How Is Graves’ Disease Treated?

Graves’ disease (GD) affects 1%–1.5%¹ of the population and is the leading underlying cause of hyperthyroidism (accounting for approximately 50%–80%² of cases). 

It’s classified as an autoimmune condition that stems from the thyroid gland; however, it can have other effects, including³ sexual dysfunction, changes in metabolism, cardiac problems, skeletal effects, and significant eye-related issues (Graves’ orbitopathy). 

How does Graves’ disease develop?

GD begins in the thyroid gland, a butterfly-shaped organ in the neck. The disease develops when the thyroid gland begins to overproduce thyroid hormones. 

The increase in thyroid hormone causes hyperthyroidism.

Left unchecked, hyperthyroidism can cause significant effects on the eyes (Graves’ orbitopathy), sex hormones and sexual function, skin, and cardiovascular health. Hyperthyroidism can even increase anxiety and depression. 

For these reasons, it’s essential to look into treatment options. 

Treatment options

Three main treatment options are available for GD. These include administering antithyroid medications, surgery, or radioactive iodine (RAI) therapy. 

The goal of these treatments is to help your thyroid hormone levels to return to normal. 

You can also take Beta-blockers to help reduce the fast heart rate and jittery feelings that can be symptoms of hyperthyroidism.  

The recommended treatment for your particular case depends on your hyperthyroid status, your specific situation, and your geographical location. 

Treatment in the US favors a course of antithyroid medication for 12–18 months.³ If euthyroidism (normal thyroid levels) is not achieved in this time, then definitive RAI or surgery is advised. 

However, in Europe, long-term use of antithyroid medications³ is preferred. 

Beta-blockers

The racing heart, tremors, anxiety, and heat intolerance typical of hyperthyroidism and GD⁴ is a result of increased beta-adrenergic activity, which enables increased levels of adrenaline and similar hormones to affect the body. These symptoms can be problematic and affect your quality of life, so treating them is important. 

Many beta-blockers are generally effective in relieving these symptoms. 

Thionamides

Also called antithyroid medication, these drugs include methimazole (the most commonly used) and propylthiouracil.

They work by being transported into the thyroid gland and, once there, prevent crucial steps in the creation of thyroid hormone.⁴ 

Unfortunately, the remission rate of thionamide treatment is only 30%–40%,⁴ so generally, a more definitive solution, such as surgery or RAI, is recommended. 

Radioactive iodine

This is taken orally in liquid or capsule form. It works by very quickly being taken up by the thyroid cells and causing ionizing cellular damage through the iodine’s beta-emissions. This treatment works because the thyroid is the only organ that uptakes iodine.

The result is thyroiditis, fibrosis, and the gradual destruction of the thyroid gland. 

RAI therapy usually causes thyroid hormone levels to return to normal within 6–18 weeks⁴ of treatment. 

Surgery

Surgery can be a subtotal thyroidectomy (STT, partial removal of the thyroid) or total thyroidectomy (TT, complete removal of the thyroid). 

Surgery provides the most effective treatment option when you consider remission rates. In fact, TT is approximately 100 times⁵ more likely to succeed in hyperthyroid treatment than a single dose of RAI. 

However, surgery causes permanent hypothyroidism, requiring lifelong levothyroxine⁶ medication to maintain normal thyroid function, and is very rarely recommended as a first-line treatment for Graves’ disease in the United States. 

Outcomes and side effects to consider

Cancer, infertility, and birth defects

Despite the common belief that radiation causes irreversible infertility and/or birth defects, studies have shown no link between⁴ radioiodine, birth defects, and infertility. 

There are some reports of increased thyroid or small bowel cancer following radioiodine treatments, although it’s unclear if this is caused by radioiodine or something else. 

However, some studies⁶ showed a dose-dependent increase in cancer risk involving the upper esophagus, the respiratory tract, or breasts. These sites are considered to be places where iodine accumulates.

Surgical risks

There is always a risk associated with general anesthesia in surgery. 

In addition to this, risks associated with thyroidectomy are laryngeal nerve palsy (0.7%–0.9%⁵ of cases, which can cause vocal cord paralysis), temporary hypocalcemia (7.4%–9.6%⁶ of cases), causing tingling of limbs and muscle weakness, and long term hypoparathyroidism (0.9%–1.0%⁶ of cases, which can cause headaches, hair loss, and muscle aching). 

The lowdown

GD is the most common cause of hyperthyroidism and reflects an autoimmune issue involving the thyroid gland. Left untreated, this disease can cause widespread symptoms. 

Three main treatment options have been presented here. Each comes with some risk and different rates of success. Thinking about your goal (e.g., the amount of remission) and the side effects you may be able to tolerate is important when considering your options. You should discuss your specific case with your physician to find your optimal treatment plan.