, and the physician is led to believe that pretreatment with antithyroid drugs is, in fact, harmful.

Several years ago I suggested that all elderly patients with hyperthyroidism, even those who are asymptomatic, be treated [2]. It was noted that in the elderly, no correlation existed between symptoms and the degree of elevation of thyroid hormone levels. Since then I have encountered several minimally symptomatic elderly patients with hyperthyroidism who initially refused treatment. On repeat evaluation 1 to 2 years later, these patients had developed symptoms even though their thyroid hormone levels had not changed. It therefore appears that in the elderly, the magnitude of the elevation of thyroid hormone levels is not as important as the duration of hyperthyroidism.

Conversely, when the elderly patient with hyperthyroidism is treated with antithyroid drugs, chemical euthyroidism may be achieved several months before the patient feels any clinical improvement. If the patient is treated with Iodine-131 at the time of clinical euthyroidism and then is rendered chemically hyperthyroid for 1 to 2 weeks, it is unlikely that any clinical sequelae will follow.