What’s the Best Way to Treat Graves’ Disease?

Your heart is racing. Your hands are shaking. You’re way too hot and having trouble sleeping. Your brain is off. You’re constantly hungry.

These are common symptoms of Graves’ disease, the most common cause of hyperthyroidism (excessive production of thyroid hormones) in the United States. It affects about 1 million Americans. And it’s unknown why.

“At any point in life, the body can make the thyroid stimulating antibody, and then the symptoms begin,” says Hyesoo Lowe, MD, Medical Director of the Columbia Thyroid Center. “For some people, Graves' disease has a clear beginning and ending. For others, it is more like a well-controlled chronic illness.” 

Treatment of Graves' disease involves the same medications and interventions used since the 1940s. Over the years, the way these treatments are deployed has changed and Lowe has seen the benefits.

“The conversations we have with patients about treating Graves' have gotten longer because there are more options for short- and long-term management,” says Lowe.

We spoke to Lowe, an expert in Graves’ disease, to find out more.

What is Graves' disease?

Graves' disease is one of a variety of autoimmune conditions. In people with Graves’ disease, the immune system makes an antibody that stimulates the thyroid gland to make excessive thyroid hormone in an unregulated fashion.

Normally, the body makes enough thyroid hormones, directed by the brain and how much thyroid hormone you already have. It's a tight loop, says Lowe: The brain responds to the thyroid supply and knows to shut off and turn on at the appropriate times.

When thyroid isn’t working as it should, the range of health problems and symptoms can be dramatic because the thyroid plays a role in regulating metabolism, body temperature, energy level, mood, and organ functioning ((including the brain, how the heart beats, and how the digestive system and muscles work).

In Graves’ disease, the immune system produces antibodies that overstimulate the thyroid cells to produce thyroid hormone and cause hyperthyroidism.

Like other autoimmune conditions, Graves' disease affects more women than men.

Symptoms of Graves’ disease

“When the thyroid is overactive it’s often obvious because it is quite uncomfortable,” says Lowe. Typically, Graves’ disease starts with heat intolerance, sweats, feeling extra hungry. It can progress to unintentional weight loss, heart palpitations, insomnia, tremulousness, frequent bowel movements, and breathlessness.

The original description of Graves' disease was “exophthalmic goiter” (large thyroid with protruding eyes) because about one-third of people with Graves' experience this eye symptom. It can cause redness of the eyes, light sensitivity, protuberant eyes, double vision, and vision loss.

People in their 20s and 30s may have few of these symptoms or not feel them until the condition is more severe because their bodies are able to handle some amount of hyperthyroidism. Maybe the heart is a little faster than usual at rest or with usual exercise. Maybe they feel out of breath when normally they would not be.

People in their 60s and older may not feel all the symptoms either because age changes the way people detect bodily sensations. Some may have low energy, weight loss, or newly develop an abnormal heart rhythm.

Graves' disease treatment options

There are multiple options when it comes to treating Graves’s disease.

Medications

Currently, the initial treatment for Graves' disease in the United States is medication. There are two: methimazole and propylthiouracil, both approved more than 70 years ago.

People usually begin to feel better after starting medication. But it takes 12 to 18 months on medication to determine if Graves' disease will go into remission (when the thyroid gland is no longer overactive and antibodies are reduced to normal and/or undetectable levels).

Recent data shows continuing medication can be safe and effective. In fact, emphasizes Lowe, lengthening the term to two years or more increases the possibility of remission. Translation: For some people, especially those who are feeling well, continuing medication can be a good idea. Some people just take a little bit longer.

Up to 50% of patients have a chance of Graves’ remission. But remission is not a cure: Graves' can recur later in life. The challenge is that it’s impossible to know who will fall into each group. 

Definitive treatment options

After 12 to 18 months on medication, if the Graves’ disease did not go into remission, patients are often advised to have radioactive iodine or surgery to remove the overactive thyroid gland.

“Some people are happy to wait it out a little bit longer to see if it can resolve. Others are ready to move on to radioactive iodine or surgery,” says Lowe.

These treatments are considered definitive (Graves’ will not recur). After, there’s permanent hypothyroidism.

“You go from having too much thyroid hormone to having too little but that does not mean trading one problem for another,” says Lowe. The good news is managing hypothyroidism is easier and more predictable. Replacement thyroid hormone is available in pill form.

Radioactive iodine to deactivate thyroid cells

Over the last few decades, doctors in the United States have shifted away from radioactive iodine as the initial treatment. But it remains effective and definitive.

“Deactivating thyroid cells is like removing the thyroid without surgery,” says Lowe. It’s all or none (lesser doses do not work because Graves’ disease will return).

This treatment is ideal for elderly people and anyone whose body cannot handle surgery. People who are allergic to antithyroid medication or feel poorly on them may also opt for radioactive iodine or surgery.

The risk of radioactive iodine is worsening of thyroid related eye disease and possible risk of future secondary cancers.

Surgery to remove the thyroid gland

Thyroidectomy, the surgery to remove the thyroid gland completely, is quick and final. It’s the preferred option for people who want or need prompt definitive treatment, including people who have poor control of severe hyperthyroidism, people who have other complications from hyperthyroidism, and people hoping to get pregnant.

It’s unsafe to be on antithyroid medication during pregnancy, and radioactive iodine requires pregnancy to be delayed by one year or more.

The main risk of surgery is damage to the parathyroid glands that control the body’s calcium.

The Bottom Line

Finding the right treatment course for each individual person with Graves' disease is key. “Revisit the options regularly with your doctor to arrive at the best plan for you,” says Lowe.