Can rhTSH (Thyrogen) be used as an alternative to thyroxine withdrawal for remnant ablation or adjuvant therapy in patients who have undergone near-total or total thyroidectomy?

• In patients with American Thyroid Association (ATA) low-risk and ATA intermediate- risk DTC without extensive lymph node involvement (i.e., pT1 to pT3, cN0 / cNx/ pN1a, M0) in whom radioactive iodine (RAI) remnant ablation or adjuvant therapy is planned:
  • Preparation with rhTSH stimulation:
    • Is an acceptable alternative to thyroid hormone withdrawal for achieving remnant ablation:
      • Based on evidence of superior short-term quality of life, noninferiority of remnant ablation efficacy, and multiple consistent observations suggesting no significant difference in long-term outcomes
• In patients with ATA intermediate-risk DTC who have extensive lymph node disease (multiple clinically involved LN) in the absence of distant metastases:
  • Preparation with rhTSH stimulation may be considered as an alternative to thyroid hormone withdrawal prior to adjuvant RAI treatment
• In patients with ATA high-risk DTC with attendant higher risks of disease-related mortality and morbidity:
  • More controlled data from long-term outcome studies are needed before rhTSH preparation for RAI adjuvant treatment can be recommended
• In patients with DTC of any risk level with significant comorbidity that may preclude thyroid hormone withdrawal prior to iodine RAI administration:
  • rhTSH preparation should be considered
    • Significant comorbidity may include:
      • A significant medical or psychiatric condition that could be acutely exacerbated with hypothyroidism, leading to a serious adverse event
      • Inability to mount an adequate endogenous TSH response with thyroid hormone withdrawal

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