Investigations

• TSH suppressed

• radioisotope scan

The isotope scan enables a diagnosis of Graves' disease to be made when the scan shows uniform increased uptake. Increased irregular uptake would suggest a toxic multinodular goitre, while there is poor or no uptake with de Quervain's thyroiditis and thyrotoxicosis factitia.

Management principles

• Establish the precise cause before initiating treatment.

• Educate patients and emphasise the possibility of development of recurrent hyperthyroidism or hypothyroidism and the need for lifelong monitoring.

Treatment modalities 5 6

• radioactive iodine therapy (I131)

• thionamide antithyroid drugs (initial doses)

o carbimazole 10-45 mg (o) daily o propylthiouracil 200-600 mg (o) daily

• adjunctive drugs o beta-blockers (for symptoms in acute florid phase) o lithium carbonate (rarely used when there is intolerance to thionamides) o Lugol's iodine: mainly used prior to surgery

• surgery o subtotal thyroidectomy or o total thyroidectomy

Treatment of Graves' disease

There is no ideal treatment, and selection of antithyroid drugs, radioiodine or surgery depends on many factors including age, size of goitre, social and economic factors and complications of treatment.

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