Management Aspects of Medical Therapy in Graves Disease

Abstract

Objective: Graves disease (GD) is the most common cause of hyperthyroidism. Treatment options include antithyroid drugs (ATDs), radioactive iodine, and surgery. In this review, we focus on the medical aspects of managing GD.

Methods: The authors conducted a literature review of PubMed to include studies and review articles on GD management, ATDs, long-term safety of antithyroid drugs, hyperthyroidism in pregnancy, Graves ophthalmopathy, and special circumstances related to hyperthyroidism.

Results: In adjunction to ATDs, medical management for GD also includes beta-blockers, glucocorticoids, and iodine containing agents. ATDs are currently the preferred option for initial management of GD, reflecting a shift in practice observed in the United States over the past 2 decades. ATDs in appropriate doses are well-tolerated and safe when used for longer duration, during pregnancy, and other circumstances discussed in this article. Routine thyroid function tests are important for monitoring. Thyrotropin receptor antibody plays an essential role in determining duration of treatment and assessing the likelihood of recurrence.

Conclusion: Medical management of GD with antithyroid drug is safe and effective. Long-term use beyond 24 months in patients with elevated thyrotropin receptor antibody is a reasonable alternative option to surgery and radioactive iodine due to higher rates of remission.

Keywords: Graves disease; antithyroid drugs; hyperthyroidism; thyroid function tests.

Fig. 1.

Antithyroid drugs: pharmacokinetics and mechanism of action. MMI = methimazole; PTU = propylthiouracil; T4 = thyroxine; TPO = thyroid peroxidase; T3 = triiodothyronine.

Fig. 2.

Proposed algorithm for initial and long-term medical management of Graves disease. ATD = antithyroid drug; CBC = complete blood count; FT4 = free thyroxine; FT3 = free triiodothyronine; LFT = liver function test; MMI = methimazole; TFT = thyroid function test; TRAb = thyrotropin receptor antibody; TSH = thyroid-stimulating hormone.