Graves'%20disease Treatment
Principles of Therapy
Treatment methods will depend on:
- Clinical presentation
- Age of patient
- Elderly without cardiac problems and children: Antithyroid agents - first-line agent
- Elderly with cardiac problems: Radioactive Iodine
- Clinician preference
- Patient’s input
Pharmacotherapy
Antithyroid Agents
- Preferred therapy in pregnant women and children, patients with high likelihood of remission, elderly, or others with comorbidities increasing surgical risk or with limited life expectancy
- May also be a treatment option for patients with previously operated or irradiated necks or lack access to an experienced/high-volume thyroid surgeon, patients with moderate-severe active Graves' orbitopathy and those needing rapid biochemical disease control
- 30-40% of patients remain euthyroid 10 years after antithyroid treatment
- Remission is most likely to occur in patients with mild hyperthyroidism and small goiters
- Patients unable to attain remission after 12-18 months of antithyroid therapy can continue antithyroid therapy for another 12 months or opt for radioactive Iodine or thyroidectomy
- 10-15% of patients become hypothyroid 15 years after treatment
- Usually takes 4-8 weeks to control symptoms
- May use beta-blockers to control symptoms during this period, but not always needed
- Contraindicated in patients with previous known major adverse reactions to antithyroid drugs
- Inhibit thyroid peroxidase and hence the synthesis of thyroid hormone
- Fewer tablets are needed for initial treatment compared with Propylthiouracil (PTU)
- In most circumstances, preferred thionamide antithyroid agent than PTU
- Inhibits thyroid peroxidase and hence the synthesis of thyroid hormone, and blocks the extrathyroidal deiodination of thyroxine (T4) to triiodothyronine (T3)
- Preferred over Methimazole during first trimester of pregnancy, thyrotoxic crises and in patients with adverse reactions with Methimazole that are not candidate for radioiodine therapy or surgery
- Eg Atenolol, Bisoprolol, Metoprolol, Propranolol
- Should be given to elderly patients with symptomatic thyrotoxicosis and to other thyrotoxic patients with heart rate >90 beats/minute or coexistent cardiovascular disease
- Should be considered in all patients with symptomatic thyrotoxicosis
- Decreases heart rate, systolic blood pressure, muscle weakness and tremor
- Shows improvement in the degree of irritability, emotional lability and exercise tolerance
- Helps prevent episodes of hypokalemic periodic paralysis
- High-dose Propranolol inhibits peripheral conversion of T4 to T3