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EPIDEMIOLOGY
Prevalence

400 per 100,000 persons

Lifetime risk of 1% in men and up to 2% in women
60-80% of cases are due to Graves' disease
Peak onset at 20-50 years
It affects females more than males (ratio 9:1)

Incidence
0.77/1,000 annually in women
0.14/1,000 annually in men

SYMPTOMS

Weight loss or gain

Change in appetite
Irritability
Weakness and fatigue
Diarrhoea steatorrhoea
Sweating
Tremor
Mental illness: may range from
anxiety to psychosis
Heat intolerance
Loss of libido
Oligomenorrhoea or amenorrhoea

SIGNS

Palmar erythema
Sweaty and warm palms
Fine tremor
Tachycardia
Hair thinning or diffuse alopecia
Urticaria, pruritus
Brisk reflexes
Goitre
Proximal myopathy
Lid lag

COMPLICATIONS
Osteoporosis

Angina & Heart failure

Atrial Fibrillation

Gynaecomastia

THYROTOXIC CRISIS OR STORM

May present in either previously undiagnosed or
ineffectively treated cases
Infections, poor compliance and radio-iodine therapy are
all precipitants.
It presents with fever, tachycardia, delirium or coma,
seizures, vomiting, diarrhoea and jaundice.
Treatment involves correcting the thyroid hormones,
using high doses of propylthiouracil, fluid resuscitation
and treating any precipitating causes.
It has 20-30% mortality due to arrhythmias and
hypothermia.

CAUSES OF THYROTOXICOSIS
Graves' disease:
This is the most common cause of hyperthyroidism and has an
autoimmune basis.

It is mediated by B and T lymphocytes, characterised also by

the presence of thyroid-stimulating immunoglobulins (TSIs).

The condition is characterised by a small to moderate diffuse,

firm goitre with 50% of these showing ophthalmopathy.

There may be a personal or family history of autoimmune

disease.
Associated with other autoimmune conditions - eg, pernicious
anaemia, type 1 diabetes mellitus.

CLINICAL FEATURES OF GRAVES

DISEASE
Exophthalmos
Opthalmoplegi
a
25-50%
Pretibial
myxoedema
<5%

Thyroid
acropachy
10-20%

Left sided
6th cranial
nerve palsy

OTHER CAUSES OF THYROTOXICOSIS

Toxic nodular goitre: the presence of a multinodular goitre
without the specific features of Graves' disease (common in the
elderly).
Solitary thyroid nodule: palpable, toxic adenoma

Transient hyperthyroidism usually results from a viral

infection. Presents with features of hyperthyroidism with pyrexia
and pain in the neck

Self-medication: over-the-counter iodine supplements; 'energy

boosting' preparations containing thyroid hormones

Follicular carcinoma of the thyroid gland

Drugs such as amiodarone, lithium, exogenous iodine
Ovarian teratomas

INVESTIGATIONS

INVESTIGATIONS
A radioactive iodine uptake
test and thyroid scan
together characterizes or
enables determination of
the cause of
hyperthyroidism.
The uptake test uses
radioactive iodine injected
or taken orally to measure
the amount of iodine
absorbed by the thyroid
gland.
Persons with
hyperthyroidism absorb
much more iodine than
healthy persons

 Beta-blockers (such as propranolol,

40mg/6h) are recommended to provide
rapid relief of marked adrenergic symptoms
associated with thyrotoxicosis (for example
tremor and tachycardia).
Some experts advise the use of Diltiazem
(a rate-limiting calcium-channel blocker) if
the use of beta-blockers is contraindicated,
by conditions such as asthma. However,
such use is currently off-label.

Thionamides (carbimazole and

propylthiouracil) act very quickly and inhibit
the production of thyroid hormones. Full
benefit may take 2-3 weeks to become
apparent.
Thionamides are used:
Short-term in preparation for radioiodine
treatment or surgery.
Medium-term with the aim of inducing
remission of Graves' disease.
Long-term in people in whom definitive
treatment of hyperthyroidism (surgery and
radioiodine) is relatively contraindicated.

Two different treatment regimens may be

initiated by a specialist:
Titration-block regimen: a thionamide is
used and the dose is adjusted every 46
weeks based on free thyroxine (FT4)
measurements.
Block and replace regimen: a thionamide
is used to 'block' the synthesis of thyroid
hormone. FT4 is monitored and
levothyroxine is added in when the FT4 is
normalized. Adjustments to the dose of
levothyroxine are made to maintain the FT4
within the reference range.

 Carbimazole is most commonly used to

begin with, in a dose of 10 mg bd/tds
initially (depending on weight)
Once the patient is euthyroid the dose
is reduced until the patient is on the
lowest amount to maintain the T4 and
T3 within the normal range.
Remission is usually achieved at 18-24
months, after which attempts may be
made to stop antithyroid drugs.
Minor side-effects include:
nausea and a bitter taste after
taking medication
<0.5% of patients agranulocytosis

Radioiodine is used in secondary care to

treat nearly all types of hyperthyroidism,
especially in elderly people.
Radioactive iodine is given and is taken up
by the thyroid gland, leading to destruction
of the gland. Some may need a second
treatment. It can take 3-4 months to take
effect.
Radio-iodine has the advantages that it is
relatively inexpensive and a definitive
method of treating hyperthyroidism.

 It is contraindicated in pregnancy and in women

who are breastfeeding.
Other situations where radioiodine therapy might
not be appropriate include in:
Frail, elderly people with limited life
expectancy.
People with thyroid cancer or suspected
thyroid cancer.
People with urinary incontinence.
Hypothyroidism is also a potential and common
complication. Estimates suggest that between
50% to 80% of patients can develop
hypothyroidism. Therefore, there is a need for
long-term follow-up of the TFTs.

Surgical total or near-total thyroidectomy, performed

in secondary care, is used to prevent recurrent
hyperthyroidism. Thyroidectomy also eliminates
compressive symptoms from large toxic multinodular
goitres.
The main indications for surgery are:
Presence of a co-existing potentially malignant
thyroid nodule.
Large goitre
Poor response to antithyroid drugs
Intolerance of antithyroid drugs.
The person's preference.

 Thyroidectomy carries a risk of damage to the

recurrent laryngeal nerve (hoarse voice) and
hypoparathyroidism.
However, subtotal or near total thyroidectomy
achieves a 98% cure rate.