What are the treatment options for Graves' disease?

Treatment Options for Graves' Disease

The primary treatment options for Graves' disease include antithyroid medications (methimazole as first-line), radioactive iodine therapy, and thyroidectomy, with the choice depending on patient factors, disease severity, and contraindications. 1

First-Line Medical Management

Antithyroid Medications

• Methimazole (MMI) is the preferred antithyroid medication 1, 2:

  • Starting dose: 10-40 mg daily
  • Treatment duration: 12-18 months in adults, 24-36 months in children
  • Goal: Maintain Free T4 or FTI in high-normal range using lowest possible dose
  • Monitoring: Every 2-3 weeks initially, then every 4-6 weeks until euthyroid

• Propylthiouracil (PTU) is reserved for 1, 3:

  • First trimester of pregnancy
  • Patients who cannot tolerate methimazole
  • Patients with severe liver injury

Symptomatic Management

• Beta-blockers (propranolol or atenolol) for symptomatic relief of 1:
  • Tachycardia
  • Tremor
  • Anxiety
  • Heat intolerance
  • Continue until thyroid hormone levels normalize

Selenium Supplementation

• Recommended for patients with mild Thyroid Eye Disease (TED)
• Typical dose: 200 μg daily 1

Definitive Treatment Options

Radioactive Iodine (RAI)

• Indicated when 1, 4:
  • Relapse occurs after completing antithyroid drug course
  • Patient prefers definitive treatment
  • Contraindications:
    • Pregnancy
    • Active/severe orbitopathy
    • Breastfeeding (must wait four months after RAI)
  • Steroid prophylaxis warranted in patients with mild/active orbitopathy

Thyroidectomy

• Should be performed by an experienced high-volume thyroid surgeon 1, 4
• Preparation includes:
  • Methimazole treatment to achieve euthyroidism
  • Potassium iodide solution pre-surgery
• Indicated for:
  • Patients with severe hyperthyroidism
  • Large goiters
  • Patients who refuse or have contraindications to other treatments

Treatment Algorithm

1. Initial Presentation:

   • Start methimazole 10-40 mg daily (dose based on severity)
   • Add beta-blockers for symptomatic relief
   • Consider selenium 200 μg daily if TED present

2. After 12-18 months of treatment:

   • If TSH-R antibodies normalized: Consider discontinuing methimazole
   • If TSH-R antibodies remain elevated: Continue methimazole for additional 12 months or consider definitive treatment

3. If relapse occurs after completing antithyroid treatment:

   • Recommend definitive treatment (RAI or thyroidectomy)
   • Alternative: Long-term low-dose methimazole maintenance

4. Special Populations:

   • Pregnancy: Switch from MMI to PTU during first trimester, then back to MMI
   • Children: Longer treatment course (24-36 months) with methimazole

Monitoring and Safety

• Side effects to monitor 1:

  • Agranulocytosis
  • Hepatotoxicity
  • Vasculitis
  • Instruct patients to report sore throat, fever, rash, or liver dysfunction symptoms immediately

• Treatment failure signs:

  • Persistent elevation of thyroid hormones
  • Worsening symptoms despite adequate treatment

Common Pitfalls to Avoid

• Failure to monitor for antithyroid medication side effects
• Inappropriate use of RAI in pregnancy or active orbitopathy
• Inadequate follow-up of thyroid function tests
• Overlooking drug interactions
• Not treating adrenal insufficiency before hyperthyroidism (can precipitate adrenal crisis)

The response to methimazole is influenced by daily dose, pretreatment T3 levels, and goiter size 5. Approximately 50% of patients experience relapse after completing antithyroid drug therapy 6, highlighting the importance of discussing definitive treatment options with patients early in the disease course.