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ENGLISH ABSTRACT
中国甲状腺功能亢进症和其他原因所致甲状腺毒症诊治指南
中华医学会内分泌学分会
中国医师协会内分泌代谢科医师分会
中华医学会核医学分会
中华医学会外科学分会甲状腺及代谢外科学组
中国医师协会外科医师分会甲状腺外科医师委员会
作者及单位信息
·
DOI： 10.3760/cma.j.cn311282-20220624-00404-1
Guidelines for Diagnosis and Management of Hyperthyroidism and Other Causes of Thyrotoxicosis
Chinese Society of Endocrinology
Chinese Endocrinologist Association
Chinese Society of Nuclear Medicine
Thyroid and Metabolism Surgery Group, Chinese Society of Surgery
Committee of Thyroid Surgeons, Chinese Medical Association
Shan Zhongyan
Authors Info & Affiliations
Chinese Society of Endocrinology
Chinese Endocrinologist Association
Chinese Society of Nuclear Medicine
Thyroid and Metabolism Surgery Group, Chinese Society of Surgery
Committee of Thyroid Surgeons, Chinese Medical Association
Shan Zhongyan
Department of Endocrinology and Metabolism, The First Hospital of China Medical University, Shenyang 110001, China
·
DOI： 10.3760/cma.j.cn311282-20220624-00404-1
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摘要

甲状腺功能亢进症(甲亢)是内分泌系统的常见病，为了规范中国甲亢临床诊治，5个学会联合制定了本指南。指南结合该领域的科学证据及临床医生的经验，制定了107条推荐意见，内容涵盖了甲状腺毒症病因的鉴别、Graves病诊断和治疗方案的选择、对特殊人群的甲亢例如青少年甲亢、妊娠期甲亢、老年甲亢的个性化管理、甲亢特殊类型如Graves眼病、亚临床甲亢、甲状腺危象、药源性甲亢等临床诊治，指南适用于从事临床工作的内科、外科、核医学科、全科医学等科室的医生。

甲状腺功能亢进症;甲状腺毒症;指南;诊治
ABSTRACT

Hyperthyroidism is a common endocrine disorder. To standardize the clinical diagnosis and treatment of hyperthyroidism in China, five societies jointly published this guideline. Based on scientific evidence and expert expertise in this area, the guideline has formulated 107 recommendations, covering the identification of the etiology of thyrotoxicosis, diagnosis and treatment options of Graves′ disease, individualized management of hyperthyroidism in special populations such as adolescent hyperthyroidism, pregnancy hyperthyroidism and elderly hyperthyroidism, and the clinical diagnosis and treatment of special types of hyperthyroidism such as Graves′ ophthalmopathy, subclinical hyperthyroidism, thyroid storm and drug-induced hyperthyroidism. The guideline is suitable for doctors engaged in clinical work in internal medicine, surgery, nuclear medicine, general practice and other departments.

Hyperthyroidism;Thyrotoxicosis;Guideline;Diagnosis and management
Shan Zhongyan(Department of Endocrinology and Metabolism, The First Hospital of China Medical University, Shenyang 110001, China), Email: mocdef.3ab61naygnohznahsumc

This guideline is published with 《 Chinese Journal of Endocrinology and Metabolism》 simutaneously.

Copyright by Chinese Medical Association
No content published by the journals of Chinese Medical Association may be reproduced or abridged without authorization. Please do not use or copy the layout and design of the journals without permission.
All articles published represent the opinions of the authors, and do not reflect the official policy of the Chinese Medical Association or the Editorial Board, unless this is clearly specified.
引用本文

中华医学会内分泌学分会,中国医师协会内分泌代谢科医师分会,中华医学会核医学分会,等. 中国甲状腺功能亢进症和其他原因所致甲状腺毒症诊治指南[J]. 国际内分泌代谢杂志,2022,42(05)：401-450.

