Abstract

• What is the best treatment for adults with Graves' disease in 2016? To answer this question, we reviewed the literature using the standard Prescrire methodology.
   
• When the symptoms of hyperthyroidism are poorly tolerated, a beta-blocker relieves tachycardia, anxiety and tremor.
   
• Three treatments have been shown to be effective in controlling hyperthyroidism: antithyroid drugs, radioiodine, and thyroidectomy.
  
  
• Carbimazole and its metabolite thiamazole are the antithyroid drugs with the best harm-benefit balance, except during the first trimester of pregnancy. About 50% of patients are cured after 12 to 18 months of treatment.
   
• Antithyroid drugs carry a risk of rare but serious adverse effects, including agranulocytosis. Hepatitis is more frequent with propylthiouracil.
   
• Radioiodine is administered as a single oral dose, in order to destroy the thyroid gland. Permanent cure is achieved in about 80% of cases, usually after 1 or 2 months. Permanent hypothyroidism is frequent, occurring at various intervals after treatment.
   
• Radioiodine may exacerbate pre-existing ophthalmopathy or provoke its onset, especially among smokers. Corticosteroid therapy reduces this risk. Protective measures are used for a few days or weeks in order to avoid radiation exposure among close contacts. Radioiodine is contraindicated during pregnancy.
   
• Surgical thyroidectomy may be total with little risk of recurrence, or subtotal with about an 8% risk of recurrence.
   
• The complications of surgery mainly consist of hypoparathyroidism and permanent paralysis of the recurrent laryngeal nerve, which occur after 1% to 5% of procedures. 
   
• In practice, the choice of treatment depends on the patient's preferences and situation, including a woman's desire to conceive, size of the goitre, the degree of hyperthyroidism, and the presence of ophthalmopathy. 
   

©Prescrire 1 March 2017

"Graves' disease in adults. Antithyroid drugs, radioactive iodine, or sometimes thyroidectomy" Prescrire Int 2017; 26 (180): 72-77. (Pdf, subscribers only)