What are the treatment options for Grave's disease?

Treatment Options for Graves' Disease

Methimazole is the preferred first-line treatment for most patients with Graves' disease, with a standard protocol of 12-18 months of therapy and monitoring every 4-6 weeks initially, then every 2-3 months once stable. 1, 2

First-Line Treatment: Antithyroid Medications

• Methimazole is indicated for patients with Graves' disease with hyperthyroidism for whom surgery or radioactive iodine therapy is not appropriate, or to ameliorate symptoms in preparation for definitive therapy 3
• The standard protocol involves:
  • Initial dose of 30 mg/day of methimazole with gradual titration based on thyroid function tests 1
  • Goal is to maintain FT4 in high-normal range using lowest possible dose 1
  • Treatment duration of 12-18 months for adults 1, 2
  • Extended treatment of 24-36 months for children 4

Adjunctive Therapy

• Beta-blockers are recommended for symptomatic relief of tachycardia, tremor, and anxiety 1, 2
• For patients with ophthalmopathy:
  • Ocular lubricants are almost always needed to combat exposure related to eyelid retraction and proptosis 2
  • Selenium supplementation may reduce inflammatory symptoms in milder thyroid eye disease 2
  • Teprotumumab (IGF-IR inhibitor) reduces proptosis and clinical activity score in active thyroid eye disease 2

Second-Line Treatment Options

Radioactive Iodine (RAI)

• Indicated when patients do not respond to antithyroid medications or relapse after completing a course of treatment 1
• Contraindications:
  • Pregnancy and breastfeeding 1, 2
  • Active/severe orbitopathy (steroid prophylaxis is warranted in patients with mild/active orbitopathy) 4
• Patients should not breastfeed for four months after RAI treatment 1

Thyroidectomy

• Recommended for patients who:
  • Do not respond to antithyroid medications 1
  • Have very large goiters 1
  • Have contraindications to both antithyroid drugs and RAI 1
  • Have concomitant suspicious or malignant thyroid nodules 5
  • Have coexisting hyperparathyroidism 5
• Should be performed by an experienced high-volume thyroid surgeon to minimize complications such as hypoparathyroidism and vocal cord paralysis 1, 5

Management of Special Populations

Pregnancy

• Women treated with methimazole should be switched to propylthiouracil when planning pregnancy and during the first trimester 1, 2
• After the first trimester, switching back to methimazole is recommended 2
• Goal is to maintain maternal FT4 in high-normal range using lowest possible dose 1

Severe Disease/Thyroid Storm

• Hospitalization for intensive management is required 1
• Treatment includes:
  • Beta-blockers for symptomatic relief 1
  • High-dose antithyroid drugs 1
  • Consideration of additional therapies such as steroids and saturated solution of potassium iodide (SSKI) 1

Monitoring and Follow-up

• Initial monitoring of thyroid function every 2-3 weeks, then every 4-6 weeks once stable 1, 2
• Watch for common side effects of antithyroid drugs, particularly within the first 90 days of therapy 1, 5
• For patients with persistently high TSH-R-Ab at 12-18 months, options include:
  • Continue methimazole treatment with repeat TSH-R-Ab measurement after an additional 12 months 4
  • Opt for definitive therapy with RAI or thyroidectomy 4
• For relapse after completing a course of antithyroid drugs, definitive treatment is recommended, though continued long-term low-dose methimazole can be considered 4

Common Pitfalls to Avoid

• Failing to recognize transition from hyperthyroidism to hypothyroidism 1, 2
• Overlooking ophthalmopathy or thyroid bruit, which are diagnostic of Graves' disease 1
• Using radioactive iodine in pregnant or breastfeeding women 1, 2
• Delaying treatment of severe ophthalmopathy, which can lead to permanent vision loss 2
• Underestimating the impact of iodine intake on response to treatment (higher iodine intake is associated with delayed response to methimazole) 6