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GRAVES' DISEASE
Treatment Guideline Chart
Graves' disease is an autoimmune disorder that results into overproduction of thyroid hormones.
Thyrotoxicosis signs and symptoms include hyperactivity, irritability, insomnia, dysphoria, sweating, heat intolerance, palpitations, weakness, fatigue, weight loss despite increased appetite, diarrhea, steatorrhea polyuria, decreased libido, tachycardia, tremor, goiter, alopecia, gynecomastia, eyelid lag or retraction and rarely periodic paralysis.
Clinical features in thyrotoxic patient that suggests Graves's disease are ophthalmopathy, thyroid dermopathy, thyroid acropachy, diffuse goiter, antibodies to thyroid peroxidase or thyroglobulin and thyroid radionuclide scan demonstrating a diffuse goiter.

Surgical Intervention

  • Surgery is not the first-line treatment; pharmacotherapy is usually preferred over surgery
  • Near-total or total thyroidectomy is the preferred surgery
  • Up to 98% success rate when performed by experienced surgeons
  • May be option for:
    • Suspected thyroid cancer (excision of thyroid nodules to rule out malignancy)
    • Patients with an obstructive goiter or very large goiter (≥80 g)
    • Patients with large thyroid nodules (>4 cm) or nonfunctioning or hypofunctioning thyroid nodules on 123I or 99mTc pertechnetate scanning
    • Patients with coexisting hyperparathyroidism
    • Patients who want unsightly goiter removed
    • Patients who refuse radioactive Iodine and want definitive treatment
    • Patients with relatively low uptake of radioactive Iodine
    • Pregnant patients who are intolerant of antithyroid agents
      • Thyroidectomy is best performed in the second trimester of pregnancy
    • Women planning pregnancy in <6 months
    • Patients with high TRAb levels 
    • Some physicians prefer surgery in pediatric/adolescent patients, especially if large goiter
    • Patients with moderate to severe Graves' orbitopathy
  • Potential complications: Hypoparathyroidism, laryngeal edema and paralysis, hemorrhage and nerve damage
  • Contraindicated in patients with significant comorbidity including presence of cardiopulmonary disease, end-stage cancer or other debilitating illness and lack of access to experienced surgeons
Prior to Surgery
  • Restoration of euthyroidism to decrease risk of thyrotoxic storm
    • Antithyroid drug treatment prior to surgery, with or without beta-adrenergic blockade and, with or without inorganic iodide given x 7-10 days prior to surgery to block thyroid hormone synthesis (cool down)
    • Inorganic iodide given x 7-10 days prior to surgery to block thyroid hormone synthesis, reduce gland vascularity, decrease blood flow and intraoperative blood loss during thyroidectomy
  • Calcium and vitamin D supplementation may be considered preoperatively in patients at increased risk for transient or permanent hypoparathyroidism
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