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Graves' Disease

January 23, 2022

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Graves’ disease (also known as Graves disease) is an autoimmune disease which usually involves the thyroid gland becoming overactive. It also can involve the eyes (Thyroid Eye Disease) in about ¼ of individuals and less commonly can affect the skin (Graves Dermopathy). Graves' disease is the most common cause of hyperthyroidism overall and is more common in women than in men. 

Endocrine Connection

Autoimmune diseases occur when the body’s immune system starts to make antibodies which target areas of the body that they should not. Usually, the immune system is supposed to protect our bodies and help fight disease. The antibodies in Graves' disease (thyroid-stimulating hormone receptor antibodies) primarily target the thyroid gland. In response to these antibodies, the thyroid gland becomes overactive and starts to make too much thyroid hormone. This results in high thyroid hormone levels, and we call this hyperthyroidism.  

Although Graves disease most commonly targets the thyroid gland, the same antibodies can impact other areas of the body like the eyes (Thyroid Eye Disease) and the skin (Graves Dermopathy). In Thyroid Eye Disease, these same antibodies cause growth of the tissues in the back of the eyes, causing eye bulging, pain, and double vision, among other symptoms. Graves Dermopathy is a rare complication of Graves disease and is likely caused by inflammation in tissues under the skin. Pregnant women with uncontrolled Graves’ disease are at greater risk of miscarriage, premature birth, and having a baby with low birth weight. 

Below are some tests that are used to diagnose Graves' Disease:

Clinic Visit: During a clinic visit, your healthcare provider will discuss your symptoms, as well as personal and family medical histories. They will also check for enlargements of your thyroid gland, any eye irritation, blood pressure, and/or signs of trembling. 

Blood Tests: When thyroid hormone levels are high, the pituitary doesn't need to make as much TSH. Very low levels of TSH and high levels of T4 and T3 in your blood suggest hyperthyroidism. An antibody test called thyrotropin receptor antibody test (TRAb) can detect the antibody in the blood which causes Graves’ Disease.  

Radioactive Iodine Uptake Test: The thyroid absorbs iodine from your blood and uses it to make thyroid hormone. When the thyroid produces too much thyroid hormone, it absorbs more iodine. This test involves swallowing a capsule containing a small, harmless amount of radioactive iodine. The amount of iodine taken up by your thyroid is then measured. A high uptake of radioactive iodine suggests Graves’ disease. 

Thyroid Ultrasound: A thyroid gland impacted by Graves’ disease is often enlarged and may have increased blood flow; both of these elements can be visualized by thyroid ultrasound.  Ultrasound can also be performed if there are any concerns for a thyroid hormone-producing nodule (called a toxic nodule), which is an alternate cause of hyperthyroidism. 

Graves’ Disease symptoms can include:  

  • Symptoms of hyperthyroidism, such as feeling hot and excessive sweating, palpitations, trembling of the hands, increased frequency of bowel movements.
  • Symptoms of Thyroid Eye Disease, such as bulging of the eyes, pain with moving the eyes, swelling around the eyes, and double vision.  In severe cases, there can be a loss of vision. 

Research has shown that the following factors can increase your risk of developing graves’ disease. These include:  

  • Women develop Graves disease more commonly than men, particularly during reproductive years 
  • Individuals with family history of thyroid disease 
  • Individuals with other autoimmune diseases 

Graves is treatable and can be well controlled. Some patients may go into remission, but many need long-term treatments for this condition. Several treatments are available, including: 

Antithyroid Medications: These medications lower the amount of hormone the thyroid makes. The preferred drug is methimazole. For pregnant or breastfeeding women, propylthiouracil (PTU) may be preferred. These medications help control hyperthyroidism while waiting to see if the disease goes into remission, and sometimes can be used for long-term management of Graves’ disease. 

Radioactive Iodine: This treatment is usually in amounts higher than in the radioactive iodine uptake test. Radioactive iodine cures hyperthyroidism from Graves’ disease in a majority of patients. Radioactive iodine works through slowly destroying the overactive thyroid gland, and therefore patients will need to be started on thyroid hormone supplementation when the treatment takes effect. This treatment is generally tolerated well but can worsen Graves eye disease if it is present. 

Surgery: Removing the thyroid gland through surgery is a permanent solution, but not usually preferred because of the risk of damaging the nearby parathyroid glands (which control calcium metabolism in the body) and the nerves to the larynx (voice box). Surgery is recommended when antithyroid medication and radioactive iodine therapy may not be tolerated or appropriate and may be the treatment of choice in women with anticipated plans for pregnancy. 

Beta Blockers: Beta blockers can control many symptoms, especially rapid heart rate, trembling, and anxiety. But they do not cure the disease because the thyroid still produces too much thyroid hormone. 

  • Is my hyperthyroidism caused by Graves’ Disease or another condition?  
  • Which treatment is best for me - antithyroid medications, radioactive iodine, or surgery?  
  • What sort of blood test monitoring would I need if I take antithyroid medications? Which side effects should I monitor for?  
  • What sort of side effects are there for radioactive iodine? How quickly would it work? What sort of blood test monitoring would I need?  
  • What are the complications seen with surgery? How frequently do they happen?  
  • How likely is it that my Graves’ disease will go into remission on its own? 
  • Do I need evaluation for my heart or bones? 
  • How often should I see my doctor after treatment? 

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