Graves’ disease is an autoimmune disorder that results in an overactive thyroid, the gland in the lower part of the neck that helps control metabolism. Some patients think that this is a condition that will send them to the grave, but it can vary from mild to severe and is almost always treatable.
Graves’ disease affects about 50 per 100,000 people. It is much more common in women and it is more common in people aged 20 to 40 years old, but it can happen at any age.
The disease causes the immune system to inappropriately make something called thyroid stimulating immunoglobulin (TSI), which causes overactive thyroid. Depending on the levels of the stimulation by TSI, the disease can be mild or severe.
Graves’ disease is diagnosed through blood work or radiology tests.
Not everyone has the exact same symptoms, but most people will have some degree of heat intolerance, unintentional weight loss, tremor, muscle weakness, hair loss, more frequent and looser bowels, anxiety, irritability or poor concentration. In younger women, the menstrual cycle will be less often and lighter. In more extreme situations, the heart can go into an irregular rhythm called atrial fibrillation. It also can result in weakened bone strength. In the worst cases, patients can develop a life-threatening condition called thyroid storm, which can cause high body temperature, fast heart rate, an altered mental status, heart failure, and possibly death.
What is Graves opthalmopathy?
About half of patients with Graves’ disease also have changes to their eyes. The same protein made by the immune system that affects the thyroid also can cause inflammation in the tissues behind the eyes, pushing them forward. It can be mild and hardly noticeable, or so severe that it can cause double vision and loss of vision. Active smokers with Graves’ disease seem to get it more often and it can get worse after treatment with radioactive iodine. It sometimes will improve on its own given enough time, but some patients need corrective eye surgery, especially if their vision is affected.
What is Graves dermopathy?
This is an infrequent and late consequence of Graves’ disease. It is swelling in the tissue of the leg, usually the shin. It can be diagnosed either clinically or with a skin biopsy. Sometimes it is only a cosmetic issue, but other times it can be painful and disfiguring. Treatment is to correct the hyperthyroidism, but topical steroid creams can somewhat help
It is not known exactly which genes make people susceptible to Graves’ disease, but it is more common in those people who already have an autoimmune condition, such as type 1 diabetes, lupus or rheumatoid arthritis, or who have other family members with other autoimmune thyroid conditions or any other autoimmune condition. The period after a woman delivers a baby is an especially high-risk time for thyroid diseases, including Graves’ disease.
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If left untreated, it is possible that the autoimmune condition will go away eventually, but this could take decades. Therefore, it is necessary to treat Graves’ disease. There are three main ways to treat Graves’: surgical removal of the thyroid, ablation of the thyroid with radioactive iodine or suppressing the thyroid’s production of the excess hormone with medications.
I usually do not recommend surgery unless the other two treatment options are not acceptable. Once someone has had surgery, there is no thyroid left to be activated by the immune system, which means that the eye disease could continue. The surgery is relatively low-risk, but we usually get the patient back to a normal thyroid state with medications before surgery. Patients are in the hospital overnight and then have to take thyroid replacement pills for the rest of their life. Finding the correct dose can take a little effort, but patients usually do well once the correct dose is found.
Radioactive iodine treatment can be used to kill the thyroid cells from the inside. Essentially, the patient ends up like the patient after surgery (no active thyroid) without the scar or other potential complications of surgery. However, it can take weeks to months for the iodine to fully work. Most people will need lifelong therapy with thyroid replacement medication after this treatment. Some may need a second or third dose for it to work completely. The hyperthyroidism can worsen before it gets better after radioactive iodine, so, sometimes, we stay away from this treatment in patients with severe eye problems. In addition, smokers also tend to have worsening eye disease after radioactive iodine. Only certain licensed radiologists or endocrinologists can order the radioactive iodine.
There are two medications that can can treat the disease: methimazole and propylthiouracil. Both block iodine, the main building block for thyroid hormone, from getting into the thyroid gland, thereby suppressing the production of new thyroid hormone. Higher doses are used initially and then slowly decreased as directed by the thyroid blood tests. About 30 percent of those started on these medications will eventually come off and stay off after one to two years. We also use these medications as a bridge to either surgery or radioactive iodine. There are some rare side effects, including effects on the liver and white blood cells.
When the patient is very symptomatic, we also use a blood pressure medication called beta blockers. These medications help decrease the heart rate and the hyper feelings of the patient while the other treatments are working.