What is Graves’ Disease?

Overview

The endocrine system, a network of organs and glands within our body, is responsible for producing hormones that regulate various bodily functions. The thyroid gland: a butterfly-shaped structure located on the front side of your neck, plays a crucial role in this system by producing thyroid hormones that impact energy consumption in almost every organ in your body.¹

Graves' disease is the most common cause of hyperthyroidism: overactive thyroid gland.² This disease is named after Robert Graves, an Irish physician, the first person to describe this type of hyperthyroidism about 150 years ago.³ Graves' disease is an autoimmune disease, where our body's immune system attacks the thyroid gland which results in excess production of thyroid hormones than your body demands. This condition should be diagnosed promptly and failure to do so can lead to a thyroid storm which is life-threatening.²

In this article, we will discuss causes, risk factors, signs and symptoms, diagnosis, management, and FAQs of Graves' disease.

Causes of graves’ disease

Graves' disease is an autoimmune disorder that occurs when the body's immune system mistakenly attacks healthy thyroid tissue. This happens when the immune system produces antibodies that target the thyroid cells. Unlike most autoimmune diseases where antibodies attack and destroy the body's own cells, in Graves' disease, the thyrotropin receptor antibodies (TRAb) bind to receptors on the thyroid cells and cause them to overproduce and release thyroid hormones.²

The cause behind Graves’ disease is still unknown. However, people assigned females at birth (AFAB) and people older than 30 years are more prone to get Graves' disease. Also, if you have one of the below conditions, you are at a higher risk of getting Graves' disease.²

• Family history of Graves' disease or Hashimoto’s disease: another form of thyroid disease
• Other autoimmune disorders, such as:
  • vitiligo, which causes light-coloured patches on your skin
  • Type 1 diabetes, which is a type of diabetes that affects the production of insulin by destroying pancreatic cells
  • rheumatoid arthritis, which mainly affects your joints
• Consumption of nicotinic products like cigarettes

Signs and symptoms of graves’ disease

Hyperthyroidism

Most symptoms of Graves' disease are due to the excessive production of thyroid hormones by the diseased thyroid gland. Therefore, most people with Graves' disease will present with classic symptoms of hyperthyroidism.²

• Loss of weight despite an increased appetite
• Irregular or rapid heartbeat
• Sleep disturbances, nervousness, irritability
• Tremors (shivering hands)
• Heat intolerance and excessive sweating
• Frequent bowel opening
• Neck swelling (goitre)
• Menstrual irregularities like cessation of periods or reduced bleeding in people AFAB

However, older adults will sometimes have unspecific symptoms like:²

• Fatigue
• Loss of weight
• New-onset atrial fibrillation 

 Eye disease

Graves' disease is the only type of hyperthyroidism that can be associated with eye symptoms.² Around one-third of patients with Graves' have some signs and symptoms of eye disease such as:

• Inflammation of the eyes
• Swelling around the eyes
• Bulging of the eyes
• Redness of eyes

Thyroid related skin problems

Skin conditions associated with Graves' disease are rarely seen and occur  in approximately 2% to 3% of patients.² Skin conditions experienced are namely:

• Thickened and reddish skin with a rough texture
• Graves' dermopathy or pretibial myxoedema can cause painless swelling around your shin

Thyroid storm

In rare cases, undiagnosed and untreated overactive thyroid glands can cause this life-threatening condition: thyroid storm.

This sudden aggravation of thyroid symptoms happens due to:

• An infection
• Pregnancy or childbirth
• Poor compliance with thyroid treatments
• Damaged thyroid gland due to trauma

N.B. If you notice rapid heartbeat, fever, confusion, yellowish discolouration of eyes, or loss of consciousness you should contact emergency services immediately.

Management and treatment for graves’ disease

Diagnosis

Initial blood tests

Your GP may arrange a blood test to check your thyroid hormone levels. This blood test is known as the thyroid function test.

This test checks the levels of:

• Thyroid-stimulating hormone (TSH) – a hormone produced by the pituitary gland situated at the base of the brain that regulates the production of thyroid hormones
• Triiodothyronine (T3) – one of the two main thyroid hormones
• Thyroxine (T4) – another main thyroid hormone

Your thyroid hormone levels will be compared with the normal thyroid hormone levels of a healthy person. If this reveals abnormal levels, usually low TSH levels along with high levels of T3 and T4 indicate an overactive thyroid.

If these tests show abnormal results you will be referred to a specialist to find out the cause of overactive thyroid by carrying out further investigations.

Further blood tests

If your specialist suspects that you have Graves' disease you may be offered another blood test to find out the levels of anti-thyroid antibodies.

Thyroid scan and radioactive iodine uptake

A thyroid ultrasound scan may be used to find out lumps and nodules of your thyroid.

Sometimes, this is done together with the radioactive iodine test. You will be asked to swallow radioactive iodine; this can be given via injections as well. Then a scan will be performed to find out the amount of iodine uptake, and distribution of iodine which helps differentiate and to confirm the diagnosis of Graves' disease.

