Graves Disease

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Graves Disease
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The Case (1)

• 55 F
• Graves disease diagnosed at ?? one year ago
• Initial presentation sweating, good appetite,
  easy nervousness
• Physical examination enlarged thyroid gland
  about 5 cm in diameter at both lobes
• PTU 1 bid

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The Case (2)

• 95/7/17 MVP, TVP
• 7/22 Af i RVR (HR 220) ?Amiodarone
• 7/23 Bradycardia, conscious change ?
  Pericardiocetesis, 580mL
• 7/24 Re-op
• PTU 1 qd during 7/19-7/24, then DC
• HR?, free T4 4.53, TSHlt0.15 on 8/11
• Newmazole 1 tid since 8/15

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Graves disease

• 60 to 80 of hyperthyroidism
• Autoimmune disorder
• Common between 30 and 40 years
• Woman, 0.5 per 1000
• Family history

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Clinical Presentation

• Manifestations of hyperthyroidism hypermetabolic
  state
• Manifestations of Graves disease
• Ophthalmopathy
• Localized dermopathy
• Thyroid acropachy

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Diagnostic Modality

• Decreased TSH
• Increased free T4 and increased T3
• TSHR-Ab
• Thyroid radioactive iodine uptake and scan

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Treatment

• Anti-thyroid drugs
• Radioactive iodine therapy (RAI)
• Surgery

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Anti-thyroid drugs

• Propylthiouracil
• Carbimazole ? Methimazole
• Both inhibit thyroid peroxidase
• PTU also inhibits T4 to T3 conversion
• Immunomodulatory action?

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Adverse effects

• Rash
• Arthralgias
• Urticaria
• GI symptoms
• Agranulocytosis

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Drug Therapy

• The Titration regimen is just as effective as the
  Block-Replace regimen with a significantly lower
  incidence of adverse effects.
• The optimal duration of anti-thyroid drug therapy
  for the Titration regimen is 1218 months.
• There is no benefit from continued T4 replacement
  after a course of anti-thyroid treatment.

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Radioactive Iodine Therapy

• 131I
• Long latency period
• Contraindication pregnancy, lactation,
  ophthalmopathy?
• Only slight increased risk of mortality from
  thyroid cancer but no other malignancies
• Nausea, pain

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ATD vs. RAI (1)
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ATD vs. RAI (2)
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Surgery

• Young age
• Male sex
• Pregnancy/lactation
• Patient preference
• Large or nodular goiter
• Inability to tolerate ATDs

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Complications

• Thyroid storm or thyrotoxic crisis
• Hypothyroidism
• Recurrent hyperthyroidsim
• Recurrent laryngeal nerve injury
• Hypoparathyroidism

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Conclusions

• Current treatment for Graves disease is
  effective, but the ideal treatment is still not
  available.
• Further understanding about immunologic processes
  involved should allow better diagnostic methods
  and treatments.