Let’s talk about management.
Let’s try to control the symptoms first.
So, before you do anything, you want to make
sure that you’re able to properly regulate
the blood pressure and the heart rate in a
patient with Graves’ disease.
With all that T3, T4, you cause increased
sensitisation of your catecholamines upon
the beta-1 receptor, so it would only make
sense that you try to control heart rate and
control or manage your palpitations.
So, you’re looking for drugs that are then
going to slow down or block your beta receptors.
Atenolol or, if it’s non-selective, propranolol.
Used to control the palpitations.
“Hey, doc, I feel like my heart is going
to jump out of my chest.”
tachy-, anxiety, heat intolerance.
The ophthalmopathy, local symptoms, how do
you control this?
Lubricants in the eye drops because it’s
like you have all that orbit that’s protruding
My goodness, it is now exposed to the elements,
So, therefore, at this point, the lacrimal
gland can only take care of what’s normally,
you know, controlled by the eyelids, but if
it’s exophthalmos symptomatic, be smart
about how you manage your patient.
Take your time.
Understand what the patient is complaining
of and then manage your patient accordingly.
May require oral steroids, if at all responsive
to anti-inflammatory, radiotherapy or perhaps
even surgical decompression because you are
looking at increased intraocular pressure,
So, therefore, it might necessitate some of
that decompression that you want to make sure
that you address in Graves’ ophthalmopathy.
Targeting the disease itself.
So, now, we’ll talk about, apart from symptomatic
treatment or management that we discussed
earlier, let’s go and start taking care
of the thyroid gland.
Thionamides, inhibits thyroid peroxidase.
It does not inhibit the release of pre-formed
So, therefore, what has already been formed
is formed, but if you inhibit the peroxidase,
because back to you understanding of the synthesis
of your thyroid hormones, well, all that you’re
doing is inhibiting the synthesis of new thyroid
What’s been formed has already performed...
has already been formed.
Same concept could also be used with warfarin,
Warfarin, you cannot take care of the pre-formed
coags, but you can sure as heck take the newly
Means slow onset, just like warfarin.
Concept first, then memorise.
Low incidence of side effects.
Major, however, side effect would be what’s
called reversible agranulocytosis.
What you’re worried about if a patient is
Susceptibility to infection, rare, but as
far as your questions are concerned, whatever
may be rare or not, you still want to extremely
Rare hepatotoxicity, but could also very much
be part of your side effect profile with thionamides.
What are my thionamides?
These include methimazole.
Drug maintains therapy in non-pregnant patients
as once a daily dosing, whereas if you’re
thinking about PTU, it’s three time a day
Methimazole, associated with aplasia cutis.
Make sure you know the dermopathologic issue
that you find with methimazole.
PTU, in addition, I pointed this out earlier,
in addition to inhibiting peroxidase, which
as a general rule of thumb with thionamides,
all inhibit the enzyme.
In addition, PTU will also inhibit the dehydrogenase
peripherally so that you’re not able to
convert T4 to T3.
Therefore, all intent purposes you’re trying
to manage a patient with Graves’ disease.
And it’s preferred in pregnancy, as it is
less likely to cross the placental barrier.
So, methimazole, technically, non-pregnant.
PTU could be used in pregnancy, if needed.
Remission rate with the drug is less than
50%; best in milder diseases.
All depends to severity of your Graves’
As I’ve told you earlier, that exophthalmos
in Graves’ ophthalmopathy, if it’s a milder
diseases, you can actually find improvement
Let’s continue with targeting disease.
Let’s move away from thionamides with methimazole
Let’s move into radioactive iodine ablative
This time, we’re not diagnosing.
We are in fact ablating or damaging, removing
the tissue of the thyroid so that you decrease
This is what the boards will love.
You can accidentally remove so much of your
thyroid gland that you might then render patient
going into hypothyroid.
Now, that’s an age-old question.
Just keep that in mind.
Hormones, it’s really difficult to control,
What you would use here to monitor the amount
of damage to tissue would be thyroid globulin.
There was the discussion that we had earlier
It is the most common treatment in US for
Iodine is taken into and concentrated in thyroid
gland and a single dose treatment, very effective,
at complete ablation thyroid function (high
cure rate), but works slowly.
So, here’s the iodine.
Remember the sodium iodine?
It’ll take it right up.
It doesn’t know the difference, thyroid
gland, does it?
But, when it does, it is at that point in
Graves’ thyroid which is now being destroyed
on purpose with radio-ablative therapy.
Obviously, this is not the same radio isotope
of iodine that you’d use for diagnostic
This is for management and treatment, is the
ultimate cure, cure.
Disadvantages – may produce permanent hypothyroidism.
With enough damage of your Graves’ thyroid
gland, you might render your patient into
Maintain patient on thyroid hormone replacement
after radioactive iodine has been given.
Absolutely contraindicated in pregnancy and
breast feeding, for obvious reasons; it’s
If by chance you get such a question and for
whatever reason there has been radiation exposure
by the pregnant woman, then you know that
the foetal thyroid is destroyed.
All kinds of issues.
May worsen Graves’ ophthalmopathy, especially
Keep that in mind.
That’s one of those clinical tags that is
always added and if you can remember it, that’d
be great so that you know as to what’s going
on with your patient.