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Graves disease

Diffuse thyrotoxic goiter; Hyperthyroidism - Graves; Thyrotoxicosis - Graves; Exophthalmos - Graves; Ophthalmopathy - Graves; Exophthalmia - Graves; Exorbitism - Graves

Graves disease is an autoimmune disorder that leads to an overactive thyroid gland (hyperthyroidism). An autoimmune disorder is a condition that occurs when the immune system mistakenly attacks healthy tissue.

Causes

The thyroid gland is an important organ of the endocrine system. The gland is located at the front of the neck above where the collarbones meet. This gland releases the hormones thyroxine (T4) and triiodothyronine (T3), which control body metabolism. Controlling metabolism is important for regulating mood, weight, and mental and physical energy levels.

When the body makes too much thyroid hormone, the condition is called hyperthyroidism. (An underactive thyroid leads to hypothyroidism.)

Graves disease is the most common cause of hyperthyroidism. It is due to an abnormal immune system response that causes the thyroid gland to produce too much thyroid hormone. Graves disease is most common in women over age 20. But the disorder can occur at any age and can affect men as well.

Symptoms

Younger people may have these symptoms:

  • Anxiety or nervousness, as well as problems sleeping
  • Breast enlargement in men (possible)
  • Problems concentrating
  • Fatigue
  • Frequent bowel movements
  • Hair loss
  • Heat intolerance and increased sweating
  • Increased appetite, despite having weight loss
  • Irregular menstrual periods in women
  • Muscle weakness of the hips and shoulders
  • Moodiness, including irritability and anger
  • Rapid or irregular heartbeat
  • Shortness of breath with activity
  • Tremor

Many people with Graves disease have problems with their eyes:

  • The eyeballs may seem to be bulging out and may be painful.
  • Eyes can feel irritated and be tearing.
  • Double vision may be present.

Older people may have these symptoms:

Exams and Tests

The health care provider will do a physical exam and may find that you have an increased heart rate. An exam of your neck may find that your thyroid gland is enlarged (goiter).

Other tests include:

  • Blood tests to measure levels of TSH, T3, and free T4
  • Radioactive iodine uptake and scan

This disease may also affect the following test results:

  • Orbit CT scan or ultrasound
  • Thyroid stimulating immunoglobulin (TSI)
  • Thyroid peroxidase (TPO) antibody
  • Anti-TSH receptor antibody

Treatment

Treatment is aimed at controlling your overactive thyroid. Medicines called beta-blockers are often used to treat symptoms of rapid heart rate, sweating, and anxiety until the hyperthyroidism is controlled.

Hyperthyroidism is treated with 1 or more of the following:

  • Antithyroid drugs can block or change how the thyroid gland uses iodine. These drugs may be used to control the overactive thyroid gland before surgery or radioiodine therapy or as a long-term treatment.
  • Radioiodine therapy in which radioactive iodine is given by mouth. It then concentrates in the overactive thyroid tissue and causes damage.
  • Surgery may be done to remove the thyroid.

If you have had radioactive iodine treatment or surgery, you will need to take replacement thyroid hormones for the rest of your life. This is because these treatments destroy or remove the gland.

TREATMENT OF THE EYES

Some of the eye problems related to Graves disease often improve after treatment with medicines, radiation, or surgery. Radioiodine therapy can sometimes make eye problems worse. Eye problems are worse in people who smoke, even after the hyperthyroidism is treated.

Sometimes, prednisone (a steroid medication that suppresses the immune system) is needed to reduce eye irritation and swelling.

You may need to tape your eyes closed at night to prevent drying. Sunglasses and eye drops may reduce eye irritation. In rare cases, surgery or radiation therapy (different from radioactive iodine) may be needed to prevent further damage to the eye and loss of vision.

Outlook (Prognosis)

Graves disease often responds well to treatment. Thyroid surgery or radioactive iodine often will cause an underactive thyroid (hypothyroidism). Without getting the correct dosage of thyroid hormone replacement, hypothyroidism can lead to:

  • Depression
  • Mental and physical sluggishness
  • Weight gain

When to Contact a Medical Professional

Call your provider if you have symptoms of Graves disease. Also call if your eye problems or other symptoms get worse or do not improve with treatment.

