Published online Oct 27, 2026. doi: 10.4254/wjh.123267
Revised: July 2, 2026
Accepted: September 15, 2026
Published online: October 27, 2026
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The initial management of antithyroid drug (ATD)-naive patients presenting with hyperthyroidism and concurrent liver injury represents a critical clinical dilemma. While uncontrolled thyrotoxicosis itself can induce significant hepatocellular damage, clinicians often withhold ATDs due to concerns about exacerbating liver injury through drug-induced hepatotoxicity, leading to delayed definitive therapy and uncertain outcomes.
To evaluate the efficacy and safety of ATDs in treating hyperthyroidism-induced liver injury (HTI-LI), and to explore its impact on long-term prognosis.
In this retrospective and prospective follow-up real-world cohort study, we enrolled 140 hospitalized patients with HTI-LI who were ATD-naïve at diagnosis. Patients were stratified into an ATD treatment group (n = 100) and a non-ATD group (n = 40) based on actual clinical management. Comprehensive longitudinal data on thyroid function, liver biochemistry, coagulation profiles, and clinical outcomes were collected. All-cause mortality was ascertained through active telephone follow-up over a median of 54 months. Multivariate Cox proportional hazards models were used to assess the independent association between ATD use and survival.
ATD therapy led to rapid and significant normalization of thyroid hormones (free triiodothyronine, free thyroxine, thyroid stimulating hormone; all P < 0.05) and was associated with marked improvement in liver injury markers – including alanine aminotransferase, aspartate aminotransferase, total and direct bilirubin, alkaline phosphatase, and γ-glutamyl transferase – as well as restoration of hepatic synthetic function (elevated total protein) and coagulation parameters (reduced prothrombin time and international normalized ratio; all P < 0.05). Critically, ATD use conferred a profound survival benefit: The 3-year mortality rate was 9.4% in the non-ATD group (inclu
These findings demonstrate that, under close monitoring, early initiation of ATD therapy in ATD-naïve patients with HTI-LI is not only safe but also highly effective – simultaneously controlling thyrotoxicosis, promoting hepatic recovery, and substantially improving long-term survival. Our results challenge the prevailing conservative “watchful waiting” paradigm and provide robust evidence to support proactive, individualized ATD use as a cornerstone of integrated management in this high-risk population.
Core Tip: Hyperthyroidism-related liver injury is common in clinical practice, yet evidence for initial antithyroid drug (ATD) use in ATD-naive patients is insufficient. This study demonstrates that early ATD treatment is safe and effective, can improve thyroid function and liver injury recovery, and may reduce long-term adverse outcomes, providing a reference for clinical decision-making.