Graves' disease is an autoimmune thyroid disease in which the body produces IgG antibodies to the thyroid-stimulating hormone (TSH) receptor. It is the most common cause of thyrotoxicosis and is typically seen in women aged 30-50 years.

Features

• typical features of thyrotoxicosis
• specific signs limited to Grave's (see below)

Features seen in Graves' but not in other causes of thyrotoxicosis

• eye signs
  • lid retraction (most common sign, seen in 90%) - sympathetic overactivity leading to overaction of the levator palpebrae superioris and Müller’s muscle → 'staring' appearance
  • exophthalmos (most specific sign)
  • ophthalmoplegia
• pretibial myxoedema
• thyroid acropachy, a triad of:
  • digital clubbing
  • soft tissue swelling of the hands and feet
  • periosteal new bone formation

Autoantibodies

• TSH receptor stimulating antibodies (90%)
• anti-thyroid peroxidase antibodies (75%)

Thyroid scintigraphy

• diffuse, homogenous, increased uptake of radioactive iodine

Thyroid scintigraphy (I-123) shows homogenous uptake consistent with Graves' disease - e Image used on license from Radiopaedia

Management

Despite many trials, there is no clear guidance on the optimal management of Graves' disease. Treatment options include anti-thyroid drugs (ATDs, for example carbimazole), radioiodine treatment and surgery.

Anti-thyroid drugs have emerged as the most popular first-line therapy for Graves' disease in recent years. Factors that particularly support their use include anti-thyroid drugs significant symptoms of thyrotoxicosis, or patients with a significant risk of hyperthyroid complications (e.g. elderly patients, cardiovascular disease).

Initial treatment to control symptoms

• propranolol is used to help block the adrenergic effects
  • stop once euthyroid and symptoms resolved (e.g. not bradycardic)
  • usually stopped within weeks of starting carbimazole