Graves’ Disease: An Overview Of Treatment Options

Graves’ disease is a common form of hyperthyroidism (overactive thyroid), accounting for around 60–80%¹ of cases of hyperthyroidism. 

Another name for Graves' disease is diffuse toxic goiter, and this condition is more common in women. Some studies¹ suggest that the lifetime risk of getting Graves’ disease if you are a woman is 3%, while if you are a man, it is 0.5%.

Graves’ disease is most common in people between the ages of 20 and 50. One large study¹ of nurses over 12 years showed that 4.6 out of 1000 women aged between 25 and 42 years were diagnosed with Graves’ disease.

Graves’ disease primarily affects your thyroid gland but can affect other organs, such as your eyes and skin. Because thyroid hormones influence the functioning of every cell in your body, if you have Graves’ disease, you can experience widespread symptoms ranging from tremors to diarrhea to heat intolerance. 

Thyrotoxicosis

Graves’ disease is a form of hyperthyroidism. In hyperthyroidism, the thyroid produces too much thyroid hormone. Thyroid hormone influences the rate at which your cells work, so increased thyroid hormone levels result in your cells working too hard. 

When the amount of thyroid hormone produced becomes dangerously high, it is referred to as thyrotoxicosis. 

Some symptoms of thyrotoxicosis include:

• Unintentional or unexplained weight loss

• Irregular heartbeat

• Very fast heartbeat (usually over 100 beats per minute)

• Tremors or shakiness

• Muscle weakness

• Anxiety and irritability

Thyroid storm

Severe thyrotoxicosis is often referred to as a thyroid storm or thyroid crisis. A thyroid storm is dangerous and potentially life-threatening and should be treated immediately. Signs and symptoms of a thyroid storm include:

• Very rapid heart rate

• High fever

• Agitation and confusion

• Diarrhea

• Decreased level of consciousness

If you have been diagnosed with Graves’ disease, you’ll likely want to know about the available treatment options and how effective they are. 

What are the main treatment options?

The three main treatment modalities for managing Graves’ disease are medication, radioactive iodine, and surgery. 

Beta-blockers block the effects of thyroid hormone on many tissues in the body and are effective at controlling many symptoms of thyrotoxicosis. 

They’re not a permanent cure but help control the symptoms and are often used with other treatment types.

Antithyroid drugs include methimazole (also called thiamazole) and propylthiouracil. Both of these medications prevent thyroid hormone creation in the thyroid gland. 

After beginning treatment with antithyroid drugs, it takes a few weeks to months for your thyroid hormone levels to return to normal ranges. 

There is a chance of relapsing if you stop treatment. Antithyroid drugs are often used before treatment with radioactive iodine or before surgery. 

Radioactive iodine is ingested either as a capsule or liquid. Once it’s absorbed, it’s taken up by thyroid cells, which it then starts to destroy. Other body tissues don’t take up radioactive iodine, ensuring a concentrated treatment.

Surgery is the treatment option of choice¹ if you have a very enlarged thyroid, if there is any chance that you could have cancer in your thyroid, and if your enlarged thyroid is pressing on your throat and causing problems. 

Surgery involves complete removal of the thyroid gland and is a relatively safe procedure in the hands of an experienced surgeon.

Initially, treatment may aim to get the symptoms of your Graves’ disease under control. This is especially true if your symptoms are severe. The next step is to reduce thyroid hormone production. 

Radioactive iodine therapy

Radioactive iodine therapy is generally considered first-line therapy for Graves’ disease.² It works on the principle that your thyroid gland normally takes up iodine to synthesize thyroid hormone.

The thyroid takes up the radioactive iodine you ingest, which then slowly destroys the cells in your thyroid that normally produce thyroid hormone. The result is a decrease in thyroid hormone production. 

Treatment usually takes a few weeks to months. The radioactive iodine isn’t taken up by other tissues in your body, so it doesn’t affect any other organs. 

If the dose of radioactive iodine that you take initially isn’t sufficient, you may need a repeat course to destroy all of the cells in the thyroid that are producing the excess thyroid hormone. You can take beta-blockers between courses of radioactive iodine to manage your symptoms. 