DOI:10.3760/cma.j.cn311282-20220624-00404-1

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英文缩写 中文全称 英文全称
AACE 美国临床内分泌医师协会 American Association of Clinical Endocrinologists
AAV 抗中性粒细胞胞浆抗体相关血管炎 ANCA Associated Vasculitis
ANCA 抗中性粒细胞胞浆抗体 Antineutrophil Cytoplasmic Antibodies
ATA 美国甲状腺学会 American Thyroid Association
ATDs 抗甲状腺药物 Antithyroid Drugs
CAS 临床活动性评分 Clinical Activity Score
CGA 老年综合评估 Comprehensive Geriatric Assessment
CRO 医生报告结局 Clinician－Reported Outcome
DON 甲状腺相关眼病视神经病变 Dysthyroid Optic Neuropathy
EBSLN 喉上神经外支 External Branch of Superior Laryngeal Nerve
ECT 发射型计算机断层显像 Emission Computed Tomography
EGO 甲状腺功能正常性Graves眼病 Euthyroid Graves′ Ophthalmopathy
FT 3 游离三碘甲腺原氨酸 Free Triiodothyronine
FT 4 游离甲状腺素 Free Thyroxine
GD 格雷夫斯病 Graves′ Disease
GO Graves眼病 Graves′ Ophthalmopathy
GTD 妊娠滋养细胞疾病 Gestational Trophoblastic Disease
GTT 妊娠期一过性甲状腺毒症 Gestational Transient Thyrotoxicosis
hCG 人绒毛膜促性腺激素 Human Chorionic Gonadotropin
HPT 下丘脑－垂体－甲状腺轴 Hypothalamic－Pituitary－Thyroid Axis
HT 桥本甲状腺炎 Hashimoto′s Thyroiditis
ICIs 免疫检查点抑制剂 Immune Checkpoint Inhibitors
irAE 免疫相关不良反应 Immune－Related Adverse Events
LT 4 左甲状腺素 Levothyroxine
MMI 甲巯咪唑 Methimazole
MTX 甲氨蝶呤 Methotrexate
NIS 钠碘转运体 Sodium－Iodide Symporter
NSAIDs 非甾体抗炎药 Nonsteroidal Anti－inflammatory Drugs
PPT 产后甲状腺炎 Postpartum Thyroiditis
PRO 患者报告结局 Patient－Reported Outcome
PSV 收缩期峰血流速度 Peak Systolic Velocity
PTH 甲状旁腺激素 Parathyroid Hormone
PTU 丙硫氧嘧啶 Propylthiouracil
QoL 生活质量评分 Quality of Life
RAIU 甲状腺 131I摄取率 Radioactive Iodine Uptake
RLN 喉返神经 Recurrent Laryngeal Nerve
RTX 利妥昔单抗 Rituximab
rT 3 反T 3 Reverse Triiodothyronine
RTH 甲状腺激素抵抗 Resistance to Thyroid Hormone
SH 亚临床甲状腺功能亢进症 Subclinical Hyperthyroidism
SSTR 生长抑素受体 Somatostatin Receptor
T 3 三碘甲腺原氨酸 Triiodothyronine
T 4 甲状腺素 Thyroxine
