Diagnosis and Treatment of Graves’ Disease

The diagnosis of Graves’ disease is mostly straightforward, depending on recognition of the cardinal features of the disease and confirmation by tests including serum TSH, free T4, and TSH receptor antibodies. The differential diagnosis includes other causes of thyrotoxicosis, such as secretory thyroid nodules, various forms of inflammatory or destructive thyroiditis, or thyrotoxicosis factitia. The mainstay of treatment of Graves’ disease for most patients remains thionamide antithyroid drugs, with radioiodine (I) and thyroidectomy surgery being necessary for patients whose hyperthyroidism is not controlled following one or more courses of antithyroid drug or for whom antithyroid drugs are unlikely to result in durable remission. As none of these treatment modalities have limitations, shared decision making should be used to determine each patient’s preference. Stratification of disease severity at presentation, based on patient age, goiter size, degree of hyperthyroidism, and concentration of TSH receptor antibodies reliably predicts prognosis and should be used to inform choice of primary therapy. Subclinical hyperthyroidism owing to Graves’ disease has a high progression rate to overt hyperthyroidism and antithyroid drug therapy should be the primary mode of therapy for most patients. Graves’ disease in children and young adults has a worse outcome than in adults and primary treatment with a prolonged course of antithyroid drugs is recommended, with many cases requiring eventual definitive treatment with thyroidectomy or radioiodine, when timing is appropriate to the educational and social situation. Other special situations including pregnancy and thyroid eye disease are also reviewed. As none of the existing therapies are ideal, there are a range of new therapeutic options currently in clinical trials, including approaches to deplete serum TSH receptor antibodies from plasma and to directly block TSH receptor signaling using both small molecule antagonists and biologics. These advances are likely to change the physician’s armamentarium for management of Graves’ disease substantially in the next decade. For complete coverage of all related areas of Thyroidology please visit our Free web-site https://www.thyroidmanager.org. For complete coverage of all related areas of Endocrinology, please visit our on-line FREE web-text, WWW.ENDOTEXT.ORG.