Go to the emergency room or call the local emergency number (such as 911) if you have symptoms of hyperthyroidism with:

  • Decrease in consciousness
  • Fever
  • Rapid, irregular heartbeat

References

Burch HB, Cooper DS. Management of Graves disease: a review. JAMA. 2015;314(23):2544-2554. PMID: 26670972 www.ncbi.nlm.nih.gov/pubmed/26670972.

Davies TF, Lauerberg P, Bahn RS. Hyperthyroid disorders. In: Melmed S, Polonsky KS, Larsen PR, Kronenberg HM, eds. Williams Textbook of Endocrinology. 13th ed. Philadelphia, PA: Elsevier; 2016:chap 12.

Marino M, Vitti P, Chiovato L. Graves' disease. In: Jameson JL, De Groot LJ, de Kretser DM, et al, eds. Endocrinology: Adult and Pediatric. 7th ed. Philadelphia, PA: Elsevier Saunders; 2016:chap 82.

    • Endocrine glands

      Endocrine glands - illustration

      Endocrine glands release hormones (chemical messengers) into the bloodstream to be transported to various organs and tissues throughout the body. For instance, the pancreas secretes insulin, which allows the body to regulate levels of sugar in the blood. The thyroid gets instructions from the pituitary to secrete hormones which determine the rate of metabolism in the body (the more hormone in the bloodstream, the faster the chemical activity; the less hormone, the slower the activity).

      Endocrine glands

      illustration

    • Thyroid enlargement - scintiscan

      Thyroid enlargement - scintiscan - illustration

      This image shows enlargement of the thyroid gland and extension down behind the breastbone (retrosternal space). The image, called a scintiscan, was generated using a radioactive isotope.

      Thyroid enlargement - scintiscan

      illustration

    • Graves' disease

      Graves' disease - illustration

      Graves disease is an autoimmune disorder that involves overactivity of the thyroid gland (hyperthyroidism). Hallmarks of the condition are bulging eyes (exophthalmos), heat intolerance, increased energy, difficulty sleeping, diarrhea, and anxiety.

      Graves' disease

      illustration

    • Thyroid gland

      Thyroid gland - illustration

      The thyroid gland, a part of the endocrine (hormone) system, plays a major role in regulating the body's metabolism.

      Thyroid gland

      illustration

      • Endocrine glands

        Endocrine glands - illustration

        Endocrine glands release hormones (chemical messengers) into the bloodstream to be transported to various organs and tissues throughout the body. For instance, the pancreas secretes insulin, which allows the body to regulate levels of sugar in the blood. The thyroid gets instructions from the pituitary to secrete hormones which determine the rate of metabolism in the body (the more hormone in the bloodstream, the faster the chemical activity; the less hormone, the slower the activity).

        Endocrine glands

        illustration

      • Thyroid enlargement - scintiscan

        Thyroid enlargement - scintiscan - illustration

        This image shows enlargement of the thyroid gland and extension down behind the breastbone (retrosternal space). The image, called a scintiscan, was generated using a radioactive isotope.

        Thyroid enlargement - scintiscan

        illustration

      • Graves' disease

        Graves' disease - illustration

        Graves disease is an autoimmune disorder that involves overactivity of the thyroid gland (hyperthyroidism). Hallmarks of the condition are bulging eyes (exophthalmos), heat intolerance, increased energy, difficulty sleeping, diarrhea, and anxiety.

        Graves' disease

        illustration

      • Thyroid gland

        Thyroid gland - illustration

        The thyroid gland, a part of the endocrine (hormone) system, plays a major role in regulating the body's metabolism.

        Thyroid gland

        illustration

      Tests for Graves disease

       

      Review Date: 2/3/2016

      Reviewed By: Brent Wisse, MD, Associate Professor of Medicine, Division of Metabolism, Endocrinology & Nutrition, University of Washington School of Medicine, Seattle, WA. Also reviewed by David Zieve, MD, MHA, Isla Ogilvie, PhD, and the A.D.A.M. Editorial team.

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