Graves’ disease: management
Despite many trials there is no clear guidance on the optimal management of Graves’ disease. Treatment options include titration of anti-thyroid drugs (ATDs, for example carbimazole), block-and-replace regimes, radioiodine treatment and surgery. Propranolol is often given initially to block adrenergic effects
ATD titration
• carbimazole is started at 40mg and reduced gradually to maintain euthyroidism
• typically continued for 12-18 months
• patients following an ATD titration regime have been shown to suffer fewer side-effects than those on a block-and-replace regime
Block-and-replace
• carbimazole is started at 40mg
• thyroxine is added when the patient is euthyroid
• treatment typically lasts for 6-9 months
The major complication of carbimazole therapy is agranulocytosis
Radioiodine treatment
• contraindications include pregnancy (should be avoided for 4-6 months following treatment) and age < 16 years. Thyroid eye disease is a relative contraindication, as it may worsen the condition
• the proportion of patients who become hypothyroid depends on the dose given, but as a rule the majority of patient will require thyroxine supplementation after 5 years