Radioactive iodine can be taken orally as a liquid or a capsule. This treatment is not recommended for women who are pregnant or breastfeeding as it can cause damage to the fetus or infant. 

Once you have completed your course of radioactive iodine, you’ll likely develop hypothyroidism or an underactive thyroid. This is expected since the radioactive iodine will have destroyed the cells in your thyroid that produce thyroid hormone. 

Hypothyroidism can be managed with a once-daily dose of thyroid medication.

Complications and side effects 

One possible complication² of radioactive iodine therapy is that it can worsen Graves’ ophthalmopathy, also known as Graves’ eye disease, in certain cases. 

Graves’ eye disease occurs when your body’s immune system attacks the tissues and muscles around your eyes. 

Therefore, radioactive iodine therapy should not be considered if you have severe or very active Graves’ eye disease. 

If you have mild Graves’ eye disease, you may need to be treated with steroid medication before your radioactive iodine therapy to make sure that your eye symptoms don’t get worse.

There are very few documented side effects² of radioactive iodine. One possible side effect is a temporary inflammation of the thyroid, called thyroiditis. 

This occurs in about 1% of patients who take radioactive iodine, which usually only lasts a few weeks. It can be effectively managed with medications such as beta-blockers and anti-inflammatories. 

Beta-blockers 

Drugs called beta-adrenergic blockers, or beta-blockers, are often started immediately after diagnosis if you have symptoms. 

Beta-blockers work quickly to block the effects of excess thyroid hormone. They are effective in managing a racing heart, irregular heartbeat, tremors, anxiety or irritability, heat intolerance, sweating, diarrhea, and muscle weakness.

Beta-blockers may be particularly useful¹ in controlling your symptoms if you have an underlying heart problem or are older. 

Although beta-blockers control some symptoms of hyperthyroidism, they don’t treat Graves’ disease. In general, beta-blockers are used for symptom control and in conjunction with another form of Graves’ disease treatment. 

You cannot take beta-blockers if you have asthma because they can trigger an asthma attack. 

Different types of beta-blockers include:

• Propranolol (Brand names: Inderal, InnoPran XL)

• Atenolol (Brand name: Tenormin)

• Metoprolol (Brand names: Lopressor, Toprol-XL)

• Nadolol (Brand name: Corgard).

Antithyroid drugs

The two available antithyroid drugs (ATDs) used to treat Graves’ disease in the US are methimazole and propylthiouracil. These medications belong to a class of drugs called thioamides. Thioamides work by blocking the formation of thyroid hormones in your thyroid. 

Usually, your thyroid produces two thyroid hormones: thyroxine (T4) and triiodothyronine (T3). T3 is the predominantly active hormone, and T4 is converted into active T3 in your thyroid and surrounding tissues. 

Methimazole and propylthiouracil block the formation of T3 and T4 in the thyroid.

It may take a few weeks to months for your thyroid hormone levels to return to a normal range after starting treatment with methimazole or propylthiouracil. 

Methimazole is usually the drug of choice² for Graves’ disease because it has fewer side effects than propylthiouracil and is less toxic to the liver. It also has a slightly quicker onset of action and can be taken as a once-a-day dose. Propylthiouracil needs to be taken three times a day.

If you’re pregnant, propylthiouracil is used preferentially to methimazole in the first trimester of pregnancy. Methimazole is teratogenic and can cause congenital disabilities if taken during the first trimester. 

Side effects³ of the thioamides include:

Allergic reactions

These can present with itching or skin rashes. Usually, itching can be managed with a simple antihistamine.  

Neutropenia (low white blood cell count)

Neutropenia is used to describe a very low white blood cell count. White blood cells usually protect your body from infection, so when you have a low white cell count, you become vulnerable to infections, which can be life-threatening.² 

Although this can only be diagnosed by a blood test, some symptoms that suggest your white cell count is low are a sore throat, sores in your mouth, sores in your nose, swollen gums, skin infections, and unexplained fevers. 

Liver failure

Although this is a rare side effect, it can be very dangerous. Propylthiouracil is more likely to cause liver damage than methimazole. 

