How are Graves' disease symptoms managed?

Management of Graves' Disease Symptoms

Methimazole is the preferred first-line treatment for Graves' disease symptoms, 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

Diagnostic Confirmation

• Confirm diagnosis with TSH, Free T4, and consider TSH receptor antibody testing if clinical features suggest Graves' disease 1
• Physical examination findings of ophthalmopathy or thyroid bruit are diagnostic of Graves' disease and should prompt early endocrine referral 2
• Imaging (CT or MRI) can confirm diagnosis and evaluate extraocular muscle enlargement and orbital fat volume in patients with thyroid eye disease 2

First-Line Treatment: Antithyroid Medications

• Methimazole is the preferred first-line agent for most patients with Graves' disease 1, 3
• Titrate dose based on thyroid function tests, with goal to maintain FT4 in high-normal range using lowest possible dose 1
• Monitor thyroid function every 4-6 weeks during initial treatment phase, then every 2-3 months once stable 1
• For persistent hyperthyroidism (>6 weeks), refer to endocrinology for additional workup and possible medical thyroid suppression 2

Adjunctive Therapy

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

Special Populations

• For pregnant women, switch from methimazole to propylthiouracil during planning pregnancy and first trimester 1, 4
• For elderly patients (>70 years) or those with comorbidities, consider starting with lower doses of thyroid replacement if hypothyroidism develops 2
• For patients with severe symptoms affecting activities of daily living, consider holding immune checkpoint inhibitors (if applicable) until symptoms resolve 2

Second-Line Treatment Options

• For patients who don't respond to antithyroid drugs after 12-18 months, consider radioactive iodine therapy or thyroidectomy 1, 5
• Radioactive iodine is contraindicated in pregnancy, breastfeeding, and patients with active/severe orbitopathy 1, 5
• Thyroidectomy should be performed by an experienced high-volume thyroid surgeon 1, 5

Management of Thyroid Eye Disease

• For moderate-to-severe thyroid eye disease, consider orbital decompression, high-dose steroids, or radiation treatment 2
• If orbital decompression is indicated, strabismus repair should be delayed until after the decompression 2
• Fresnel or ground-in prism can provide temporary relief from diplopia while awaiting definitive treatment 2

Severe Disease/Thyroid Storm

• Hospitalize patients with severe symptoms for intensive management 1
• Use beta-blockers, high-dose antithyroid drugs, and consider additional therapies such as steroids and saturated solution of potassium iodide (SSKI) 1
• Endocrine consultation is recommended for all patients with severe symptoms 2

Common Pitfalls to Avoid

• Failing to recognize transition from hyperthyroidism to hypothyroidism, which is common with thyroiditis 1
• Not monitoring thyroid function closely enough (every 2-3 weeks after diagnosis) to catch transition to hypothyroidism 2
• Using radioactive iodine in pregnant or breastfeeding women 1
• Initiating thyroid hormone before steroids in patients with both adrenal insufficiency and hypothyroidism 2