TA 毒性甲状腺腺瘤 Toxic Thyroid Adenoma
TAO 甲状腺相关眼病 Thyroid－Associated Ophthalmopathy
TBG 甲状腺素结合球蛋白 Thyroxine－Binding Globulin
Tg 甲状腺球蛋白 Thyroglobulin
TgAb 甲状腺球蛋白抗体 Thyroglobulin Antibody
TKI 酪氨酸激酶抑制剂 Tyrosine Kinase Inhibitor
TMNG 毒性多结节性甲状腺肿 Toxic Multinodular Goiter
TPE 血浆置换治疗 Therapeutic Plasma Exchange
TPO 甲状腺过氧化物酶 Thyroid Peroxidase
TPOAb 甲状腺过氧化物酶抗体 Thyroid Peroxidase Antibody
TRAb TSH受体抗体 TSH Receptor Antibody
TBAb TSH受体阻断性抗体 TSH Receptor Blocking Antibodies
TRH 促甲状腺激素释放激素 Thyrotropin Releasing Hormone
TSAb TSH受体刺激性抗体 TSH Stimulating Antibodies
TSH 促甲状腺激素 Thyroid Stimulating Hormone
TSHR TSH受体 Thyroid Stimulating Hormone Receptor
TT 3 总三碘甲腺原氨酸 Total Triiodothyronine
TT 4 总甲状腺素 Total Thyroxine
TTR 甲状腺素转运蛋白 Transthyretin
VFD 声带功能障碍 Vocal Fold Dysfunction
TSHoma 分泌TSH的垂体腺瘤 TSH－Secreting Pituitary Adenoma
英文缩略语
排序 推荐 内容 推荐等级 证据等级
1 推荐3－1 FT 4和FT 3是诊断甲状腺毒症的主要指标，需注意某些因素对检测结果的潜在影响 强推荐 中等质量证据
2 推荐3－2 在下丘脑－垂体－甲状腺轴调节功能完整的情况下，应利用第三代免疫测定方法检测血清TSH作为甲状腺毒症诊断中最敏感的初始筛查指标 强推荐 高质量证据
3 推荐3－3 第三代测定的TRAb，可以用于甲状腺毒症的病因鉴别和GD甲亢的诊断 强推荐 中等质量证据
4 推荐3－4 如果临床表现和TRAb检测结果不能明确甲状腺毒症的病因，可通过RAIU和(或)甲状腺ECT显像辅助诊断(妊娠期及哺乳期除外) 强推荐 中等质量证据
5 推荐3－5 超声检查是鉴别甲状腺毒症病因的重要影像学手段 强推荐 高质量证据
6 推荐3－6 甲亢患者如果存在GD特征性临床表现，能够诊断GD；依据患者临床表现不能确定病因时，首选第三代TRAb检测；TRAb阴性或低滴度阳性时，可行甲状腺ECT显像或超声检测甲状腺内动脉PSV，辅助诊断GD 强推荐 中等质量证据
7 推荐4－1 应在有全身失代偿症状的严重甲状腺毒症患者中考虑甲状腺危象，BWPS评分≥45考虑存在甲状腺危象，需要积极治疗。对于BWPS评分在25~44之间的患者，应基于临床判断是否采用积极治疗 强推荐 中等质量证据
8 推荐4－2 甲状腺危象患者应给予积极综合治疗，包括ATDs、β－受体阻滞剂、无机碘化物、糖皮质激素、营养支持、针对诱因治疗以及呼吸心脏监测等 强推荐 低质量证据
9 推荐5－1 所有有症状的甲亢患者，尤其老年患者、静息心率超过90次/min或合并心血管疾病的甲亢患者，均可使用β－受体阻滞剂 强推荐 中等质量证据
10 推荐5－2 MMI和PTU均为GD的主要治疗药物。采用ATDs治疗时一般首选MMI，以下情况可考虑优先使用PTU：妊娠早期；治疗甲状腺危象时；对MMI反应差又不愿意接受 131I和手术治疗者 强推荐 中等质量证据
11 推荐5－3 根据甲亢严重程度确定ATDs起始剂量，当FT 3、FT 4接近或达到正常范围时进入ATDs减量期，当TSH、FT 3、FT 4正常时进入ATDs维持量期。ATDs剂量调整要个体化 强推荐 低质量证据
