Management

GRAVE’S DISEASE –MANAGEMENT

I. Management of Hyperthyroidism of Grave’s disease

The most common methods of treatment are:

  • Antithyroid medicines
    • Medications like Methimazole, Carbimazole and Propylthiouracil decreases the production of thyroid hormone.
    • Initially full dose of Methimazole (30-40 mg) or Propylthiouracil (300-400 mg) are given orally until the patient becomes euthyroid (i.e. normal thyroid function). Once the thyroid hormone levels become normal, the dose is gradually decreased to a level where the patient remains in a euthyroid state.
    • These drugs may take 6 weeks to 3 months to stabilize the thyroid hormone levels in blood.
    • Propylthiouracil may be safer in pregnant women.
  • Surgery: Subtotal thyroidectomy (surgical removal of most of the thyroid gland) may be considered in:
    • young people
    • people who have a large goiter
    • those who are allergic to or develop severe side effects to antithyroid drugs.

Patient should be treated with Antithyroid drugs to make them euthyroid before surgery. At times due to excess removal of thyroid gland a hypothyroidism like state may set in. In such cases, thyroid hormone replacement therapy is indicated.

  • Radioactive iodine:
    • It may take 2-3 months to show improvement after a single dose of radio active iodine.
    • It is a preferred mode of treatment in older people (> 40 years of age).
    • It does not increase the risk of thyroid cancer, leukemia or other cancers. However, it should be avoided during pregnancy due to risk to fetus.

II. Management of eye symptoms

Lid retraction usually resolves when the patient becomes euthyroid (normal thyroid function), and exophthalmos usually lessens gradually over a period of 2-3 years.

  1. General eye protective measures include:
  • Elevating the head end of bed.
  • Wearing tinted glasses
  • Sleeping with the eyelids taped shut
  • Applying Methylcellulose gels and eye drops (‘artificial tears”) which help to relieve gritty discomfort of dry eyes.
  • Double vision may be corrected by using glass prisms.

Ib. Steroids: For progressive cases of exophthalmos Prednisone is given. Higher doses of prednisone are used when there is optic nerve compression. If significant improvement is not seen within 7-10 days orbital decompression surgery is to be done. This saves vision though double vision may often persist even after operation.

Ic. Surgery: Corneal ulceration is an indication for eyelid surgery (lateral tarsorrhaphy)

III. Management of skin symptoms

Most often the problem disappears without any treatment. Treatment, if required involves application of a topical glucocorticoid (e.g. fluocinolone) which relieves the itching and hardness.