What tests are ordered for a Graves' disease workup?

From the Guidelines

For a Graves' disease workup, order TSH, free T4, and consider T3, as well as TSH receptor antibody testing, as these tests are crucial in confirming hyperthyroidism and its autoimmune etiology, as suggested by the 2021 ASCO guideline update 1. When evaluating a patient for Graves' disease, it is essential to consider the clinical features and suspicion of the disease, such as ophthalmopathy and T3 toxicosis.

• The initial workup should include:
  • TSH and free T4 to confirm hyperthyroidism
  • T3 to help diagnose highly symptomatic patients with minimal FT4 elevations
  • TSH receptor antibody testing to confirm the autoimmune etiology of Graves' disease
• Additional tests, such as thyroid peroxidase antibodies (TPO) and thyroglobulin antibodies (TgAb), may be considered to assess autoimmune activity, but are not explicitly mentioned in the 2021 ASCO guideline update 1.
• A radioactive iodine uptake scan may be helpful in visualizing the overactive thyroid gland, but its use is not specified in the provided guideline.
• Other tests, such as complete blood count, comprehensive metabolic panel, thyroid ultrasound, and orbital imaging (CT or MRI), may be ordered based on individual patient needs and clinical presentation, but are not directly related to the diagnosis of Graves' disease as per the 2021 ASCO guideline update 1.

From the Research

Diagnostic Tests for Graves' Disease

The following tests are commonly ordered for a Graves' disease workup:

• Measurement of serum levels of anti-TSH-receptor antibodies (TRAb) 2
• Thyroid ultrasonography 2
• Thyroid-stimulating hormone (TSH) assay 3
• Free T4 and possibly free T3 assays to assess biological severity and monitor treatment efficacy 3
• Anti-TSH-receptor (TSH-R) antibody screening 3
• Scintigraphy (reserved for rare cases of Graves' disease with negative antibody findings or when another etiology is suspected) 3
• Thyroid ultrasound scan (may be contributive, but not recommended in first line) 3
• Thyrotropin-binding inhibitory immunoglobulin (TBII) competitive-binding assay or thyroid-stimulating immunoglobulin (TSI) bioassay 4

Additional Tests

In some cases, additional tests may be ordered to rule out other conditions or to monitor the effectiveness of treatment:

• Adhesion molecules (intercellular adhesion molecule-1, vascular cell adhesion molecule-1, and E-selectin) to assess vascular atherosclerosis 5
• Carotid artery stiffness (pulse wave velocity) and thickness (carotid intima media thickness) to assess vascular atherosclerosis 5