12 推荐5－4 ATDs治疗疗程一般为18~24个月，持续低剂量MMI治疗能够提高甲亢缓解率。高滴度TRAb者建议适当延长疗程。疗程足够、TRAb阴性、小剂量ATDs维持TSH正常，常为停药的指征，预示缓解可能性大 强推荐 低质量证据
13 推荐5－5 不建议在ATDs治疗过程中常规加用甲状腺激素制剂(干甲状腺片或LT 4)，但某些病例两药可以联用以保持甲状腺功能正常 弱推荐 低质量证据
14 推荐5－6 轻微的皮肤不良反应可以在不停用ATDs的情况下同时进行抗组胺治疗。出现严重的过敏反应时，不推荐换用另一种ATDs，而应采用 131I或手术治疗等其他方案 强推荐 低质量证据
15 推荐5－7 所有服用ATDs的患者出现发热、咽痛、口腔溃疡或其他感染的早期征象时，应立即停用ATDs并检测血白细胞计数和分类 强推荐 低质量证据
16 推荐5－8 ATDs服用前后均应进行血白细胞计数和分类的监测，尤其治疗的前3个月之内 弱推荐 低质量证据
17 推荐5－9 服用ATDs的患者出现瘙痒性皮疹、黄疸、大便颜色变浅或深色尿、关节痛、腹痛或腹胀、厌食、恶心或乏力，应立即检测肝功能 强推荐 低质量证据
18 推荐5－10 服用ATDs的患者应在治疗前后监测肝功能，尤其治疗的前6个月 弱推荐 低质量证据
19 推荐6－1 131I是成人GD的主要治疗方法之一，治疗的目的是消除甲亢状态，可以甲状腺功能正常或发生甲减 强推荐 中等质量证据
20 推荐6－2 妊娠期和哺乳期患者禁用 131I治疗 强推荐 低质量证据
21 推荐6－3 131I治疗前1~2周内应避免进食富碘食物和药物 弱推荐 低质量证据
22 推荐6－4 重症GD患者 131I治疗3~7 d后可服用ATDs，以预防或缓解临床症状加重 强推荐 低质量证据
23 推荐6－5 131I治疗后1~3个月复查，如病情较重时，应根据需要密切随诊 强推荐 低质量证据
24 推荐6－6 131I治疗3个月后无明显缓解或治疗无效，或6个月后未完全缓解的GD患者，可再次行 131I治疗 弱推荐 低质量证据
25 推荐6－7 GD的自然转归或 131I治疗后转归均可致甲减的发生 强推荐 中等质量证据
26 推荐6－8 行 131I治疗的GD患者应遵循辐射安全注意事项。 131I治疗后的女性患者，应采取避孕措施至少6个月，待甲状腺激素水平正常后再考虑妊娠 强推荐 低质量证据
27 推荐7－1 GD甲亢患者手术治疗须严格把握适应证和禁忌证 强推荐 低质量证据
28 推荐7－2 GD患者应在术前服用ATDs(ATDs过敏或不能耐受者除外)，使甲状腺功能正常后再行手术治疗 强推荐 低质量证据
29 推荐7－3 完善的术前准备如控制心率、补钙和维生素D 3等是保证手术顺利进行和预防术后并发症的重要措施 强推荐 低质量证据
30 推荐7－4 GD患者ATDs不耐受或需短时间内接受手术时，可联合碘剂、β－受体阻滞剂、地塞米松进行术前准备 弱推荐 低质量证据
31 推荐7－5 GD的手术方式首选全甲状腺或近全甲状腺切除术。GD患者的手术治疗应由具有丰富手术经验的外科医师实施 强推荐 中等质量证据
32 推荐7－6 充分的术前准备和轻柔的手术操作是预防甲状腺危象的关键。早期诊断和综合治疗对改善预后有重要作用 强推荐 中等质量证据
33 推荐7－7 甲亢患者术前、术后常规口服补充钙剂和维生素D 3，并根据术后患者临床症状和血清钙、PTH结果制定具体治疗方案 弱推荐 低质量证据
34 推荐7－8 甲亢患者术后出血概率高于一般甲状腺手术，术中应精细操作，合理使用能量器械，妥善止血，一旦发生术后出血，应立即积极处理 强推荐 中等质量证据
35 推荐7－9 GD是导致术中喉返神经损伤的高危因素，所有GD患者术前均应进行声音和声带评估；术中应常规识别并保护喉返神经 强推荐 低质量证据
36 推荐7－10 甲状腺切除术后，对于已知或疑似VFD患者，尤其对声音特别关注的患者，应进行喉镜检查，由耳鼻喉科医生进行早期评估和治疗 强推荐 中等质量证据
37 推荐8－1 131I可用于治疗具有自主摄取功能并伴有甲亢的良性甲状腺结节 强推荐 高质量证据
