Treatment of Graves' Disease

Initial Diagnostic Workup

• The American College of Physicians recommends confirming diagnosis with TSH, Free T4, and considering TSH receptor antibody testing if clinical features suggest Graves' disease, with monitoring of thyroid function every 4-6 weeks during initial treatment phase 1, 3

First-Line Treatment: Antithyroid Medications

• The American Academy of Family Physicians suggests that methimazole is the preferred first-line agent for most patients, with standard protocol of 12-18 months of therapy and monitoring every 4-6 weeks initially, then every 2-3 months once stable 1, 2
• The American Academy of Family Physicians recommends titrating dose based on thyroid function tests, with goal to maintain FT4 in high-normal range using lowest possible dose 4

Adjunctive Therapy

• The American Heart Association recommends beta-blockers for symptomatic relief of tachycardia, tremor, and anxiety, with close monitoring of thyroid function every 2-3 weeks after diagnosis to catch transition to hypothyroidism in patients with thyroiditis 6, 1, 2

Second-Line Treatment Options

• The American Thyroid Association indicates that radioactive iodine is contraindicated in pregnancy and breastfeeding, and patients should not breastfeed for four months after RAI treatment 4, 5
• The American Thyroid Association recommends thyroidectomy for patients who do not respond to antithyroid medications, have very large goiters, or have contraindications to both antithyroid drugs and RAI 4

Management of Special Populations

• The American College of Obstetricians and Gynecologists suggests considering switching to methimazole after first trimester of pregnancy, with goal to maintain maternal FT4 in high-normal range using lowest possible dose 4

Severe Disease/Thyroid Storm

• The American Association of Clinical Endocrinologists recommends hospitalizing patient for intensive management, with beta-blockers for symptomatic relief, high-dose antithyroid drugs, and consideration of additional therapies such as steroids and saturated solution of potassium iodide (SSKI) 2

Monitoring and Follow-up

• The Endocrine Society recommends monitoring thyroid function every 2-3 weeks initially, then every 4-6 weeks once stable, and watching for common side effects of antithyroid drugs 1, 4

Common Pitfalls to Avoid

• The American Association of Clinical Endocrinologists advises against failing to recognize transition from hyperthyroidism to hypothyroidism, which is common with thyroiditis, and overlooking ophthalmopathy or thyroid bruit, which are diagnostic of Graves' disease 6, 2
• The American College of Radiology recommends avoiding use of radioactive iodine in pregnant or breastfeeding women 4