Graves' Disease

Definition
Graves' disease is the most common form of hyperthyroidism. It occurs when your
immune system mistakenly attacks your thyroid gland and causes it to overproduce
the hormone thyroxine.

The abnormal immune response can affect the tissue behind your eyes as well as parts
of your skin. The higher thyroxine level in Graves' disease can greatly increase your
body's metabolic rate, leading to host of health problems.

Graves' disease is rarely life-threatening. Although it may develop at any age and in
either men or women, Graves' disease is more common in women and usually begins
after age 20.

There's no way to stop your immune system from attacking your thyroid gland, but
treatments for Graves' disease can ease symptoms and decrease the production of
thyroxine.

Symptoms

Exophthalmos
 Graves' dermopathy

Graves' disease symptoms may include:

 Anxiety
 Irritability
 Difficulty sleeping
 Fatigue
 A rapid or irregular heartbeat
 A fine tremor of your hands or fingers
 An increase in perspiration
 Sensitivity to heat
 Weight loss, despite normal food intake
 Brittle hair
 Enlargement of your thyroid gland (goiter)
 Light menstrual periods
 Frequent bowel movements

Graves' ophthalmopathy
It's also fairly common for your eyes to exhibit mild signs of a condition known as
Graves' ophthalmopathy. In Graves' ophthalmopathy, your eyeball bulges out past its
protective orbit (exophthalmos). This occurs as tissues and muscles behind your eye
swell and cause your eyeball to move forward. Because your eye is so far forward, the
front surface of your eye can become dry. Cigarette smokers with Graves' disease are
more likely to have eye problems.
Graves' ophthalmopathy may cause these mild signs and symptoms:

 Excess tearing and sensation of grit or sand in either or both eyes

 Reddened or inflamed eyes
 Widening of the space between your eyelids
 Swelling of the lids and tissues around the eyes
 Light sensitivity

Less often, Graves' ophthalmopathy can produce these signs and symptoms:

 Ulcers on the cornea

 Double vision
 Limited eye movements
 Blurred or reduced vision

Graves' dermopathy
An uncommon sign of Graves' disease is reddening and swelling of the skin, often on
your shins and on the top of your feet, called Graves' dermopathy.

Causes

Normally, your immune system uses naturally occurring proteins (antibodies) and
white blood cells (lymphocytes) to help eliminate viruses, bacteria and foreign
substances (antigens) that invade your body.

In Graves' disease, your immune system mistakenly attacks your thyroid gland, but
instead of destroying the gland, an antibody called thyrotropin receptor antibody
(TRAb) stimulates the thyroid to make excessive amounts of thyroid hormone.

Your thyroid is part of your endocrine system, which includes a collection of glands
and tissues that produce hormones. These chemical messengers coordinate many of
your body's activities, from digestion to metabolism to reproduction. Thyroxine — a
hormone produced by the thyroid — controls your metabolic rate.

Doctors don't know the cause of Graves' disease, what may lead your immune system
to attack your thyroid gland. However, they believe a combination of factors,
including heredity, sex, age and stress, may determine your likelihood of developing
Graves' disease.

When to seek medical advice

See your doctor if you have signs and symptoms suggesting Graves' disease, which
may include an enlarged thyroid, protruding eyes, anxiety, intolerance to heat, tremor
and weight loss. Go to an emergency room if you are experiencing heart-related signs
and symptoms, such as a rapid or irregular heartbeat.

Tests and diagnosis

To diagnose Graves' disease, your doctor typically uses these procedures:

 Physical exam. Your doctor examines your eyes to see if they're irritated or
protruding and looks to see if your thyroid gland is enlarged. Because Graves'
disease increases your metabolism, your doctor will check your pulse and
blood pressure and look for signs of trembling. Your doctor will also ask you
about your symptoms and your personal and family medical histories.
 Blood sample. Your doctor will likely order blood tests to determine your
levels of thyroid-stimulating hormone (TSH) and thyroxine. TSH, produced
by your pituitary gland, is the hormone that normally stimulates the thyroid
gland. In Graves' disease, an abnormal antibody called TRAb mimics TSH,
causing elevated thyroxine even while TSH levels remain low. If you have
very low levels of TSH and high levels of thyroxine, your doctor may
diagnose Graves' disease.
 Radioactive iodine uptake. Your body needs iodine to make thyroxine. By
giving you a small amount of radioactive iodine and later measuring the
amount of radioiodine in your thyroid gland, your doctor can determine the
rate at which your thyroid gland takes up iodine. A high uptake of radioactive
iodine indicates your thyroid gland is producing too much thyroxine, as is the
case in Graves' disease. Low uptake occurs in some of the other causes of
hyperthyroidism.

Complications
Any time your body produces too much thyroid hormone, because of Graves' disease
or another cause, it can lead to a number of complications:

 Heart problems. Some of the most serious complications of hyperthyroidism

involve the heart. These include a rapid heart rate, a heart rhythm disorder
called atrial fibrillation and congestive heart failure — a condition in which
 your heart can't circulate enough blood to meet your body's needs. These
complications are generally reversible with appropriate treatment.
 Brittle bones. Untreated hyperthyroidism can also lead to weak, brittle bones
(osteoporosis). The strength of your bones depends, in part, on the amount of
calcium and other minerals they contain. Too much thyroid hormone interferes
with your body's ability to incorporate calcium into your bones.
 Thyrotoxic crisis. Hyperthyroidism also places you at risk of thyrotoxic crisis
— a sudden intensification of your signs and symptoms, leading to a fever, a
rapid pulse and even delirium. This complication is rare, but if it occurs, seek
immediate medical care.