38 推荐8－2 TMNG和TA甲亢 131I治疗前宜使用β－受体阻滞剂治疗，不建议预先使用ATDs治疗 弱推荐 低质量证据
39 推荐8－3 TMNG和TA甲亢患者在接受 131I治疗6个月后如甲亢仍未缓解、结节缩小不明显或无变化，或 131I治疗后3个月疗效仍不明显时，应该选手术治疗，如患者拒绝手术，可考虑再次 131I治疗 强推荐 中等质量证据
40 推荐8－4 手术治疗TMNG和TA前使用ATDs联合或不联合β－受体阻滞剂治疗甲亢，术前不推荐服用碘剂 强推荐 低质量证据
41 推荐8－5 TMNG应首选全甲状腺或近全甲状腺切除术，其次为双侧甲状腺次全切除术或一侧腺叶切除+对侧次全切除术，并由经验丰富的外科医生完成 强推荐 中等质量证据
42 推荐8－6 对于孤立性TA，首选同侧腺叶切除术，如果TA位于峡部，可选峡部切除术 强推荐 中等质量证据
43 推荐8－7 TMNG或TA的长期MMI治疗可用于一些老年患者或伴发其他疾病预期寿命有限的患者，还可用于主动要求这种治疗的患者 弱推荐 中等质量证据
44 推荐9－1 SH患者进行心电图、心脏超声和骨密度评估 强推荐 高质量证据
45 推荐9－2 TSH持续性<0.1 mU/L，或年龄≥65岁，或有合并症(心脏病高危因素、心脏病患者、骨质疏松症、未接受雌激素或二膦酸盐的绝经妇女)及有甲亢症状的SH个体都应接受治疗 强推荐 高质量证据
46 推荐9－3 对于年龄<65岁，无心血管疾病、骨质疏松等合并症，TSH水平在0.1 mU/L至参考范围下限之间，且无甲亢相关症状的SH患者应暂时观察和随访 强推荐 中等质量证据
47 推荐9－4 对于合并高代谢症候群的SH患者，可使用β－受体阻滞剂。如明确需要治疗，其治疗原则应基于病因且遵循临床甲亢相同的治疗原则 强推荐 中等质量证据
48 推荐10－1 β－受体阻滞剂用于有甲亢症状的儿童和青少年，特别是心率超过100次/min的患者 强推荐 低质量证据
49 推荐10－2 ATDs治疗是初诊儿童和青少年GD患者一线治疗，药物首选MMI 强推荐 中等质量证据
50 推荐10－3 建议以书面形式向患者或监护人提供ATDs不良反应的相关信息，在开始ATDs治疗前评估血常规和肝功能，并在用药后密切监测不良反应，及时处理 强推荐 中等质量证据
51 推荐10－4 儿童和青少年GD患者，ATDs治疗后如出现严重不良反应、复发或不能坚持药物治疗，建议改用 131I或甲状腺全切术治疗，不建议更换其他ATDs 强推荐 低质量证据
52 推荐10－5 儿童和青少年GD患者如果在1~2年的MMI治疗后仍未缓解、或接受长程ATDs治疗的青少年患者，需6~12个月评估病情情况，重新考量适合的治疗方式 强推荐 低质量证据
53 推荐10－6 儿童和青少年应避免使用生物制剂类的免疫调节剂 强推荐 中等质量证据
54 推荐10－7 儿童和青少年GD患者须严格掌握手术适应证，术前应使用MMI使甲状腺功能恢复正常，同时术前应服用碘制剂 强推荐 低质量证据
55 推荐10－8 儿童GD的手术方式选择全甲状腺或近全甲状腺切除术，术后须终身行LT 4替代治疗 强推荐 中等质量证据
56 推荐10－9 对于5岁以上的儿童和青少年GD甲亢患者， 131I治疗是安全有效的治疗方法。对ATDs治疗无效或有严重不良反应以及有手术禁忌证或不宜手术的儿童和青少年GD患者可应用 131I治疗。但是5岁以内的儿童GD患者应避免应用 131I治疗 弱推荐 低质量证据
57 推荐11－1 诊断妊娠期甲状腺毒症，要应用妊娠期特异性甲状腺功能指标的参考范围 强推荐 中等质量证据
58 推荐11－2 GD妇女应在甲状腺功能正常、病情平稳后再妊娠，以减少不良妊娠结局 强推荐 低质量证据
59 推荐11－3 GTT与妊娠早期hCG产生过多有关，不主张给予ATDs治疗 强推荐 低质量证据
60 推荐11－4 妊娠早期首选PTU治疗。妊娠期原则上不采用手术治疗甲亢，若病情需要，甲状腺切除术最佳时机为妊娠中期。不推荐LT 4与ATDs联合用药 强推荐 中等质量证据
61 推荐11－5 妊娠中晚期若需继续ATDs治疗者，继续应用PTU还是转换成MMI无明确推荐 无推荐 低质量证据
