From the Guidelines
The initial workup for suspected Graves' disease should include thyroid function tests, thyroid-stimulating immunoglobulin (TSI) or TSH receptor antibody (TRAb) testing, and a radioactive iodine uptake scan or thyroid ultrasound, with treatment typically beginning with antithyroid medications, such as methimazole or propylthiouracil, and beta-blockers as needed to control adrenergic symptoms 1.
Initial Workup
The initial workup for suspected Graves' disease includes:
- Thyroid function tests (TSH, free T4, free T3)
- Thyroid-stimulating immunoglobulin (TSI) or TSH receptor antibody (TRAb) testing
- A radioactive iodine uptake scan or thyroid ultrasound These tests help confirm the diagnosis and guide treatment decisions.
Treatment
Treatment typically begins with:
- Antithyroid medications, most commonly methimazole at 10-30 mg daily (divided into 1-3 doses) or propylthiouracil (PTU) at 100-300 mg daily (divided into 2-3 doses), with PTU preferred in the first trimester of pregnancy due to lower teratogenic risk
- Beta-blockers, such as propranolol 10-40 mg every 6-8 hours, can be added to control adrenergic symptoms like tachycardia and tremor Patients should be monitored with thyroid function tests every 4-6 weeks initially, with medication doses adjusted to achieve normal thyroid hormone levels.
Definitive Treatment Options
Definitive treatment options after 12-18 months include:
- Radioactive iodine ablation
- Thyroidectomy if remission is not achieved Patients should be counseled about potential side effects of antithyroid medications, including rash, hepatotoxicity, and rare but serious agranulocytosis (which presents with fever and sore throat) 1.
Additional Considerations
Additional considerations for patients with Graves' disease include:
- Ocular lubricants and punctal plugs to combat exposure related to eyelid retraction and proptosis
- Selenium supplementation in patients with selenium deficiency to reduce inflammatory symptoms
- Treatment with teprotumamab, a human monoclonal antibody inhibitor of IGF-IR, to reduce proptosis and clinical activity score of disease in patients with active disease 1.
From the Research
Initial Workup for Graves' Disease
- The initial workup for Graves' disease involves patient history, physical examination, and laboratory tests 2
- Laboratory tests typically include measurements of thyroid-stimulating hormone (TSH) and free thyroxine (T4) levels
- A diagnosis of Graves' disease is often confirmed by the presence of TSH receptor antibodies
Treatment Options for Graves' Disease
- Treatment options for Graves' disease include antithyroid drugs, radioactive iodine, and/or surgery, plus supportive therapy 2
- Antithyroid drugs, such as methimazole, are often used as the initial treatment for Graves' disease
- The addition of exogenous L-thyroxine (T4) to methimazole may not improve remission rates or reduce TSH receptor antibody concentrations 3, 4
Prognostic Indicators for Graves' Disease
- Elevated serum TSH concentrations during methimazole therapy may be a favorable prognostic indicator for long-term remission in patients with Graves' disease 5
- The occurrence of hypothyroidism during antithyroid drug treatment with methimazole may also be a favorable indicator for long-term remission 5
Current Diagnosis and Management of Graves' Disease
- The current diagnosis and management of Graves' disease involve understanding the disease pathophysiology, diagnostic and treatment strategies, and prevention of disease relapse 6
- Clinicians should follow the latest guidelines from professional organizations, such as the American Thyroid Association (ATA), European Thyroid Association (ETA), and Japan Thyroid Association/ Japan Endocrine Society, to provide optimal and comprehensive management for Graves' disease patients 6