Graves’ Disease

Graves’ disease is an autoimmune condition where your immune system creates antibodies called thyroid-stimulating immunoglobulins (TSIs). They mimic thyroid-stimulating hormone (TSH), and trick the thyroid gland into producing more hormones than is necessary (overactive).¹

Around 75% of people with an overactive thyroid have Graves’ disease.¹  Other names for it include Basedow disease, Parry disease, and Graves’ hyperthyroidism .¹

People with Graves’ disease can develop other conditions such as Graves’ dermopathy (also called pretibial myxedema), a skin condition or Graves’ ophthalmopathy also known as thyroid eye disease which causes eye problems.¹

What causes it?

The causes of Graves’ disease are not clear, like most autoimmune conditions .   It could be that some people are genetically predisposed and something triggers it such as environmental factors i.e. stress, infection or pregnancy.

You may, therefore, be at a higher risk of developing it if it runs in your family, or if you have other conditions that affect the immune system, such as type 1 diabetes or rheumatoid arthritis . Smoking also increases the risk of developing it so it is important to stop smoking especially if it runs in your family.¹

What are the symptoms?

Similar to hyperthyroidism, symptoms of Grave’s disease include:^3,4

• feeling nervous or anxious
• difficulty sleeping
• feeling irritable or having mood swings
• being thirstier than usual
• needing to pee more frequently
• tiredness
• muscle weakness
• diarrhoea
• feeling itchy
• losing interest in sex

When it affects the eyes, symptoms include:^5,6

• dry or gritty eyes
• eye irritation
• redness
• swelling or puffiness of eyelids
• bulging eyes
• double vision
• pressure behind the eyes
• constant tearing
• photophobia (extreme sensitivity to light)

In rare cases, it can also cause a skin condition called pretibial myxoedema, where the skin on your shins thickens and reddens. Although it usually occurs on the shins, it may also appear in other areas of the body such as the feet, ankles and elbows.^7,8

How is it tested?

You may need a number of blood tests to check your hormone and antibody levels, including:⁹

• a thyroid function test to check your T3, T4 and TSH levels
• a blood test to check for TSIs
• an erythrocyte sedimentation rate (ESR) test that looks at inflammation levels

High levels of TSIs or inflammation can indicate Graves’ disease.⁵

So, depending on the results, you may need a thyroid scan, a procedure where a small amount of radioactive iodine is introduced into your body to see a detailed image of your thyroid on a scan.⁹

If high levels of radioactive iodine were absorbed by your thyroid this will mean that you have Graves’ disease.¹⁰

What is the treatment?

The treatment for Graves’ disease depends on your age, any other conditions you have, and if you’re pregnant and is the same as the treatment for hyperthyroidism. There are three main options:⁵

• carbimazole or propylthiouracil – these medications are called antithyroid medications and stop your thyroid producing too much hormone, but can take up to two months to start working. Be aware that these antithyroid medications can have some side effects that include allergic reactions such as rashes and itching. More serious side effects can affect a small number of people such as a decrease in the number of white blood cells in your body,⁵ causing agranulocytosis and liver failure in rare cases^11,12
• “block and replace” – a mixture of antithyroid medications and levothyroxine
• beta-blockers such as propranolol to manage a fast heart rate
• radioactive iodine treatment – a type of radiotherapy for more advanced Grave’s disease that destroys the cells that produce hormones. People with eye problems (thyroid eye disease) or who are pregnant cannot be treated with ¹³
• surgery – sometimes doctors may need to remove part or all of the thyroid

What’s the prognosis?

People with Graves’ disease respond well to medication in general but eye problems can continue in people that smoke after treating their hyperthyroidism.⁴

Most people develop hypothyroidism after radioactive iodine treatment and surgery. As their thyroid cannot produce enough thyroid hormone, they often need to take hormone replacement medication like levothyroxine for life.¹⁴

The prognosis for people with pretibial myxoedema depends on early diagnosis and treatment so it is important that you visit your doctor as soon as you see any skin changes.¹⁵

You can find more information on Thyroid Eye Disease from the Thyroid Eye Disease Charitable Trust.

