Graves disease

The thyroid gland is an important organ of the endocrine system. The gland is located at the front of the neck above where the collarbones meet. This gland releases the hormones thyroxine (T4) and triiodothyronine (T3), which control body metabolism. Controlling metabolism is important for regulating mood, weight, and mental and physical energy levels.

When the body makes too much thyroid hormone, the condition is called hyperthyroidism. (An underactive thyroid leads to hypothyroidism.)

Graves disease is the most common cause of hyperthyroidism. It is due to an abnormal immune system response that causes the thyroid gland to produce too much thyroid hormone. Graves disease is most common in women over age 20. But the disorder can occur at any age and can affect men as well.

Younger people may have these symptoms:

• Anxiety or nervousness, as well as problems sleeping
• Breast enlargement in men (possible)
• Problems concentrating
• Fatigue
• Frequent bowel movements
• Hair loss
• Heat intolerance and increased sweating
• Increased appetite, despite having weight loss
• Irregular menstrual periods in women
• Muscle weakness of the hips and shoulders
• Moodiness, including irritability and anger
• Rapid or irregular heartbeat
• Shortness of breath with activity
• Tremor

Many people with Graves disease have problems with their eyes:

• The eyeballs may seem to be bulging out and may be painful.
• Eyes can feel irritated and be tearing.
• Double vision may be present.

Older people may have these symptoms:

• Rapid or irregular heartbeat
• Chest pain
• Memory loss
• Weakness and fatigue

The health care provider will do a physical exam and may find that you have an increased heart rate. An exam of your neck may find that your thyroid gland is enlarged (goiter).

Other tests include:

• Blood tests to measure levels of TSH, T3, and free T4
• Radioactive iodine uptake and scan

This disease may also affect the following test results:

• Orbit CT scan or ultrasound
• Thyroid stimulating immunoglobulin (TSI)
• Thyroid peroxidase (TPO) antibody
• Anti-TSH receptor antibody

Treatment is aimed at controlling your overactive thyroid. Medicines called beta-blockers are often used to treat symptoms of rapid heart rate, sweating, and anxiety until the hyperthyroidism is controlled.

Hyperthyroidism is treated with 1 or more of the following:

• Antithyroid drugs can block or change how the thyroid gland uses iodine. These drugs may be used to control the overactive thyroid gland before surgery or radioiodine therapy or as a long-term treatment.
• Radioiodine therapy in which radioactive iodine is given by mouth. It then concentrates in the overactive thyroid tissue and causes damage.
• Surgery may be done to remove the thyroid.

If you have had radioactive iodine treatment or surgery, you will need to take replacement thyroid hormones for the rest of your life. This is because these treatments destroy or remove the gland.

TREATMENT OF THE EYES

Some of the eye problems related to Graves disease often improve after treatment with medicines, radiation, or surgery. Radioiodine therapy can sometimes make eye problems worse. Eye problems are worse in people who smoke, even after the hyperthyroidism is treated.

Sometimes, prednisone (a steroid medication that suppresses the immune system) is needed to reduce eye irritation and swelling.

You may need to tape your eyes closed at night to prevent drying. Sunglasses and eye drops may reduce eye irritation. In rare cases, surgery or radiation therapy (different from radioactive iodine) may be needed to prevent further damage to the eye and loss of vision.

Graves disease often responds well to treatment. Thyroid surgery or radioactive iodine often will cause an underactive thyroid (hypothyroidism). Without getting the correct dosage of thyroid hormone replacement, hypothyroidism can lead to:

• Depression
• Mental and physical sluggishness
• Weight gain

Call your provider if you have symptoms of Graves disease. Also call if your eye problems or other symptoms get worse or do not improve with treatment.

Go to the emergency room or call the local emergency number (such as 911) if you have symptoms of hyperthyroidism with:

• Decrease in consciousness
• Fever
• Rapid, irregular heartbeat

Burch HB, Cooper DS. Management of Graves disease: a review. JAMA. 2015;314(23):2544-2554. PMID: 26670972 www.ncbi.nlm.nih.gov/pubmed/26670972.

Davies TF, Lauerberg P, Bahn RS. Hyperthyroid disorders. In: Melmed S, Polonsky KS, Larsen PR, Kronenberg HM, eds. Williams Textbook of Endocrinology. 13th ed. Philadelphia, PA: Elsevier; 2016:chap 12.

Marino M, Vitti P, Chiovato L. Graves' disease. In: Jameson JL, De Groot LJ, de Kretser DM, et al, eds. Endocrinology: Adult and Pediatric. 7th ed. Philadelphia, PA: Elsevier Saunders; 2016:chap 82.