Therapeutic target
Achieve a euthyroid metabolic state (= thyroid levels in the normal range).
Therapy recommendations
- Thyrostatic drugs (drugs that inhibit thyroid function and are used to treat hyperthyroidism)
- In manifest hyperthyroidism (hyperthyroidism) → thioamide type (thiamazole and carbimazole) or with propylthiouracil (PTU); duration of therapy: one year (to one and a half years) of thyrostatic therapy [laboratory: determination of free peripheral thyroid hormones 1 to 2 times per month].
- In latent hyperthyroidism (rare) individual decision.
- Beta-blockers for tachycardia (heart rate > 100 beats/min) → propranolol
- In case of progression of orbitopathy (protruding eyes) despite euthyroid metabolic state (normal thyroid function) → high-dose therapy with glucocorticoids (prednisolone/methylprdnisolone); in rare cases, if necessary. retrobulbar radiotherapy (orbital radiation; orbita = “bony eye socket”))possibly in the future: antibody teprotumumab; this has been approved as an orphan drug in the USA (see below protruding eyes (exophthalmos)/medicinal therapy).
- No remission (regression of symptoms) within 12 to 18 months:
- Radioiodine therapy (RJT) or
- Thyroidectomy (surgical removal of the entire thyroid gland).
- Thyrotoxic crisis: see below Hyperthyroidism/Thyrotoxic crisis/Drug therapy.
- Therapy of endocrine ophthalmopathy (see below).
- Therapy during pregnancy and lactation (see below).
- See also under “Further therapy”.
Further notes
- The serum TRAK level (thyrotropin receptor autoantibodies, usually called TSH receptor autoantibodies) allows prognostic information on disease progression. A TRAK serum level of ≤10 IU/l about 6 months after disease onset largely excludes remission (“permanent attenuation of symptoms “)(“permanent attenuation of symptoms “).
- Long-term thyrostatic therapy can be considered in the absence or small goiter, mild hyperthyroidism, low TRAK titer, and low perfusion rate on duplex sonography.
Therapy of endocrine ophthalmopathy
- In case of progression of the orbitopathy (immunologically induced inflammation of the orbital contents/protruding eyes) despite euthyroid metabolic state → high-dose therapy with glucocorticoids (prednisolone/methylprdnisolone); in rare cases, retrobulbar radiotherapy if necessary.
- The monoclonal antibody teprotumumab may be the first effective drug for the treatment of exophthalmos (protrusion of the eyeball) in Graves’ disease. The antibody binds to the receptor for insulin-like growth factor 1 (IGF-1), which promotes the proliferation of fibroblasts in the eye socket.
Therapy during pregnancy and lactation
Determination of TRAK (thyrotropin receptor autoantibodies, usually called TSH receptor autoantibodies) at the end of the second or beginning of the third trimester (22-28 weeks of gestation) to assess fetal or neonatal risk of hyperthyroidism. Fetal and neonatal monitoring for hyperthyroidism at 2- to 3-fold the upper reference value.
- If TRAk elevated → risk of hyperthyroidism (hyperthyroidism) of the fetus: risk pregnancy, ie, review of fetal development every four weeks by the gynecologist.
In case of manifest hyperthyroidism:
- In case of tachycardia: Administration of beta-blockers possible
- 1st trimester (third trimester): propylthiouracil (PTU).
- 2nd + 3rd trimester: thiamazole (note: thiamazole is embryotoxic in the 1st trimester!).
- Fetal malformation risk is not increased with adequate therapy.
- Breastfeeding: PTU; Cave (Attention! ): Hypothyroidism (thyroid test) of the mother.
Note: Iodide administration indicated in pregnancy must be avoided!
