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Graves Disease

Introduction

Graves disease is a disorder of the thyroid gland in which an abnormal immune response of the body against the thyroid gland results in excessive production of thyroid hormones. The thyroid is a small gland in the front part of the neck which produces hormones that control many important body functions like metabolism, heart rate, physical growth, brain development, sexual development, etc.

Etiology

A combination of genetic and environmental factors is thought to be responsible for the disease, although the exact cause is still unclear. A person is more likely to have this disease if they have a family member with the condition. The environmental factors that can trigger the disease include physical or emotional stress, infection, smoking, pregnancy, and delivery. In this disease, the body produces antibodies that attach themselves to the thyroid gland and stimulate it to release uncontrolled amounts of thyroid hormones. Usually, a small gland at the base of the brain called the pituitary gland releases a hormone called thyroid-stimulating hormone TSH that controls the release of thyroid hormones. Due to increased thyroid hormones, TSH levels get reduced in this disease, and there is no thyroid gland control.

Signs and Symptoms

Since the thyroid gland affects many organ systems, there is a wide range of signs and symptoms.

  • Increased basal metabolic rate
  • Weight loss despite normal or increased appetite
  • Heat sensitivity, warm moist skin, increased sweating
  • Increased heart rate, palpitations
  • Anxiety, irritability, depression, sleep disturbance
  • Sexual dysfunction, changes in the menstrual cycle
  • Diarrhea
  • Hyperactivity, Fatigue, tiredness
  • Hair loss
  • Enlargement of the thyroid gland
  • A fine tremor of hands
  • Bulging eyes (graves ophthalmopathy)
  • Thick skin at the shin (pretibial myxedema)
  • Swelling around eyes, lid lag
  • Muscle weakness

Risk Factors and Epidemiology

  • Family history
  • Sex- females are more affected than males
  • Age – people under 40 years
  • Other autoimmune disorders – like diabetes 1, rheumatoid arthritis, etc
  • Pregnancy
  • Smoking
  • Stress
  • Infection (bacterial/viral)

Diagnosis

  • History and Physical Examination: the doctor questions symptoms and examines the patient for the signs discussed above.
  • Blood Tests: A blood sample would be taken to assess the levels of thyroid hormones (T3, T4 ) and thyroid-stimulating hormones(TSH)
  • Radioactive Iodine Uptake: iodine is needed to make thyroid hormones. In this test, a small amount of radioactive iodine is given to the patient, and later a scan is done to check the activity of the thyroid gland
  • Ultrasound: ultrasound of the thyroid gland can be ordered, and if the diagnosis is unclear, a CT scan or MRI can be done.

Differential Diagnosis

  • Thyroiditis
  • Exogenous and ectopic hyperthyroidism
  • Hashitoxicosis
  • Toxic adenoma
  • Toxic multi nodular goiter

Complications

Eye Complications

A small percentage of all Graves' patients will develop a thyroid eye disease in which your eye muscles and tissues become swollen. This can cause exophthalmos -- your eyeballs protrude from their sockets -- and is considered a hallmark of Graves' disease, even though it’s rare. But having this complication doesn’t have anything to do with how severe your Graves’ disease is. It isn't clear whether such eye complications stem from Graves' disease itself or a totally separate but closely linked disorder. If you have developed thyroid eye disease, your eyes may ache and feel dry and irritated. Protruding eyeballs are prone to excessive tearing and redness, partly because the eyelids can’t protect them as well.

In severe cases of exophthalmos, which are rare, swollen eye muscles can put tremendous pressure on the optic nerve, possibly leading to partial blindness. Eye muscles weakened by long periods of inflammation can lose their ability to control movement, resulting in double vision.

Skin Complications

Some people with Graves’ may develop a rare skin condition known as pretibial myxedema or Graves dermopathy. It is a lumpy reddish thickening of the skin on the shins. It is usually painless and is not severe. Like exophthalmos, this condition does not necessarily begin with the onset of Graves and doesn’t have to do with how severe your disease is.

