What is the initial treatment for Graves' disease?

From the Guidelines

The initial treatment for Graves' disease typically involves antithyroid medications, with methimazole being the first choice for most patients at doses ranging from 10-40 mg daily based on disease severity. According to the most recent and highest quality study available, 1, hyperthyroidism is treated with antithyroid medications, such as methimazole, or nonreversible thyroid ablation therapy. Propylthiouracil (PTU) is an alternative, particularly for women in the first trimester of pregnancy or those with methimazole allergies, usually dosed at 100-300 mg daily divided into multiple doses. These medications work by blocking thyroid hormone production, with improvement typically seen within 2-6 weeks, and treatment continuing for 12-18 months.

Key Considerations

• Beta-blockers such as propranolol (10-40 mg every 6-8 hours) are often added initially to control symptoms like palpitations, tremors, and anxiety until the antithyroid medications take effect.
• Patients should be monitored regularly with thyroid function tests every 4-6 weeks initially, then every 2-3 months once stable.
• If medical therapy fails, or in cases of severe disease, definitive treatment with radioactive iodine therapy or thyroidectomy may be considered.
• Patients should be informed about potential side effects of antithyroid medications, including rash, joint pain, and rarely, agranulocytosis, and instructed to seek immediate medical attention if they develop fever, sore throat, or unusual infections, as noted in 1.

Treatment Approach

The goal is to maintain FT4 or FTI in the high-normal range using the lowest possible thioamide dosage, as stated in 1. Measuring the FT4 or FTI every two to four weeks can be helpful. Until thioamide therapy reduces thyroid hormone levels, a beta blocker (e.g., propranolol) can be used to reduce symptoms.

Side Effects and Monitoring

Agranulocytosis, a side effect of thioamides, usually presents with sore throat and fever, as mentioned in 1. If these symptoms develop, a complete blood cell count should be obtained, and the thioamide should be discontinued. Other side effects include hepatitis, vasculitis, and thrombocytopenia. Although suppression of fetal and neonatal thyroid function can occur with thioamide therapy for Graves' disease, it is usually transient, and treatment is rarely required, as noted in 1.

From the FDA Drug Label

In patients with Graves’ disease with hyperthyroidism or toxic multinodular goiter for whom surgery or radioactive iodine therapy is not an appropriate treatment option. To ameliorate symptoms of hyperthyroidism in preparation for thyroidectomy or radioactive iodine therapy.

The initial treatment for Graves' disease may include Methimazole 2 or Propylthiouracil 3, which are used to:

• Ameliorate symptoms of hyperthyroidism
• Prepare patients for thyroidectomy or radioactive iodine therapy
• Treat patients for whom surgery or radioactive iodine therapy is not an appropriate treatment option

From the Research

Initial Treatment for Graves' Disease

The initial treatment for Graves' disease typically involves one of three options: antithyroid drugs, radioactive iodine, or surgery.

• Antithyroid drugs are often the preferred initial treatment, as they can lead to remission in approximately 50% of patients after a 12- to 18-month course 4, 5.
• Radioactive iodine is another option, which can result in permanent cure in about 80% of cases, but may exacerbate pre-existing ophthalmopathy or provoke its onset 6.
• Surgery, such as near-total thyroidectomy, is typically reserved for patients with concomitant suspicious or malignant thyroid nodules, coexisting hyperparathyroidism, or large goiters or moderate to severe thyroid eye disease 4, 6.

Factors Influencing Treatment Choice

The choice of treatment depends on various factors, including:

• Patient preference
• Geography
• Clinical factors, such as age, history of arrhythmia or ischemic heart disease, size of goiter, and severity of thyrotoxicosis 4
• Presence of ophthalmopathy or other complications 6, 7
• Desire to conceive, as antithyroid drugs are the primary therapy during pregnancy 4, 5

Medical Management

Medical management of Graves' disease with antithyroid drugs is safe and effective, and long-term use beyond 24 months may be a reasonable alternative to surgery and radioactive iodine in patients with elevated thyrotropin receptor antibody 5, 8.

• Beta-blockers, glucocorticoids, and iodine-containing agents may also be used in conjunction with antithyroid drugs to manage symptoms and prevent complications 5.
• Routine thyroid function tests are important for monitoring, and thyrotropin receptor antibody plays an essential role in determining duration of treatment and assessing the likelihood of recurrence 5, 8.