If a patient requires more than 5 mg per day of methimazole long term do you recommend alternative treatment options such as radio-iodine ablation or surgery?  

Long term use of methimazole is generally safe as long as no history of LFT elevation or abnormally low white blood cell counts. Typically, toxic multinodular goiters respond well to low dose methimazole and patients can be managed in this fashion long-term without any issues. Graves patients may re...