It's because of this risk of liver damage that the FDA and American Thyroid Association recommend that methimazole be used above propylthiouracil as the first-line drug therapy for Graves’ disease, except in the first trimester of pregnancy.  

Low blood sugar

Methimazole can rarely cause hypoglycemia or low blood sugar. 

If you’re taking methimazole or propylthiouracil for Graves’ disease and experience any of the following symptoms, you should seek medical care immediately as you may be experiencing a side effect to the medication:

• Fatigue or weakness

• Dull pain in your stomach

• Loss of appetite

• Skin rash, itching, or easy bruising

• Yellowing of your skin or the whites of your eyes

• Fever, chills, or constant sore throat

Before starting treatment on methimazole or propylthiouracil, it’s important to have certain blood tests done. The blood tests will check your white cell count and liver function to make sure that it’s safe for you to start taking methimazole or propylthiouracil. 

If your white cell count is very low or if your liver function is poor, you may need to consider an alternative form of treatment, such as radioactive iodine therapy or surgery. 

Thioamides block thyroid hormone production, so while you’re taking them, most of your symptoms of Graves’ disease dissipate; however, they’re not usually effective as a permanent cure for Graves’ disease. 

Moreover, taking either drug for longer than a year may increase the likelihood of better long-term results. 

Surgery

Thyroidectomy is the surgical removal of the thyroid gland and is considered the most successful² treatment for Graves’ disease. 

Thyroidectomy is the treatment of choice if you have any of the following;

• A very large goiter (thyroid swelling becomes noticeable in the neck)

• Compression of the front of your throat because of the size of your goiter

• Possible thyroid cancer as well as Graves’ disease

• Nodules in your thyroid

• Moderate to severe Graves’ eye disease

If you opt for a thyroidectomy to treat your Graves’ disease, you will need to take medication to get your symptoms and thyroid hormone levels under control before surgery.

Your doctor will likely prepare you for your thyroid surgery by doing the following:

1. Treating you with beta-blockers to control your symptoms

2. Get your thyroid hormone levels within the normal range by using methimazole. 

3. Possibly having you may take a solution of potassium iodide to decrease the size of the blood vessels in your thyroid about a week before surgery.

4. Assessing your calcium and vitamin D levels and correcting them if necessary.

After surgery, you’ll need to take daily thyroid medication since your body will no longer be able to produce thyroid hormone. 

Complications of surgery

When surgery is done by an experienced surgeon, the complication rate is low. 

Possible complications include:

• Damage to the small glands alongside your thyroid that control calcium levels in your blood

• Damage to the nerve that controls your vocal cords

• Reaction to the anesthesia

Treatment of Graves’ eye disease

Although most of your symptoms should resolve after treating your Graves’ disease with either antithyroid drugs, radioactive iodine, or surgery, this may not always be the case with the signs and symptoms of Graves’ eye disease. 

You may need to look for alternative ways to control and manage your eye symptoms. 

If your eye symptoms are mild, you may be able to manage them with a combination of lubricating gels at night and artificial tear drops during the day. 

If your eyelids don’t close fully when you sleep, you may need to tape your eyes shut at night to prevent them from drying out and to avoid damage to the exposed surface of your eye. Sunglasses may help with light sensitivity. 

If your Graves’ eye disease is more severe, your doctor may recommend one of the following treatments:

CorticosteroidsOral corticosteroids can reduce inflammation and swelling around your eyes, improving symptoms. Some ophthalmologists give local steroid injections into the tissue surrounding your eyes. 

Immunosuppressive medication

Immune modulating drugs⁴ such as Rituximab may help treat Graves’ eye disease.

Orbital decompression surgery

If the swelling around your eyes caused by Graves’ eye disease is bad enough to cause pressure damage to the optic nerve, your vision may be at risk. 

In this case, your doctor may operate on your eyes to remove some of the bone around your eyes and create more space for your eyes to move back to their original position. 

The lowdown

Graves’ disease is a common form of hyperthyroidism and can present with a wide range of symptoms. Initial treatment may be targeted at controlling these symptoms, especially if they’re severe. 

While side effects are rare, they can happen. Talk to a health professional to discuss potential complications and side effects you should be aware of.