Treatment

Graves’ disease’s treatment goals are to stop the production of thyroid hormones and block the hormones’ effect on the body. Some treatments include:

  • Radioactive Iodine Therapy: With this therapy, you take radioactive iodine (radioiodine) by mouth. Because the thyroid needs iodine to produce hormones, the thyroid takes the radioiodine into the thyroid cells, and the radiation destroys the overactive thyroid cells over time. This causes your thyroid gland to shrink, and symptoms lessen gradually, usually over several weeks to several months. Radioiodine therapy may increase your risk of new or worsened symptoms of Graves' ophthalmopathy. This side effect is generally mild and temporary, but the treatment may not be recommended if you already have moderate to severe eye problems. Other side effects may include tenderness in the neck and a temporary increase in thyroid hormones. Radioiodine therapy isn't used for treating pregnant women or women who are breastfeeding. Because this treatment causes thyroid activity to decline, you'll likely need treatment later to supply your body with average amounts of thyroid hormones.
  • Anti-thyroid Medications: Propylthiouracil, methimazole: these medications interfere with the production of thyroid hormone by the gland at different levels and stop its production
  • Surgery: Surgery to remove all or part of your thyroid (thyroidectomy or subtotal thyroidectomy) is also an option for treating Graves' disease. After the surgery, you'll likely need treatment to supply your body with average amounts of thyroid hormones. Risks of this surgery include potential damage to the nerve that controls your vocal cords and the tiny glands adjacent to your thyroid gland (parathyroid glands). Your parathyroid glands produce a hormone that controls the level of calcium in your blood. Complications are rare under the care of a surgeon experienced in thyroid surgery. You'll need to take thyroid medication for life after this surgery.

Medications

Anti-thyroid medications interfere with the thyroid's use of iodine to produce hormones. These prescription medications include

 Propylthiouracil and Methimazole:

The risk of liver disease is more familiar with propylthiouracil. However, Methimazole is considered the first choice when doctors prescribe medication. However, propylthiouracil is the preferred anti-thyroid drug during the first trimester of pregnancy, as methimazole has a slight risk of congenital disabilities. Pregnant women will generally go back to taking methimazole after the first trimester.

Anti-thyroid drugs may also be used before or after radioiodine therapy as a supplemental treatment.

Side effects of both drugs include rash, joint pain, liver failure, or a decrease in disease-fighting white blood cells.

Beta-Blockers:

These medications don't inhibit the production of thyroid hormones, but they do block the effect of hormones on the body. They may provide pretty rapid relief of irregular heartbeats, tremors, anxiety or irritability, heat intolerance, sweating, diarrhea, and muscle weakness.

It includes Propranolol, Atenolol, Metoprolol, and Nadolol.

Beta-blockers aren't often prescribed for asthma because the drugs may trigger an asthma attack. These drugs may also complicate the management of diabetes.

Medications

If you have Graves' disease, make your mental and physical well-being a priority:

Eating well and exercising can improve some symptoms during treatment and help you feel better in general. For example, because your thyroid controls your metabolism, you may tend to gain weight when hyperthyroidism is corrected. Brittle bones also can occur with Graves' disease, and weight-bearing exercises can help maintain bone density.

Easing stress may be helpful, as stress may trigger or worsen Graves' disease. Listening to music, taking a warm bath, or walking can help relax you and put you in a better frame of mind. Partner with your doctor to develop a plan that involves including good nutrition, exercise, and relaxation in your daily routine.

Prognosis

The prognosis for Graves’ disease is pretty good, considering that various effective treatments are available and can stop the adverse effects of hyperthyroidism. However, lifelong treatment to maintain a normal level of thyroid hormones is often required to remain healthy.

Your physician can explain in more detail your treatment options based on your illness, other conditions you may have, and other factors. Then you can choose the Graves’ disease treatment option that best fits your lifestyle and provides your best prognosis.