Problems in Thyroid Disease

Thyroid disease is a common disorder that as affects 5-10 % of the adult U.S. population. Subclinical hypothyroidism is the most common disorder.

Graves’ Disease

This is the most common cause of thyrotoxicosis in all age groups. Autoantibodies directed at the TSH receptor stimulate both thyroid hormone synthesis and thyroid growth. Patients present with signs and symptoms of thyrotoxicosis – fatigue, weight loss, tachycardia+/- atrial arrhythmias, hyperdefecation, sweats, and tremor – associated with a goiter, eye changes, and rarely dermopathy. Graves’ disease always presents with either a goiter or some evidence of eye or skin inflammation. Although there are reports of euthyroid Graves’ disease, this presentation is rare given the new TSH assays. The presence of thyrotoxicosis without a goiter makes Graves’ disease unlikely and suggests an alternative diagnosis such as thyroiditis, surreptitious hormone ingestion, or ectopic thyroid tissue (very rare).

There are three options in treatment: antithyroid drugs (ATD), radioactive iodine (RAI), and surgery. ATD are first line therapy for most patients since Graves disease most commonly presents in younger women. ATD are safe but agranulocytosis and hepatitis may rarely occur. Both appear to be dose related and reverse upon discontinuing the drug. Long-term remissions in the U.S. are low with ATD perhaps due to dietary or genetic influences. RAI (5-25 mci PO) is a safe and effective alternative to ATD for the treatment of Graves’ disease when ATD fail or cannot be tolerated or for older patients where the rate of remission with ATD is low. The major side-effect with RAI, regardless of the dose, is permanent hypothyroidism requiring hormone replacement therapy. Surgery is used for special patients with Graves’ disease such as pregnant patients who cannot tolerate ATD, or elderly patients with severe cardiac disease who may not tolerate RAI therapy.

Graves’ ophthalmopathy will not be altered, and could be worsened, by treatment for their Graves’ disease. Treatment with RAI, for example, may worsen eye disease. There is evidence that stopping smoking will prevent progression, and in some cases reverse, Graves’ ophthalmopathy.

Leave a Reply

Your email address will not be published. Required fields are marked *