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Graves’ Disease

Brief Overview: According to UpToDate, “Graves' disease is an autoimmune disease that may consist of hyperthyroidism, goiter, thyroid eye disease (orbitopathy), and occasionally a dermopathy referred to as pretibial or localized myxedema. Hyperthyroidism is the most common feature of Graves' disease, affecting nearly all patients, and is caused by thyroid-stimulating hormone (TSH, thyrotropin)-receptor antibodies (TRAb) that activate the receptor, thereby stimulating thyroid hormone synthesis and secretion as well as thyroid growth (causing a diffuse goiter).”

Prevalence: According to NIDDK, “Graves’ disease affects nearly 1 in 100 Americans.1 About 4 out of 5 cases of hyperthyroidism in the United States are caused by Graves’ disease.”

Etiology:

  • Autoimmune production of thyroid-stimulating antibodies (TSI/TRAb).
  • Antibodies bind to the TSH receptor, causing unregulated thyroid hormone synthesis and release.
  • Genetic susceptibility combined with environmental triggers (stress, smoking, pregnancy).

Risk Factors:

  • Genetics, family history
  • Females
  • Personal history of other autoimmune disorders
  • Psychological stress, negative life events
  • Alterations in gut microbiota
  • Smoking
  • Iodine and iodine-containing drugs

Commonly Associated Conditions:

  • Graves’ ophthalmopathy (dry eyes, bulging, double vision)
  • Atrial fibrillation or other tachyarrhythmias
  • Anxiety, insomnia, tremor
  • Osteopenia or osteoporosis (untreated disease)
  • Thyroid storm (rare, life-threatening)
  • Other autoimmune disorders

Common Medications:

  • Beta-blockers – atenolol
  • Antithyroid medications – thionamides (methimazole, propylthiouracil (PTU))
  • Oral radiocontrast agents - sodium ipodate and iopanoic acid may be indicated for some
  • Oral iodine may be indicated for some
  • Glucocorticoids may be indicated for some
  • Cholestyramine

Common Labs, Imaging, and Tests:

  • TSH, free T4, total T3
  • Thyroid antibody tests
  • Thyroid ultrasound
  • Radioactive iodine uptake test

Common Symptoms: Per NIDDK, symptoms can include:

  • weight loss, despite an increased appetite
  • rapid or irregular heartbeat
  • nervousness, irritability, trouble sleeping, fatigue
  • shaky hands, muscle weakness
  • sweating or trouble tolerating heat
  • frequent bowel movements
  • an enlarged thyroid gland, called a goiter
  • Graves’ ophthalmopathy (GO):
    • bulging eyes
    • gritty, irritated eyes
    • puffy eyes
    • light sensitivity
    • pressure or pain in the eyes
    • blurred or double vision
  • Graves’ dermopathy/pretibial myxedema:
    • Reddish, thickened skin with a rough textures
    • Typically affects shins but can also affects tops of feet and other body parts

Common Treatments:

  • Medication (see above)
  • Radioiodine ablation
  • Surgery
  • Management of ophthalmopathy, if present
  • Long-term follow-up for possible transition to hypothyroidism after definitive therapy

Physical Findings:

  • Tachycardia or irregular rhythm
  • Tremor, warm moist skin
  • Diffuse goiter ± thyroid bruit
  • Hyperreflexia
  • Eye findings: lid lag, proptosis, periorbital edema
  • Pretibial myxedema (rare)

Potential Complications and Contraindications:

  • Complications:
    • According to NIDDK, “Untreated, Graves’ disease can cause serious health problems, including
      • a rapid and irregular heartbeat that can lead to blood clots, stroke, heart failure, and other heart-related problems
      • thinning bones, osteoporosis, and muscle problems
      • problems with the menstrual cycle, fertility, and pregnancy
      • eye discomfort and changes in vision.”
    • Thyroid storm
    • Afib, Heart failure
    • Osteoporosis, increased fracture risk
    • Vision-threatening ophthalmopathy
  • Contraindications / cautions:
    • Pregnancy requires specialist-directed therapy
    • Smoking worsens ophthalmopathy
    • Caution with beta-blockers in asthma/COPD or bradycardia
    • Avoid excess iodine exposure

General Health and Lifestyle Guidance:

  • Take medications exactly as prescribed; do not stop abruptly.
  • Avoid iodine-containing supplements or “thyroid support” products, as directed by healthcare provider.
  • Limit caffeine and stimulants.
  • Encourage smoking cessation (critical for eye disease).
  • Monitor heart rate and report sustained tachycardia or irregular rhythm. Always ask your healthcare provider for specific advice on when to call to report symptoms, and when to seek urgent/emergency care.  
  • Keep scheduled lab monitoring and endocrinology follow-up.

Suggested Questions to Ask Patients:

  • What symptoms are you currently experiencing (palpitations, tremor, weight loss, heat intolerance)?
  • Are you taking methimazole or PTU as prescribed? Any missed doses?
  • Any fever or sore throat since starting medication?
  • Any chest pain, shortness of breath, or irregular heartbeat?
  • Do you have eye symptoms such as dryness, pain, or double vision?
  • Are you pregnant or planning pregnancy?
  • Do you smoke or use nicotine products?
  • Any recent iodine exposure (contrast scans, supplements)?

Suggested Talking Points:

  • Graves’ disease is an autoimmune condition and the most common cause of hyperthyroidism.
  • Medications can control symptoms and hormone levels, but some patients choose a definitive treatment.
  • Report fever or sore throat immediately while on antithyroid medication. Always ask your healthcare provider for specific advice on when to call to report symptoms, and when to seek urgent/emergency care.  
  • Smoking significantly worsens Graves’ eye disease.
  • With treatment and monitoring, most patients do very well.

Sources:

This content was created with the assistance of AI. Any AI-generated content was reviewed by a Nurse Practitioner.