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ALL / Endocrinology
Graves' disease: management
Graves' disease: management
Despite many trials, there is no clear guidance on the optimal management of Graves' disease. Treatment options include anti-thyroid drugs (ATDs, for example carbimazole), radioiodine treatment and surgery.Anti-thyroid drugs have emerged as the most popular first-line therapy for Graves' disease in recent years. Factors that particularly support their use include anti-thyroid drugs significant symptoms of thyrotoxicosis, or patients with a significant risk of hyperthyroid complications (e.g. elderly patients, cardiovascular disease).
Initial treatment to control symptoms
- propranolol is used to help block the adrenergic effects
- stop once euthyroid and symptoms resolved (e.g. not bradycardic)
- usually stopped within weeks of starting carbimazole
NICE recommends that patients with Graves' disease are referred to secondary care for ongoing treatment.
- NICE suggest carbimazole should be considered in primary care if patients symptoms are not controlled with propanolol
ATD therapy
- carbimazole is started at 40mg and reduced gradually to maintain euthyroidism
- typically continued for 12-18 months
- the major complication of carbimazole therapy is agranulocytosis
- TFTs every 4–6 weeks initially, then every 2-3 months once stable
- adjust carbimazole based on free T4, not TSH (TSH may remain low for weeks after euthyroidism and can transiently stay low even in hypothyroid patients, so interpret with caution early on)
- consider stopping if: TSH normal and free T4 normal on low dose ± TRAb negative (if checked → lower relapse risk)
- an alternative regime is termed 'block-and-replace'
- carbimazole is started at 40mg
- thyroxine is added when the patient is euthyroid
- treatment typically lasts for 6-9 months
- patients following an ATD titration regime have been shown to suffer fewer side-effects than those on a block-and-replace regime
Radioiodine treatment
- often used in patients who relapse following ATD therapy or are resistant to primary ATD treatment
- contraindications include pregnancy (should be avoided for 4-6 months following treatment) and age < 16 years. Thyroid eye disease is a relative contraindication, as it may worsen the condition
- the proportion of patients who become hypothyroid depends on the dose given, but as a rule the majority of patients will require thyroxine supplementation after 5 years
+PassMedicine Notes
Despite many trials, there is no clear guidance on the optimal management of Graves' disease. Treatment options include anti-thyroid drugs (ATDs, for example carbimazole), radioiodine treatment and surgery.
Anti-thyroid drugs have emerged as the most popular first-line therapy for Graves' disease in recent years. Factors that particularly support their use include anti-thyroid drugs significant symptoms of thyrotoxicosis, or patients with a significant risk of hyperthyroid complications (e.g. elderly patients, cardiovascular disease).
Initial treatment to control symptoms- propranolol is used to help block the adrenergic effects
- stop once euthyroid and symptoms resolved (e.g. not bradycardic)
- usually stopped within weeks of starting carbimazole
- NICE suggest carbimazole should be considered in primary care if patients symptoms are not controlled with propanolol
- carbimazole is started at 40mg and reduced gradually to maintain euthyroidism
- typically continued for 12-18 months
- the major complication of carbimazole therapy is agranulocytosis
- TFTs every 4–6 weeks initially, then every 2-3 months once stable
- adjust carbimazole based on free T4, not TSH (TSH may remain low for weeks after euthyroidism and can transiently stay low even in hypothyroid patients, so interpret with caution early on)
- consider stopping if: TSH normal and free T4 normal on low dose ± TRAb negative (if checked → lower relapse risk)
- an alternative regime is termed 'block-and-replace'
- carbimazole is started at 40mg
- thyroxine is added when the patient is euthyroid
- treatment typically lasts for 6-9 months
- patients following an ATD titration regime have been shown to suffer fewer side-effects than those on a block-and-replace regime
- often used in patients who relapse following ATD therapy or are resistant to primary ATD treatment
- contraindications include pregnancy (should be avoided for 4-6 months following treatment) and age < 16 years. Thyroid eye disease is a relative contraindication, as it may worsen the condition
- the proportion of patients who become hypothyroid depends on the dose given, but as a rule the majority of patients will require thyroxine supplementation after 5 years