Treatment

Treatment options mainly include the treatment of hyperthyroidism. However, if eye disease and skin conditions coexist those conditions may be treated symptomatically.⁴

Hyperthyroidism treatment

Treatment for hyperthyroidism includes:

• Medications
• Radioactive iodine treatment
• Surgery

Antithyroid medicines 

These drugs reduce thyroid hormone levels by blocking the excess production of thyroid hormone by the thyroid gland. Carbimazole and propylthiouracil are the major drug types that you will be prescribed by your doctor.

It will usually take around 1 or 2 months of treatment before you can see any improvement.  Your doctor will gradually reduce the dose of the drugs and decide on cessation of drugs once the thyroid hormone levels become normal and remain normal for a while. However, in rare instances, some people may need to take medications for a few years or throughout their life.

Beta-blockers may help you to get symptomatic relief from symptoms such as rapid heartbeat, tremors, and nervousness. However, these drugs do not have any effect on the production of thyroid hormones.

Radioactive iodine treatment

Radioactive iodine therapy can destroy overactive thyroid cells; decreasing the amount of excess thyroid hormone produced by the thyroid gland. You will be given a capsule to swallow that contains iodine and a low-dose radioactive substance. Most of the time this will be a one-off treatment. It will take a few weeks for you to feel the benefits of the drug and in the meantime, you need to take other antithyroid medications.

This treatment option contains a very low amount of radiation. Still, you need to follow some precautions when taking radioiodine. Some of these precautions are, avoiding close contact with children and pregnant people women for a few days to weeks. Your doctor will explain these to you before the treatment. Also, people AFAB should avoid getting pregnant for 6 months and people assigned males at birth (AMAB) should not father a child for at least for 4 months due to the risk of DNA damage in the spermatozoa.

N.B. This treatment option is not for you if you have Graves' eye disease or if you are pregnant or breastfeeding.

Surgery

Removal of the complete thyroid gland, or part of it, may be recommended if:

• you have a largely swollen thyroid gland
• you have severe thyroid eye disease not responding to other treatments
• you are not suitable for other treatment options
• your symptoms relapse after other treatments

However, partial, or complete removal of the thyroid gland warrants you to take lifelong thyroxine (a hormone produced by the thyroid) and other supplementary nutrients like calcium.

Side effects of medications

There are some side effects that you may experience during the course of antithyroid medications such as:

• Allergic reactions: around 5% of people will experience allergic reactions like hives, and skin rashes
• Fever and joint pains
• Stomach upsets
• Altered taste
• Nausea

Apart from these, more serious side effects can occur in rare cases.

• Low white blood cell count can be a major serious side effect. As white blood cells play a vital part in battling infections drop in the count of white blood cells will expose you to infections

Therefore, if you experience a fever or sore throat while on these drugs you need to contact your doctor immediately, who will then arrange blood tests to confirm the white blood cell count.

The white blood cell counts will return to normal if you stop the drug immediately, but if you keep on taking the drug despite the low counts there is a high chance of getting more serious life-threatening infections.

• Liver damage is another rare but serious side effect, especially associated with the intake of propylthiouracil. If you develop dark urine, yellowish eyes, fatigue, and abdominal pain you should immediately consult your doctor and stop the drug as these can be initial symptoms of liver damage

Graves’ eye disease treatment

Most Graves' eye diseases cause mild symptoms.⁵ Eyedrops to avoid dry eyes, and wearing sunglasses to prevent light sensitivity are simple steps that can help you reduce mild symptoms. However, if you have severe symptoms your doctor may prescribe you steroids.

FAQs

How is graves’ disease diagnosed?

Your doctor will diagnose Graves' disease, clinically supported by blood investigations and a thyroid scan in some cases. The blood test assesses levels of thyroid-stimulating hormone (TSH), thyroid-specific triiodothyronine (T3), and thyroxine (T4).

How can I prevent graves’ disease?

Graves' disease is not preventable as there is no identifiable cause for Graves' disease. However, it is not contagious and you cannot get Graves' from another person.

Who is at risk of graves’ disease?

People AFAB and those older than age 30 are more prone to get Graves' disease. Also if you have one of the below conditions, you are at a higher risk of getting Graves' disease.

• Having a family history of Graves’ disease or Hashimoto’s disease: another form of thyroid disease
• Having other autoimmune disorders, such as:
  • vitiligo, which causes light-coloured patches on your skin
  • Type 1 diabetes, a type of diabetes that affects the production of insulin by destroying pancreatic cells
  • rheumatoid arthritis, which mainly affects your joints
• Consumption of nicotinic products like cigarettes

When should I see a doctor?

You should see a doctor if you show symptoms of an overactive thyroid like:

• Rapid heartbeat
• Loss of weight despite increased appetite
• Heat intolerance
• Frequent bowel opening

If you are on treatment for hyperthyroidism you should keep an eye on symptoms of agranulocytosis such as fever and/or a sore throat. You should see your doctor immediately if you experience these while on medication.

The thyroid storm is the other emergency situation in which you must immediately seek medical advice.

Summary

Graves' disease is an autoimmune disease where your own immune system acts against your body's own cells and, in this scenario, it attacks the thyroid gland resulting in excess production of thyroid hormones. Thyroid hormones influence the metabolism of almost all the tissues of our body. Diagnosis of Graves' disease is by taking your clinical history, a physical examination, and blood tests. Treatment options include medications, radioactive iodine therapy, and surgery.