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The treatment of Graves disease involves a choice of methods rather than a method of choice 1 Propranolol Propranolol is generally used for symptomatic relief until the hyperthyroidism is resolved It effectively relieves the tachycardia, tremor, diaphoresis, and anxiety that occur with hyperthyroidism due to any cause It is the initial treatment of choice for thyroid storm The periodic paralysis seen in association with thyrotoxicosis is also effectively treated with -blockade It has no effect on thyroid hormone secretion Treatment is usually begun with propranolol 20 mg orally, which is increased progressively until an adequate response is
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Patients with an established diagnosis of thyrotoxicosis usually undergo thyroid RAI uptake and scan A high RAI uptake is seen in Graves disease and toxic nodular goiter but can be
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with those taking propylthiouracil) have a lower risk of developing fulminant hepatic necrosis; methimazole therapy is also less likely to cause 131I treatment failure Rare complications peculiar to methimazole include serum sickness, cholestatic jaundice, loss of taste, alopecia, nephrotic syndrome, and hypoglycemia Methimazole is given orally in initial doses of 30 60 mg once daily; it may also be administered twice daily to reduce the likelihood of gastrointestinal upset The dosage is reduced as manifestations of hyperthyroidism resolve and as the FT4 level falls toward normal Methimazole is discontinued 4 days prior to 131I therapy for Graves disease and resumed at a lower dose 3 days after 131I therapy to avoid recurrence of hyperthyroidism About 4 weeks after 131I therapy, methimazole may be discontinued if the patient is euthyroid b Propylthiouracil Propylthiouracil is the drug of choice during breast-feeding or pregnancy, possibly causing fewer problems in the newborn Rare complications peculiar to propylthiouracil include arthritis, lupus erythematosus, aplastic anemia, thrombocytopenia, and hypoprothrombinemia Acute hepatitis occurs rarely and is treated with prednisone but may progress to liver failure Propylthiouracil is given orally in initial doses of 300 600 mg daily in four divided doses The dosage and frequency of administration are reduced as symptoms of hyperthyroidism resolve and the FT4 level approaches normal During pregnancy, the dose of propylthiouracil is kept below 200 mg/d to avoid goitrous hypothyroidism in the infant 3 Iodinated contrast agents These agents provide effective temporary treatment for thyrotoxicosis of any cause Iopanoic acid (Telepaque) or ipodate sodium (Bilivist, Oragrafin) is given orally in a dosage of 500 mg twice daily for 3 days, then 500 mg once daily These agents inhibit peripheral 5 -monodeiodination of T4, thereby blocking its conversion to active T3 Within 24 hours, serum T3 levels fall an average of 62% For patients with Graves disease, methimazole is begun first to block iodine organification; the next day, ipodate sodium or iopanoic acid may be added The iodinated contrast agents are particularly useful for patients who are very symptomatically thyrotoxic (see Thyroid Storm, below) They offer a therapeutic option for patients with T4 overdosage, subacute thyroiditis, and amiodarone-induced thyrotoxicosis and for those intolerant to thioureas and for newborns with thyrotoxicosis (due to maternal Graves disease) Treatment periods of 8 months or more are possible, but efficacy tends to wane with time In Graves disease, thyroid RAI uptake may be suppressed during treatment but typically returns to pretreatment uptake by 7 days after discontinuation of the drug, allowing 131I treatment 4 Radioactive iodine (131I) The administration of RAI is an excellent method of destroying overactive thyroid tissue (either diffuse or toxic nodular goiter) The RAI damages the cells that concentrate it There are ample data to conclude that patients who are treated with RAI in adulthood do not have an increased risk of subsequent thyroid cancer, leukemia, or other malignancies Similarly, individuals who were treated with RAI as teenagers have not shown any increased risk of malignancy in a 36-year retrospective study Children born to.
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