eMedicine Specialties > Endocrinology > Thyroid

Graves Disease: Follow-up

Author: Sai-Ching Jim Yeung, MD, PhD, FACP, Deputy Section Chief of Emergency Care, Assistant Professor, Department of General Internal Medicine, Ambulatory Treatment and Emergency Care, University of Texas MD Anderson Cancer Center
Coauthor(s): Mouhammed Amir Habra, MD, Endocrine Fellow, Department of Endocrine Neoplasia and Hormonal Disorders, University of Texas MD Anderson Cancer Center; Alice Cua Chiu, MD, Consulting Staff, Department of Internal Medicine, Division of Endocrinology, Columbia Bayshore Medical Center
Contributor Information and Disclosures

Updated: Jun 4, 2009

Follow-up

Further Inpatient Care

  • With the exception of thyroid storm, Graves disease generally is managed in an outpatient setting.
  • On occasion, patients may present with thyrotoxic heart disease, including congestive heart failure, atrial fibrillation, or other tachyarrhythmia, which requires inpatient management.
    • Prompt recognition of thyrotoxicosis is required for optimal therapy.
    • In certain cases, the patient may have to be admitted to the intensive care unit or critical care unit.
    • Appropriate subspecialty consultations (eg, endocrinologist, cardiologist) are needed.
    • Once patients' conditions are stabilized, they can be transferred to a regular room or discharged from the hospital.
  • In certain cases (ie, noncompliant patients, those who develop severe reactions to antithyroid drugs), radioiodine ablation therapy may be given in an inpatient setting.

Further Outpatient Care

  • All patients should receive long-term follow-up, regardless of the mode of therapy (ie, surgery, radioiodine, antithyroid drugs).
  • Close follow-up visits with monitoring of examination findings, thyroid hormone levels, and thyrotropin levels are required.
  • If the patient is on antithyroidal medication (eg, thioamides), liver function tests and CBC counts with differentials should be monitored based on the clinical situation.
  • Examination of the eyes should be a routine part of follow-up of these patients, given the lack of predictability of ophthalmopathy.
  • Smoking cessation techniques should be continued.

Transfer

Hyperthyroidism represents a continuum of thyroid dysfunction. In the case of thyroid storm, decompensated patients with hyperthyroidism should be cared for in an institution with personnel familiar with this disease.

Deterrence/Prevention

Prevention is difficult because of the lack of knowledge regarding the pathogenesis of this condition.

Complications

  • Agranulocytosis is an idiosyncratic reaction to antithyroid drugs. The role of serial CBC counts to predict who will develop this serious adverse reaction is not well established.
  • In contrast to patients with Graves disease, preoperative iodine treatment should not be given to patients with toxic nodular goiters because it can exacerbate hyperthyroidism.

Prognosis

The natural history of Graves disease is that most patients become hypothyroid and require replacement. Similarly, the ophthalmopathy generally becomes quiescent. On occasion, hyperthyroidism returns because of persisting thyroid tissue after ablation and high antibody titers of anti-TSI. Further therapy may be necessary in the form of surgery or radioactive iodine ablation.

Patient Education

  • Awareness of the symptoms related to hyperthyroidism and hypothyroidism is important, especially in the titration of antithyroid agents and in replacement therapy for hypothyroidism.
  • Patients also should be aware of the potential adverse effects of these medicines. They should watch for fever, sore throat, and throat ulcers.
  • Patients also must be instructed to avoid cold medicines that contain alpha-adrenergic agonists such as ephedrine or pseudoephedrine.
  • For excellent patient education resources, visit eMedicine's Endocrine System Center. Also, see eMedicine's patient education article Thyroid Problems.

Miscellaneous

Medicolegal Pitfalls

  • Postpartum thyrotoxic women with a history of Graves disease actually may have postpartum thyroiditis rather than Graves disease as the cause of their thyrotoxicity. In such cases, antithyroid drugs are not needed.
  • Thyrotoxic heart diseases such as atrial fibrillation and cardiac failure are resistant to conventional therapy without simultaneous therapy for the thyrotoxicosis.
  • Myasthenia gravis may occur in patients with Graves disease and manifests as muscle weakness; this must not be mistaken for thyrotoxic myopathy.
  • Patients with Graves disease have a slightly higher risk of thyroid cancer. One must keep a vigilant eye for new thyroid nodules or thyroid growth.

Special Concerns

Graves disease in pregnancy is made more challenging by the harmful effects of hyperthyroidism and hypothyroidism on the developing fetus. This creates a balancing act. In general, free thyroxine levels should be kept at the upper limit of normal for the assay. In this manner, one can better avoid the complication of neonatal goiter.

