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Graves' Disease Treatment: Antithyroid Drugs, Radioiodine & Surgery

Three Definitive Modalities

  1. Antithyroid drugs (ATDs) – Methimazole (MMI) preferred; PTU in 1st trimester pregnancy.
    • Mechanism: Inhibit thyroid peroxidase → block hormone synthesis.
    • Duration: 12–18 months; remission ~40–50%.
    • Monitor: CBC/LFT at baseline, then if symptoms (agranulocytosis, hepatotoxicity rare).
  2. Radioactive iodine (RAI, I‑131) – Ablates thyroid tissue.
    • Contraindicated in pregnancy/lactation.
    • May worsen Graves’ orbitopathy (give glucocorticoid cover if moderate/severe).
    • Leads to permanent hypothyroidism → lifelong levothyroxine.
  3. Thyroidectomy – Near‑total or total.
    • Indicated: large goiter, compressive symptoms, suspicious nodules, patient preference, failed ATD/RAI.
    • Risks: RLN injury (~1–2%), hypoparathyroidism (~1–5% permanent).
    • Requires experienced high‑volume surgeon.

Choosing

  • Shared decision: age, comorbidities, orbitopathy, fertility plans, access, values.
  • ATDs first line in most guidelines; RAI/surgery for definitive cure.

Beta‑blockers (propranolol) for symptomatic control while definitive therapy takes effect.

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