Symptoms of Graves' Disease
Graves' disease presents with classic hyperthyroid symptoms (tremors, nervousness, tachycardia, heat intolerance, weight loss) plus distinctive eye and skin findings that differentiate it from other causes of hyperthyroidism. 1
General Hyperthyroid Symptoms
The systemic manifestations of Graves' disease include: 1
- Tremors - fine tremor of the hands
- Nervousness and anxiety - emotional lability and hyperkinesis 2
- Insomnia - difficulty sleeping
- Excessive sweating - heat intolerance
- Tachycardia - rapid heart rate
- Hypertension - elevated blood pressure
- Weight loss - despite normal or increased appetite 2
- Goiter - thyroid enlargement 2
Distinctive Features Specific to Graves' Disease
The hallmark features that distinguish Graves' disease from other causes of hyperthyroidism are ophthalmologic and dermatologic: 1
Eye Manifestations (Graves' Ophthalmopathy)
- Eyelid lag or retraction - upper eyelid pulls back exposing more sclera 1
- Proptosis - bulging eyes due to orbital inflammation 3
- Exposure symptoms - requiring ocular lubricants due to incomplete eyelid closure 3
Skin Manifestations
- Pretibial myxedema - localized thickening of the skin, typically on the shins 1
Life-Threatening Complication
Thyroid storm is a rare but critical medical emergency characterized by severe acute exacerbation of all hyperthyroid symptoms and requires immediate recognition and treatment. 1
Treatment Options
First-Line Medical Therapy
Methimazole is the preferred first-line antithyroid drug for most patients with Graves' disease, given for 12-18 months. 3 The American Thyroid Association recommends this as standard therapy with monitoring every 4-6 weeks initially, then every 2-3 months once stable. 3
- Propylthiouracil (PTU) is reserved for specific situations: first trimester of pregnancy (switch to methimazole after first trimester), thyroid storm, or methimazole intolerance 3, 4
- Methimazole allows once-daily dosing due to longer half-life, improving adherence 5
- Monitor for agranulocytosis and hepatotoxicity - most adverse reactions occur within first 90 days 6
- Patients must report immediately: sore throat, fever, rash, or general malaise 4
Symptomatic Management
Beta-blockers provide rapid symptomatic relief of tachycardia, tremor, and anxiety while awaiting definitive control. 3
Definitive Therapies
Radioactive iodine (RAI) is the most frequently used definitive treatment in adults in the United States - it is safe, effective, and more affordable than long-term antithyroid drugs. 5, 6
- Contraindicated in pregnancy and breastfeeding 3, 6
- Can worsen or trigger thyroid eye disease in 15-20% of patients 6
- Results in permanent hypothyroidism requiring lifelong levothyroxine 6
Surgery (near-total thyroidectomy) is preferred when: 6
- Concomitant suspicious or malignant thyroid nodules exist
- Coexisting hyperparathyroidism is present
- Large goiters are present
- Moderate to severe thyroid eye disease exists and antithyroid drugs cannot be used
- Risks include: hypoparathyroidism, vocal cord paralysis, and hypothyroidism 6
Special Management for Graves' Ophthalmopathy
Ocular lubricants are almost always needed to combat exposure from eyelid retraction and proptosis. 3
- Selenium supplementation may reduce inflammatory symptoms in milder thyroid eye disease 3
- Teprotumumab (IGF-IR inhibitor) reduces proptosis and clinical activity scores in active thyroid eye disease 3
- Monitor for optic neuropathy with acuity, color vision, visual fields, pupillary exam, and fundus exam 3
Critical Pitfalls to Avoid
Failing to recognize transition from hyperthyroidism to hypothyroidism during treatment can lead to inadequate dose adjustment. 3
Delaying treatment of severe ophthalmopathy can result in permanent vision loss. 3
Using RAI in pregnant or breastfeeding women is absolutely contraindicated due to fetal thyroid damage. 3, 6