Diagnosis and Treatment of Graves’ Disease

In: Endotext [Internet]. South Dartmouth (MA): MDText.com, Inc.; 2000.


Diagnosis of the classic form of Graves’ disease is easy and depends on the recognition of the cardinal features of the disease and confirmation by tests such as TSH and FTI. The differential diagnosis includes other types of thyrotoxicosis, such as that occurring in a nodular gland, accompanying certain tumors of the thyroid, or thyrotoxicosis factitia, and nontoxic goiter. Types of hypermetabolism that imitate symptoms of thyrotoxicosis must also enter the differential diagnosis. Examples are certain cases of pheochromocytoma, polycythemia, lymphoma, and the leukemias. Pulmonary disease, infection, parkinsonism, pregnancy, or nephritis may stimulate certain features of thyrotoxicosis.

Treatment of Graves’ disease cannot yet be aimed at the cause because it is still unknown. One seeks to control thyrotoxicosis when that seems to be the major indication, or the ophthalmopathy when that aspect of the disease appears to be more urgent. The available forms of treatment, including surgery, drugs, and 131-I therapy, are reviewed. There is a difference of opinion as to which of these modalities is best, but to a large degree guidelines governing choice of therapy can be drawn. Antithyroid drugs are widely used for treatment on a long- term basis. About one-third of the patients undergoing long-term antithyroid therapy achieve permanent euthyroidism. Drugs are the preferred initial therapy in children and young adults. Subtotal thyroidectomy is a satisfactory form of therapy, if an excellent surgeon is available, but is less used in 2016. The combined use of antithyroid drugs and iodine makes it possible to prepare patients adequately before surgery, and operative mortality is approaching the vanishing point. Many young adults, are treated by surgery if antithyroid drug treatment fails.

Currently, most endocrinologists consider RAI to be the best treatment for adults, and consider the associated hypothyroidism to be a minor problem. Evidence to date after well over five decades of experience indicates that the risk of late thyroid carcinoma must be near zero. The authors advise this therapy in most patients over age 40, and believe that it is not contraindicated above the age of about 15. Dosage is calculated on the basis of 131-I uptake and gland size. Most patients are cured by one treatment. Hypothyroidism.occurs with a fairly constant frequency for many years after therapy and may be unavoidable if cure of the disease is to be achieved by 131-I.. Many therapists accept this as an anticipated outcome of treatment.

Thyrotoxicosis in children is best handled initially by antithyroid drug therapy. If this therapy does not result in a cure, surgery may be performed. Treatment with 131-I is accepted as an alternative form of treatment by some physicians, especially as age increase toward 15 years. Neonatal thyrotoxicosis is a rarity. Antithyroid drugs, propranolol and iodide may be required for several weeks until maternally-derived antibodies have been metabolized.

The physician applying any of these forms of therapy to the control of thyrotoxicosis should also pay heed to the patient’s emotional needs, as well as to his or her requirements for rest, nutrition, and specific antithyroid medication. Consult our FREE web-book WWW.ENDOTEXT.ORG for complete coverage on this and related topics.

We note that there are currently available 2 very extensive Guidelines on Diagnosis and Treatment of Graves’ Disease—The 2016 ATA guideline --- http://online.liebertpub.com/doi/pdfplus/10.1089/thy.2016.0229 (270 pages), and the AACE 2011 version on Hyperthyroidism and other Causes of Thyrotoxicosis (65 pages)--https://www.aace.com/files/hyperguidelinesapril2013.pdf.

Both are well worth reviewing.

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