 


More on Graves Disease

Overview: Graves Disease
Differential Diagnoses & Workup: Graves Disease
Treatment & Medication: Graves Disease
Follow-up: Graves Disease
Multimedia: Graves Disease
References
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Further Reading

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Keywords

Graves’ disease, diffuse toxic goiter, thyrotoxicosis, hyperthyroidism, Basedow's disease, Basedow disease, autoimmune thyroid disorder, autoimmune polyglandular syndrome, pernicious anemia, vitiligo, diabetes mellitus type 1, autoimmune adrenal insufficiency, systemic lupus erythematosus, thyroid antigens, thyroglobulin, thyroperoxidase, sodium-iodide symporter, TSH receptor, life-threatening thyrotoxic crisis, thyroid storm, Graves ophthalmopathy, thyroid acropachy, severe weight loss

osteoporosis, apathetic hyperthyroidism, cardiac hypertrophy, CTLA-4, pretibial myxedema, palpitation, nervousness, tremor, heat intolerance, hyperdefecation, inability to concentrate, proximal muscle weakness, easy fatigability with physical activity, proptosis, lid retraction, lacrimation, gritty sensation in the eye, photophobia, eye pain, diplopia, hyperhidrosis, increased sweating

restlessness, anxiety, irritability, insomnia, thyrotoxic periodic paralysis, onycholysis, alopecia, hyperactive deep-tendon reflexes, brisk deep-tendon reflexes, hypokalemic periodic paralysis, atrial fibrillation, cardiomyopathy, elevated transaminases, lid lag, irregular menstrual periods, gynecomastia, impotence, increased sex hormone–binding globulin levels,decreased free testosterone levels, decreased parathyroid hormone levels, decreased total cholesterol, decreased triglycerides, hand tremor, thyroid bruits

conjunctival injection, conjunctival chemosis, Yersinia enterocolitica, postpartum thyroid syndrome, use of interferons, use of interleukins, injection of percutaneous ethanol

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Contributor Information and Disclosures

Author

Sai-Ching Jim Yeung, MD, PhD, FACP, Deputy Section Chief of Emergency Care, Assistant Professor, Department of General Internal Medicine, Ambulatory Treatment and Emergency Care, University of Texas MD Anderson Cancer Center
Sai-Ching Jim Yeung, MD, PhD, FACP is a member of the following medical societies: American Association for Cancer Research, American College of Physicians, American Medical Association, American Thyroid Association, and Endocrine Society
Disclosure: Nothing to disclose.

Coauthor(s)

Mouhammed Amir Habra, MD, Endocrine Fellow, Department of Endocrine Neoplasia and Hormonal Disorders, University of Texas MD Anderson Cancer Center
Mouhammed Amir Habra, MD is a member of the following medical societies: American College of Physicians, American Thyroid Association, and Endocrine Society
Disclosure: Nothing to disclose.

Alice Cua Chiu, MD, Consulting Staff, Department of Internal Medicine, Division of Endocrinology, Columbia Bayshore Medical Center
Alice Cua Chiu, MD is a member of the following medical societies: American Medical Association and Endocrine Society
Disclosure: Nothing to disclose.

Medical Editor

Steven R Gambert, MD, MACP, Chairman, Department of Medicine, Physician-in-Chief, Sinai Hospital of Baltimore; Professor of Medicine, Program Director, Internal Medicine Program, Johns Hopkins University School of Medicine
Steven R Gambert, MD, MACP is a member of the following medical societies: Alpha Omega Alpha, American College of Physician Executives, American College of Physicians, American Geriatrics Society, Association of Professors of Medicine, Endocrine Society, and Gerontological Society of America
Disclosure: Nothing to disclose.

Pharmacy Editor

Francisco Talavera, PharmD, PhD, Senior Pharmacy Editor, eMedicine
Disclosure: eMedicine Salary Employment

Managing Editor

Kent Wehmeier, MD, Professor, Department of Internal Medicine, Division of Endocrinology, Diabetes, and Metabolism, St Louis University School of Medicine
Kent Wehmeier, MD is a member of the following medical societies: American Society of Hypertension, Endocrine Society, and International Society for Clinical Densitometry
Disclosure: Nothing to disclose.

CME Editor

Mark Cooper, MBBS, PhD, FRACP, Head, Diabetes & Metabolism Division, Baker Heart Research Institute, Professor of Medicine, Monash University
Disclosure: Nothing to disclose.

Chief Editor

George T Griffing, MD, Professor of Medicine, St Louis University School of Medicine
George T Griffing, MD is a member of the following medical societies: American Association for the Advancement of Science, American College of Medical Practice Executives, American College of Physician Executives, American College of Physicians, American Diabetes Association, American Federation for Medical Research, American Heart Association, Central Society for Clinical Research, Endocrine Society, International Society for Clinical Densitometry, and Southern Society for Clinical Investigation
Disclosure: Nothing to disclose.

 
 
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