AKT · Endocrine/Thyroid

Graves disease

Autoimmune TSH-receptor-stimulating antibodies

Overview

The commonest cause of hyperthyroidism — TSH-receptor-stimulating autoantibodies drive diffuse thyroid overactivity, plus the extrathyroidal features unique to Graves: orbitopathy (thyroid eye disease), pretibial myxoedema and acropachy. Managed as hyperthyroidism, with specific attention to the eye disease.

Recognise

Thyrotoxic features + DIFFUSE goitre (± bruit)
Graves-specific: orbitopathy (proptosis, lid retraction, diplopia — see ophthalmology), pretibial myxoedema, thyroid acropachy
TSH-receptor antibodies (TRAb) positive; diffuse radioiodine uptake; younger women, smoking worsens the eyes

Red flags

Dysthyroid optic neuropathy (reduced colour vision/acuity, RAPD) → urgent (sight-threatening — see ophthalmology)
Thyroid storm; new AF

Differentials & how to tell them apart

Toxic multinodular goitrenodular gland, no eye signs, hot nodules on scan, TRAb negative

Thyroiditislow uptake, transient, self-limiting

Anxiety disordernormal TFTs

Graves' disease — exophthalmos and goitre
CDC / Dr Sellers, Emory University / Public domain — Wikimedia Commons

Investigations

TFTs (↓TSH ↑T4/T3), TRAb positive, diffuse uptake on scan; assess eyes (orbitopathy).

Management

Antithyroid drug + beta-blocker; radioiodine/surgery definitive (manage the eyes)

1Treat the thyrotoxicosis (carbimazole/PTU + beta-blocker). Assess and manage orbitopathy: stop smoking, lubricants, refer active/severe eye disease.Gate: Avoid radioiodine in ACTIVE orbitopathy (can worsen it) — or give steroid cover; reduced colour vision/acuity = dysthyroid optic neuropathy → urgent ophthalmology
2Definitive radioiodine or thyroidectomy → lifelong levothyroxine; orbitopathy managed with ophthalmology (steroids/decompression). Cross-references the thyroid eye disease card on ophthalmology.

Antithyroid drug (carbimazole/PTU) + beta-blocker — as for hyperthyroidism

Radioiodine or thyroidectomy — definitive; radioiodine can worsen active orbitopathy (steroid cover)

Smoking cessation; selenium/steroids for orbitopathy — eye-disease management with ophthalmology

Key points

Diffuse goitre + eye signs + TRAb = Graves. The thing that makes it special is the orbitopathy — smoking and radioiodine both worsen it. (Thyroid eye disease is carded in depth on ophthalmology.)

Monitor & prognosis

TFTs; eye disease activity; post-treatment hypothyroidism.

Good; orbitopathy burns out over 1–3 years.

Source: NICE NG145; British Thyroid Association