A randomized trial of short-term treatment of Graves' disease with high-dose carbimazole plus thyroxine versus low-dose carbimazole

OBJECTIVE The optimal treatment regimen with thionamide drugs remains a matter for debate, We have investigated whether high doses of carbimazole, when compared with low doses, reduce relapse rates of Graves' disease. DESIGN In an open label, randomized, prospective trial of treatment of Graves' disease we compared high doses of carbimazole (6 months of 100 mg carbimazole per day plus thyroxine) to low-dose carbimazole treatment (starting at 25 mg and titrating the carbimazole dose with the aim to maintain serum thyroid function test results within the normal reference range), PATIENTS Thirty-seven patients with a first episode of Graves' disease were enrolled. MEASUREMENTS During the 6 months of treatment we evaluated the rate of normalization of serum thyroid function tests, changes in serum thyroid auto-antibody levels and the rate of side-effects during treatment, After completion of the 6-month treatment course patients were observed for 2 years for evidence of relapse of Graves' disease, RESULTS There were no differences between the two groups either in the rate of normalization of serum thyroid function tests or in serum thyroid auto-antibody levels during treatment, Of the 17 patients randomized to high-dose treatment seven suffered treatment side-effects, compared to only one of the 20 patients receiving low-dose treatment (P<0.006). There was no significant difference in 2-year posttreatment remission rates on an intention-to-treat basis between the two treatment groups (18.7% vs, 5.9%, P= NS). However, for those patients who completed 6 months of treatment thigh-dose group=9, low-dose group=16), multivariate survival analysis demonstrated a significantly longer median relapse-free interval (P<0.04) in the high-dose group (27 weeks; 25th percentile: 9.6 weeks, 75th percentile: 75 weeks) versus the low-dose group (6 weeks; 25th percentile: 4.8 weeks, 75th percentile: 13.1 weeks). CONCLUSIONS High-dose carbimazole treatment delays, but does not prevent, relapse from Graves' disease in those patients able to tolerate the treatment, However, it leads to more frequent side-effects than conventional dose treatment.