Treatments and drugs

There's no treatment to stop your immune system from producing the antibodies that
cause Graves' disease. Treatments to control the signs and symptoms of Graves'
disease are designed to decrease the production of thyroxine or to block its action.
Graves' disease treatment includes:

 Beta blockers. These medications, which include propranolol (Inderal),

atenolol (Tenormin), metoprolol (Lopressor) and nadolol (Corgard), often
relieve hyperthyroid signs and symptoms, such as a rapid heart rate,
nervousness and tremors. These medications aren't a cure for Graves' because
your body will still produce too much thyroxine, but beta blockers block some
of the action of the thyroid hormone. Beta blockers are often used in
conjunction with other forms of treatment.
 Anti-thyroid medications. These prescription medications, including
propylthiouracil and methimazole (Tapazole), prevent your thyroid from
producing excessive amounts of hormones. Typically, treatment with anti-
thyroid medications continues for at least a year. For some people with
Graves' disease, treatment with anti-thyroid medications for one to two years
causes a long-term remission of the disease. However, relapse is fairly
common. These drugs are often used along with radioactive iodine treatment
or surgery to help control signs and symptoms.
 Radioactive iodine treatment. To make thyroid hormone, your body needs
iodine and uses whatever form of iodine is available in your blood. If you take
radioactive iodine, the iodine collects in your thyroid gland, and over time the
radioactivity destroys the overactive thyroid cells. This causes your thyroid
gland to shrink, and problems lessen gradually, usually over several weeks to
several months.

Because this treatment causes thyroid activity to decline, you'll likely later
need thyroxine treatment to supply your body with normal amounts of thyroid
hormones. Treatment doesn't require a hospital stay.

Radioactive iodine treatment may increase your risk of new or worsened

symptoms of Graves' ophthalmopathy. This side effect is usually mild and
temporary, but radioactive iodine therapy may not be recommended if you
already have moderate to severe eye problems. After radioactive iodine
treatment, any iodine not taken up into the thyroid gland is excreted in your
urine and saliva.
  Surgery. If you can't tolerate an anti-thyroid drug and don't want to have
radioactive iodine therapy, surgery to remove your thyroid gland
(thyroidectomy) is an option. After the surgery, you'll likely need thyroxine
treatment to supply your body with normal amounts of thyroid hormones.

Risks of this surgery include potential damage to your vocal cords and your
parathyroid glands, tiny glands located adjacent to your thyroid gland. Your
parathyroid glands produce a hormone that controls the level of calcium in
your blood. Complications are rare under the care of a surgeon experienced in
thyroid surgery.

Treating Graves' ophthalmopathy

If Graves' disease affects your eyes (Graves' ophthalmopathy), you can manage mild
symptoms by using artificial tears liberally during the day and lubricating gels at
night. If your symptoms are more severe, your doctor may recommend:

 Medications. Treatment with prescription corticosteroids, such as prednisone,

may diminish swelling behind your eyeballs.
 Orbital decompression surgery. In this surgery, your doctor removes the
bone between your eye socket (orbit) and your sinuses — the air spaces next
to the orbit. This gives your eyes room to move back to their original position.
Possible complications include double vision and lip numbness.
 Eye muscle surgery. The inflammation caused by Graves' disease can affect
your eye muscles, making them too short to allow the eyes to align properly.
In eye muscle surgery, your doctor cuts the muscle where it attaches to your
eyeball and then reattaches it farther back. Sometimes, more than one
operation is necessary.
 Prisms. You may have double vision either because of Graves' disease or as a
side effect of surgery for Graves' disease. Though they don't work for
everyone, prisms in your glasses may correct your double vision.

Orbital radiotherapy
Orbital radiotherapy was once a common treatment for Graves' ophthalmopathy.
Orbital radiotherapy uses targeted X-rays over the course of several days to destroy
some of the tissue behind your eyes. However, some studies have suggested that this
treatment provides no benefit for people who have mild to moderately severe Graves'
ophthalmopathy.

Your doctor may recommend orbital radiotherapy if your eye problems are worsening
and prescription corticosteroids alone aren't effective or well tolerated.

Lifestyle and home remedies

For Graves' ophthalmopathy
These steps may make your eyes feel better if you have Graves' ophthalmopathy:

 Apply cool compresses to your eyes. The added moisture may soothe your
eyes.
  Wear sunglasses. When your eyes protrude, they're more vulnerable to
ultraviolet rays and more sensitive to bright light. Wearing sunglasses that
wrap around the sides of your head will lessen the irritation of your eyes from
the wind.
 Use lubricating eyedrops. Eyedrops may relieve the dry, scratchy sensation
on the surface of your eyes. At night, a paraffin-based gel such as Lacri-Lube
can be applied.
 Elevate the head of your bed. Keeping your head higher than the rest of your
body lessens fluid accumulation in the head and may relieve the pressure on
your eyes.

For Graves' dermopathy

If the disease affects your skin (Graves' dermopathy), use over-the-counter creams or
ointments containing hydrocortisone to relieve swelling and reddening. In addition,
using compression wraps on your legs may help.