Graves’ Disease

The Case (1)

55 F Graves’ disease diagnosed at 彰基

one year ago Initial presentation: sweating, good

appetite, easy nervousness Physical examination: enlarged thyr

oid gland about 5 cm in diameter at both lobes

PTU 1# bid

The Case (2)

95/7/17: MVP, TVP 7/22: Af i RVR (HR 220) →Amiodarone 7/23: Bradycardia, conscious change

→ Pericardiocetesis, 580mL 7/24: Re-op PTU 1# qd during 7/19-7/24, then DC HR↑, free T4: 4.53, TSH<0.15 on 8/11 Newmazole 1# tid since 8/15

Graves’ disease

60 to 80% of hyperthyroidism Autoimmune disorder Common between 30 and 40

years Woman, 0.5 per 1000 Family history

Clinical Presentation

Manifestations of hyperthyroidism: hypermetabolic state

Manifestations of Graves’ disease: Ophthalmopathy Localized dermopathy Thyroid acropachy

Diagnostic Modality

Decreased TSH Increased free T4 and incr

eased T3 TSHR-Ab Thyroid radioactive iodine

uptake and scan

Treatment

Anti-thyroid drugs Radioactive iodine therapy (RAI) Surgery

Anti-thyroid drugs

Propylthiouracil Carbimazole → Methimazole Both inhibit thyroid peroxidase PTU also inhibits T4 to T3 conversio

n Immunomodulatory action?

Adverse effects

Rash Arthralgias Urticaria GI symptoms Agranulocytosis

Drug Therapy

The Titration regimen is just as effective as the Block-Replace regimen with a significantly lower incidence of adverse effects.

The optimal duration of anti-thyroid drug therapy for the Titration regimen is 12–18 months.

There is no benefit from continued T4 replacement after a course of anti-thyroid treatment.

Radioactive Iodine Therapy 131I Long latency period Contraindication: pregnancy, lactat

ion, ophthalmopathy? Only slight increased risk of mortali

ty from thyroid cancer but no other malignancies

Nausea, pain

ATD vs. RAI (1)

ATD vs. RAI (2)

Surgery

Young age Male sex Pregnancy/lactation Patient preference Large or nodular goiter Inability to tolerate ATDs

Complications

Thyroid storm or thyrotoxic crisis Hypothyroidism Recurrent hyperthyroidsim Recurrent laryngeal nerve injury Hypoparathyroidism

Conclusions

Current treatment for Graves’ disease is effective, but the ideal treatment is still not available.

Further understanding about immunologic processes involved should allow better diagnostic methods and treatments.