American Thyroid Association, July 2016; 'Graves Disease' has been designated as awareness raising month. It is defined by this name because it was first described by Robert Graves in 1835.
Graves disease is the most common cause of 'hyperthyroidism', which means the production of more thyroid hormone than necessary in our body. Although it can be seen at any age, it is most common between the ages of 20-40 and is 5-7 times more common in women (usually in the reproductive age) than in men. Graves' disease develops due to an unknown disorder in the immune system. It has been determined that heredity is the most important factor in the development of this disease. For this reason, individuals with a family history of Graves' disease should have thyroid tests. Stress, sadness, smoking, consuming too much iodine-containing foods and some medications can cause this disease. These patients should definitely prefer salt without iodine and should not smoke. Since other members of the family, especially children, need to take iodized salt, it is more appropriate to prepare meals without salt, and for Graves' patients to add non-iodized salt to their meals, and for children to add iodized salt.
Three common important points are feature; Goiter (enlargement of the thyroid gland), elevation of thyroid hormones in the blood and eye findings. Complaints are not the same in every patient; depending on the severity and duration of the disease, the patient; It varies depending on sensitivity, adaptability and age. Although appetite increases, weight loss is one of the most important symptoms of this disease. Common complaints; growth in the front of the neck, restlessness, restlessness, palpitations, fatigue, weakness, tremors in the hands, hair loss, nails softening and breaking, sweating, dislike of heat, preference for cold, irritability, getting angry or excited easily, eye findings called 'ophthalmopathy'; Lively gaze, eyes projecting forward, eyelids not closing completely, insomnia, attention deficit, hot, thin and moist skin, diarrhea, increased appetite, thirst, dry mouth, frequent urination, weight loss, decrease or cessation of menstrual periods, decreased sexual desire. and decreased sperm count, breast enlargement in men, skin findings, osteoporosis, muscle weakness, easy fatigue and some psychological problems. They are neurological disorders.
It is easy to diagnose. TSH has fallen below normal and thyroid hormones called T3 and T4 have increased excessively. TPO antibodies are found to be high in 90 percent and Tg antibodies are found to be high in 60 percent. In cases where the diagnosis is doubtful, high TSH receptor antibody levels make the diagnosis. Thyroid ultrasonography should always be performed to investigate the presence of enlargement and/or nodule in the thyroid gland. In patients presenting with similar complaints; Thyroid uptake test (scintigraphy) should be performed to distinguish thyroiditis (destruction of the thyroid gland) from Graves' disease.
Today, antithyroid medication, surgical treatment and radioactive iodine treatment are used in the treatment of Graves' disease. There are three different methods. All three are not perfect treatment methods and have positive and negative aspects. Treatment selection; Factors such as the presence of an experienced surgeon, the patient's age and gender, the severity of the disease, the size of the thyroid gland, patient compliance, comorbidities and the coexistence of thyroid nodule affect it.
Antithyroid drug (ATI) treatment; Medicines containing propylthiouracil (PTU) and methimazole (MMI) are used to normalize high hormone levels in the blood by inhibiting thyroid hormone production. It has side effects at a rate of 5 percent, less for MMI. Especially if there is a sore throat and high fever, the drug should be stopped immediately and a doctor should be consulted. PTU should be preferred during pregnancy (especially the first 3 months), and MMI should be preferred during breastfeeding. It takes 4-12 weeks for the effects of these drugs to be seen. Apart from low blood pressure, asthma, heart failure and hyperthyroidism accompanied by pregnancy, medications called 'beta blockers' are also given to reduce palpitations and tremors in the hands. Medications are continued for a period of approximately 12-18 months and are discontinued when an improvement in thyroid hormones is detected. The probability of recurrence in the first 1 year, generally within the first 3-6 months, is between 20-60 percent.
Observance of ATI side effects, requiring long-term use, lack of response to the drug, while taking medication In cases of difficulty and recurrence of the disease, RAI treatment or surgical treatment, which are permanent treatment options, should be considered.
Radioactive Iodine (RAI) treatment. Heat is a method frequently applied in hyperthyroidism that is not suitable for surgical treatment and recurs after surgical treatment. Generally, thyroid functions return to normal 2-6 months after treatment, and hypothyroidism (thyroid hormone deficiency) often develops in 4-12 months. 20 percent may require a second dose 6-12 months after the first treatment. It is definitely harmful for those who are considering pregnancy within 4-6 months, pregnant women and lactating mothers. RAI treatment; A pregnancy test must be performed beforehand and pregnancy should not be allowed before 6-12 months afterwards. RAI treatment is also dangerous in these patients as it will worsen eye symptoms.
Surgical treatment (CT) has the advantage of quickly eliminating the disease. Recurrence rates; While it is 50 percent in ATI and 40 percent (0-41) in RAI, it is between 0-28 percent after CT, depending on the extent of thyroidectomy (removal of the thyroid) and follow-up period. Cases where CT is absolutely necessary in Graves' disease: large goiter (>80 g) and/or pressure symptoms, proven or suspected cancer, serious eye findings (ophthalmopathy) and high antibody levels. Situations where CT is relatively necessary are; Pregnancy and breastfeeding, unresponsiveness to ATI, development of side effects or subsequent recurrence, situations in which RAI treatment is undesirable, patient request and child age group. Having Graves' disease; CT should be considered as the first step, especially in children under 5 years of age, young men, and women who want to become pregnant in a short time or who want to continue breastfeeding. CT should come to the fore as the presence of a palpable nodule in Graves' patients carries an average cancer risk of 16.9 percent (2.3-45.8 percent). Total thyroidectomy (TT) - the complete removal of the thyroid gland - surgery, which can reduce the rate of hyperthyroidism to zero, is recommended for patients with progressive eye findings.
TT surgery is the most appropriate approach in patients who require CT. The most important issue here is whether there is a team experienced in thyroid surgery. If this method, which is more expensive than other treatment options, is to be used, the chance of success must be high and the risks associated with the surgery must be at an acceptable minimum. With CT applied by experienced teams, the chance of cure of the disease is more than 95 percent, vocal nerve paralysis and The development rate of important risks such as low calcium is less than 1-2 percent. The most important benefit of CT is that the patient can return home within 1-2 days after the thyroid hormones are normalized, and there is generally no need for any other treatment other than thyroid hormone supplementation. Stay cheerful and well-being.
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