From the Guidelines
The primary treatment for Graves' disease is antithyroid medications, with methimazole being a common first-line option, as recommended by recent guidelines 1.
Treatment Options
The treatment of Graves' disease aims to reduce thyroid hormone production and alleviate symptoms. The choice of treatment depends on individual factors, such as the severity of the disease, patient age, and presence of other health conditions.
- Antithyroid medications:
- Methimazole: 10-30 mg daily, divided into 1-3 doses
- Propylthiouracil (PTU): 100-300 mg daily, divided into 2-3 doses
- Radioactive iodine therapy: a one-time oral dose that destroys overactive thyroid cells, resulting in hypothyroidism and requiring lifelong thyroid hormone replacement
- Thyroidectomy (surgical removal of the thyroid): less common, but may be necessary in some cases
Management of Thyrotoxicosis
According to the American Society of Clinical Oncology (ASCO) guideline update 1, the management of thyrotoxicosis in patients treated with immune checkpoint inhibitor therapy involves:
- Regular monitoring of thyroid function every 4-6 weeks
- TSH and FT4 testing for case detection in symptomatic patients
- Consideration of TSH receptor antibody testing if there are clinical features and suspicion of Graves’ disease
- Grading of thyrotoxicosis and corresponding management:
Grading Management G1: Asymptomatic or mild symptoms Continue ICPi, beta-blocker for symptomatic relief, close monitoring of thyroid function G2: Moderate symptoms Consider holding ICPi, endocrine consultation, beta-blocker, hydration, and supportive care G3-4: Severe symptoms Hold ICPi, endocrine consultation, beta-blocker, hydration, supportive care, and possible hospitalization
Quality of Life and Morbidity Considerations
The treatment of Graves' disease should prioritize reducing morbidity and improving quality of life. Regular monitoring of thyroid function and adjustment of treatment as needed can help minimize symptoms and prevent long-term complications. The choice of treatment should be individualized, taking into account the patient's overall health, preferences, and values. As stated in the US Preventive Services Task Force recommendation statement 1, the principal treatment for hyperthyroidism is antithyroid medications or nonreversible thyroid ablation therapy.
From the FDA Drug Label
Methimazole tablets, USP are indicated: In patients with Graves’ disease with hyperthyroidism or toxic multinodular goiter for whom surgery or radioactive iodine therapy is not an appropriate treatment option. Propylthiouracil is indicated: in patients with Graves’ disease with hyperthyroidism or toxic multinodular goiter who are intolerant of methimazole and for whom surgery or radioactive iodine therapy is not an appropriate treatment option.
The treatment options for Graves' disease include:
- Medications:
- Surgery: thyroidectomy
- Radioactive iodine therapy
From the Research
Treatment Options for Graves' Disease
The treatment options for Graves' disease include:
- Antithyroid drugs, such as methimazole and propylthiouracil, which can lead to remission in approximately 50% of patients 4, 5, 6
- Radioactive iodine (RAI) therapy, which is easy to administer, safe, and effective, but can cause hypothyroidism and is contraindicated in pregnant women 4, 5, 7
- Surgery, such as near-total thyroidectomy, which is favored in patients with concomitant suspicious or malignant thyroid nodules, coexisting hyperparathyroidism, and in patients with large goiters or moderate to severe thyroid eye disease 4, 5, 7
Considerations for Treatment
When choosing a treatment option, considerations include:
- Patient preference and specific clinical features, such as age, history of arrhythmia or ischemic heart disease, size of goiter, and severity of thyrotoxicosis 4
- Potential adverse reactions, such as agranulocytosis and hepatotoxicity, associated with antithyroid drugs 4, 5
- The risk of hypothyroidism and other complications, such as hypoparathyroidism and vocal cord paralysis, associated with RAI therapy and surgery 4, 5, 7
Emerging Trends in Treatment
Recent studies suggest that long-term antithyroid treatment may be associated with reduced risk of recurrence without an increase in adverse effects, supporting the option of long-term treatment with antithyroid drugs 8