Professor and chief of Diabetes & Endocrinology at Apollo Hospitals,Indai
Title: Recent advances in Graves’ disease
Biography: Dr. Kalpana Dash
Graves' disease is an autoimmune disease classically presents with hyperthyroidism with diffuse goiter, infiltrative ophthalmology characterized by inflammation and involvement of intra-orbital structures, dermopathy also known as pretibial myxomatosis, and extra thyroidal features like weight loss, tachycardia, perspiration, tremor and sometimes rare involvement of the nails, fingers and long bones known as acropachy. Graves' disease is commonest cause of hyperthyroidism and represents 50–80% of cases of hyperthyroidism. Graves’ disease is common amongst women, smokers and associated with other autoimmune diseases such as type 1 diabetes mellitus, rheumatoid arthritis and collagen vascular diseases. It is also common amongst patients with family history of thyroid autoimmunity. It is an auto immune disease, in genetically susceptible individuals in whom auto antibodies are produced and result in thyroid hormone excess and glandular hyperplasia. Graves' disease reduces quality of life3, can cause tachyarrhythmia, severe weight loss, psychosis, osteoporosis, cardiac failure and sudden cardiac death. Organ specific symptoms can cause thyroid associated ophthalmology (TAO) and can risk the vision. TAO can deteriorate following radioactive iodine ablation. Tests to diagnose Graves' disease include thyroid function tests particularly ultra sensitive TSH ( thyroid stimulating hormone) assay, the measurement of free thyroxine (T4) and free triiodothyronine (T3), both of which are usually elevated in Graves' hyperthyroidism, radionuclide thyroid scintigraphy (99mTC-pertechnetate thyroid scintigraphy) demonstrating diffusely increased uptake in Graves' disease. It is helpful in distinguishing Graves’ disease from thyroiditis and autonomously hyper functioning nodule. Measurement of serum TSH-receptor antibodies is helpful in confirming the diagnosis of Graves' disease. At times patients with Graves' disease may present with sub clinical hyperthyroidism, characterized by suppression of TSH and T3 and T4 remaining within normal range. Other antibodies, including thyroid peroxidase (TPO) and thyroglobulin (Tg) antibodies, may be significantly elevated but are not specific to Graves' disease. Prompt treatment is important. There are three treatment modalities available for Graves' hyperthyroidism including a course of antithyroid drugs (thionamides) for 12-18 months. In case of relapse, radioactive iodine (RAI) therapy or surgery are other options. In Australia, UK and Europe patients receive an initial course of thalidomide therapy prior to the consideration of RAI. However in North American, RAI is the treatment of choice5. Surgery is considered in selective patients such as large goiter, contraindications to RAI therapy, relapse with anti thyroid drugs and nodular Graves’ disease. Surgery has the highest long-term remission rate (95%) but is not without risks.