Guidelines

Thyroid disease: assessment and management
NICE guideline [NG145]Published date: November 2019
https://www.nice.org.uk/guidance/ng145

Management of patients with Graves’ orbitopathy: initial assessment, management outside specialised centres and referral pathways
Petros Perros, Colin M Dayan, A Jane Dickinson, Daniel Ezra, Stephanie Estcourt, Peter Foley, Janis Hickey, John H Lazarus, Caroline J MacEwen, Julie McLaren, Geoffrey E Rose, Jimmy Uddin and Bijay Vaidya
Clin Med April 2015
https://www.rcpjournals.org/content/clinmedicine/15/2/173

The 2016 European Thyroid Association/European Group on Graves’ Orbitopathy Guidelines for the Management of Graves’ Orbitopathy
Bartalena L.,  Baldeschi L., Boboridis K.,  Eckstein A, Kahaly G.J.,Marcocci C., Perros P., Salvi M., Wiersinga W.M. on behalf of the European Group on Graves” Orbitopathy (EUGOGO)
European Thyroid Journal
https://www.karger.com/Article/Fulltext/443828

For more support check out our online community:

http://www.healthunlocked.com/thyroiduk

Date updated: 29/03/21 (V1.1)
Review date: 01/04/2022

References

1. National Organisation for Rare Disorders
   Rare Disease Database
   Graves’ disease
   https://rarediseases.org/rare-diseases/graves-disease/
2. NHS – Hyperthyroidism
   Causes
   https://www.nhs.uk/conditions/overactive-thyroid-hyperthyroidism/causes/
3. NHS – Overactive thyroid (hyperthyroidism)
   Symptoms
   https://www.nhs.uk/conditions/overactive-thyroid-hyperthyroidism/symptoms/
4. Graves’ disease
   https://medlineplus.gov/ency/article/000358.htm
5. Graves’ disease
   https://www.niddk.nih.gov/health-information/endocrine-diseases/graves-disease#symptoms
6. Graves’ Ophthalmopathy
   https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3902010/
7. Morphological Diversity of Pretibial Myxedema and Its Mechanism of Evolving Process and Outcome: A Retrospective Study of 216 Cases
   Journal of Thyroid Research
   Changgui Lan, Yi Wang, Xia Zeng, Jing Zhao and Xiaoxi Zou
   https://www.hindawi.com/journals/jtr/2016/2652174/
8. Pretiial Myxedema
   Ranjodh Singh Gill, MD, FACP, CCD;
   https://emedicine.medscape.com/article/1103765-overview
9. NHS – Diagnosis – Overactive thyroid
   https://www.nhs.uk/conditions/overactive-thyroid-hyperthyroidism/diagnosis/
10. Endocrineweb
    Graves’ Disease Diagnosis – Tests to Check Thyroid Hormone Levels
    Daniel J Toft MD, PhD
    https://www.endocrineweb.com/conditions/graves-disease/graves-disease-diagnosis
11. Carbimazole-induced agranulocytosis
    Anisha Mohan, Siby Joseph, Neeraj Sidharthan and Dhanya Murali
    J Pharmacol Pharmacother. 2015 Oct-Dec; 6(4): 228–230.
    https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4714394/
12. Hepatoxicity in hyperthyroid patient after consecutive methimazole and propylthiouracil therapies
    Endocrinology , Diabestes & Metabolism – Case Reports
    Fernando Gomez-Peralta, Pablo Velasco-Martinez, Cristina Abreu, Maria Cepeda and Marta Fernandez-Puente https://edm.bioscientifica.com/view/journals/edm/2018/1/EDM17-0173.xml
13. NHS – Treatment
    Overactive thyroid (hyperthyroidism)
    https://www.nhs.uk/conditions/overactive-thyroid-hyperthyroidism/treatment
14. You and Your Hormones
    Graves’ disease
    https://www.yourhormones.info/endocrine-conditions/graves-disease/
15. Treatment of pretibial myxedema with intralesional immunomodulating therapy
    Ziwei Ren, Min He, Fang Deng, Yan Chen, Liyin Chai, Bing Chen and Wuquan Deng
    Ther Clin Risk Manag. 2017; 13: 1189–1194.
    https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5598751/