62 推荐11－6 妊娠期间甲状腺功能控制目标是应用最小有效剂量的ATDs，使FT 4接近或轻度高于参考范围上限。妊娠早期每1~2周监测1次甲状腺功能，中晚期每2~4周监测1次，达到目标值后每4~6周监测1次 强推荐 中等质量证据
63 推荐11－7 GD妇女哺乳期如需ATDs治疗，需权衡利弊，且应在哺乳后服药 弱推荐 低质量证据
64 推荐11－8 既往应用 131I治疗或手术切除治疗、目前未治疗或正在应用ATDs治疗的GD妇女在妊娠早期应检测TRAb 强推荐 中等质量证据
65 推荐11－9 若妊娠早期TRAb阴性，妊娠中晚期不需要再次检测 弱推荐 中等质量证据
66 推荐11－10 若妊娠早期TRAb升高，建议妊娠18~22周时再次复查 强推荐 中等质量证据
67 推荐11－11 若妊娠18~22周时TRAb升高或开始应用ATDs治疗，在妊娠晚期需再次检测TRAb，以评估胎儿和新生儿监测的必要性 强推荐 中等质量证据
68 推荐11－12 PPT在产后1年内发病，典型病例临床上经历甲状腺毒症期、甲减期及恢复期3个阶段，不典型病例仅表现为甲状腺毒症期或甲减期。PPT的甲状腺毒症期需要与产后发生的GD相鉴别 强推荐 低质量证据
69 推荐11－13 PPT的甲状腺毒症期不主张给予ATDs治疗，可给予小剂量β－受体阻滞剂对症治疗。甲减期可给予LT 4治疗，4~8周随访1次，至甲状腺功能恢复正常 强推荐 低质量证据
70 推荐12－1 无年龄特异性参考范围时，建议采用成人参考范围诊断老年甲亢 强推荐 中等质量证据
71 推荐12－2 建议采取CGA方法对老年甲亢患者进行全面评估，指导治疗，预估疾病风险和预后 弱推荐 低质量证据
72 推荐12－3 病情较轻且无心脏并发症的老年GD甲亢患者，首选ATDs治疗；生存期短或不适合行 131I或手术治疗的TMNG和TA者，可选择ATDs长期维持治疗 弱推荐 低质量证据
73 推荐12－4 伴有心房颤动、快速型心律失常、心力衰竭等心脏病的老年GD甲亢、TMNG和TA，首选 131I治疗 弱推荐 低质量证据
74 推荐12－5 巨大甲状腺肿有压迫症状、怀疑合并恶性结节或合并原发性甲状旁腺功能亢进症时，应选择手术治疗 弱推荐 低质量证据
75 推荐12－6 131I治疗是老年GD甲亢的一线治疗方法 强推荐 中等质量证据
76 推荐12－7 老年GD患者在 131I治疗前应强调多学科合作，对伴有的严重基础疾病和并发症予以规范治疗。如无禁忌证，老年GD 131I治疗后宜继续予以β－受体阻滞剂，或在 131I治疗3~7 d后应用ATDs治疗 强推荐 低质量证据
77 推荐12－8 老年GD患者手术须严格掌握手术适应证，并进行妥善的围手术期支持治疗。应由有经验的医生实施全甲状腺或近全甲状腺切除术，术后须终身LT 4替代治疗 强推荐 低质量证据
78 推荐12－9 老年SH患者存在心脏病高危因素、心脏病、骨质疏松症风险时要同时积极治疗 弱推荐 低质量证据
79 推荐13－1 通过相关临床症状、体征和辅助检查，并排除其他眼科疾病，做出GO诊断，并完成临床活动度和严重程度的评估 强推荐 中等质量证据
80 推荐13－2 所有GO患者应尽快恢复并维持甲状腺功能正常，都需戒烟 强推荐 高质量证据
81 推荐13－3 有GO危险因素(吸烟、重度或不稳定甲亢、高滴度血清TRAb)、病情进展或新发GO患者，如行 131I治疗，应给予短期口服泼尼松或泼尼松龙 强推荐 高质量证据
82 推荐13－4 轻度非活动性GO，根据患者的偏好可选择ATDs、手术治疗或 131I治疗 强推荐 低质量证据
83 推荐13－5 轻度活动性GO，首选ATDs或手术治疗，如果选择 131I治疗，则应使用糖皮质激素预防GO进展 强推荐 中等质量证据
84 推荐13－6 中重度且长期非活动性GO，根据患者的偏好可选择ATDs、 131I或手术治疗，但如果选择 131I治疗并且存在危险因素(吸烟、高滴度TRAb)则应考虑糖皮质激素预防GO活动 强推荐 低质量证据
85 推荐13－7 中重度且活动性GO或GO危及视力时，甲亢应该使用ATDs治疗，必要时也可采用手术治疗，不建议应用 131I治疗 强推荐 中等质量证据
86 推荐13－8 威胁视力GO，使用ATDs治疗甲亢 强推荐 中等质量证据
87 推荐13－9 所有GO患者在病程中都应该局部使用人工泪液，角膜暴露的患者注意保护角膜，非活动性GO可以选择康复手术治疗 强推荐 低质量证据
88 推荐13－10 轻度活动性GO可以在控制危险因素前提下随访观察和(或)局部治疗，或给予6个月的补硒治疗 强推荐 中等质量证据
89 推荐13－11 中重度活动性GO的一线疗法包括单纯甲泼尼龙静脉注射或甲泼尼龙静脉注射联合麦考酚钠(或吗替麦考酚酯) 强推荐 中等质量证据
90 推荐13－12 如果对初始一线治疗反应较差，GO仍然是中重度活动性，再次评估后，可以第二次激素冲击治疗，选择剂量7.5 g方案，每周期最大累积剂量为8 g；或者选择激素联合免疫抑制剂(环孢素或硫唑嘌呤或甲氨蝶呤)治疗 强推荐 中等质量证据
91 推荐13－13 眼眶放疗是治疗中重度活动性GO有效的二线疗法 强推荐 中等质量证据
92 推荐13－14 如果对糖皮质激素治疗反应较差，GO仍然是中重度活动性，可考虑应用替妥木单抗、利妥昔单抗或托珠单抗等 强推荐 中等质量证据
93 推荐13－15 DON应立即给予大剂量甲泼尼龙单次静脉输注(每天0.5~1 g，连续3 d或第1周内隔天1次)，1~2周内如无反应或反应差应紧急行眶内减压术。眼球半脱位应尽早行眶内减压术 强推荐 中等质量证据
94 推荐13－16 严重的角膜暴露应紧急进行医学治疗或采取逐步增加侵入性手术的方式，以避免进展为角膜破裂；后者应立即手术治疗 弱推荐 低质量证据
95 推荐13－17 严重暴露性角膜病变的GO患者、静脉输注糖皮质激素治疗无效的DON患者，需要进行减压手术；GO患者在病情稳定时，可进行眼科手术康复治疗 强推荐 低质量证据
96 推荐14－1 破坏性甲状腺炎引起的甲状腺毒症可使用β－受体阻滞剂控制症状，不建议应用ATDs 强推荐 高质量证据
97 推荐14－2 亚急性甲状腺炎轻症患者可以使用NSAIDs治疗，如治疗效果不佳者，可以使用糖皮质激素 强推荐 中等质量证据
98 推荐14－3 分泌TSH的垂体腺瘤应与甲状腺激素抵抗鉴别 强推荐 中等质量证据
99 推荐14－4 手术是分泌TSH的垂体腺瘤一线治疗，应由经验丰富的外科医生进行。术前准备以及术后未缓解患者的药物治疗均首选生长抑素类似物 强推荐 低质量证据
100 推荐14－5 卵巢甲状腺肿患者在甲状腺功能正常后首选手术治疗 强推荐 低质量证据
101 推荐15－1 对于高危人群，建议在碘暴露后3~4周测定甲状腺功能以评估有无碘源性甲状腺毒症，可单用β－受体阻滞剂或联合应用ATDs治疗 强推荐 低质量证据
102 推荐15－2 高危人群在行碘造影剂前检测基线甲状腺功能 弱推荐 低质量证据
103 推荐15－3 不推荐行碘造影剂前常规预防性ATDs治疗 强推荐 低质量证据
104 推荐15－4 胺碘酮所致甲状腺毒症1型可应用ATDs治疗；2型应用糖皮质激素治疗；联合治疗用于分型未明确或单一药物治疗效果不佳的患者 强推荐 低质量证据
105 推荐15－5 ICIs首次治疗前及每个治疗周期开始前(2~3周)监测甲状腺功能变化，至少持续5~6个治疗周期。有基础甲状腺疾病者根据需要增加监测频率 强推荐 低质量证据
106 推荐15－6 ICIs相关甲状腺毒症的治疗应结合症状的严重程度、病因及irAEs等级，以决定能否继续使用ICIs以及是否给予干预药物 强推荐 低质量证据
107 推荐15－7 使用TKI、干扰素－α、白细胞介素2和锂制剂治疗前后应从临床和生化的角度监测是否出现甲状腺功能障碍。出现甲状腺毒症的患者应明确病因、根据病因进行针对性治疗 强推荐 低质量证据
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A
单忠艳(中国医科大学附属第一医院内分泌与代谢病科，沈阳　110001)，Email： mocdef.3ab61naygnohznahsumc
B

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