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Graves Disease: Causes, Symptoms and Treatment

Graves disease is an autoimmune disorder of the thyroid gland causing hyperthyroidism. Key symptoms include rapid heartbeat, weight loss, and eye problems.

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Graves disease is an autoimmune disorder of the thyroid gland causing hyperthyroidism. Key symptoms include rapid heartbeat, weight loss, and eye problems.

What is Graves Disease?

Graves disease (also known as Basedow disease or Graves-Basedow disease) is an autoimmune condition in which the immune system mistakenly produces antibodies that overstimulate the thyroid gland. These antibodies, known as TSH receptor antibodies (TRAb), cause the thyroid to produce excessive amounts of thyroid hormones, leading to hyperthyroidism. It is one of the most common causes of an overactive thyroid and affects women significantly more often than men.

Causes

The exact cause of Graves disease is not fully understood. It involves a combination of several contributing factors:

Genetic predisposition: Certain genes increase the risk of developing the condition.
Immune system dysregulation: The immune system produces antibodies that activate the TSH receptor, stimulating excess hormone production.
Environmental triggers: Stress, smoking, infections, and iodine exposure may trigger or worsen the disease.
Hormonal factors: Pregnancy and the postpartum period are recognized as potential triggers.

Symptoms

Symptoms of Graves disease arise from both the excess thyroid hormones and the autoimmune process itself:

Rapid heartbeat (tachycardia) and heart rhythm disturbances
Unintentional weight loss despite a normal or increased appetite
Nervousness, restlessness, irritability, and sleep disturbances
Excessive sweating and heat intolerance
Goiter: Enlargement of the thyroid gland, visible at the front of the neck
Thyroid eye disease (Graves ophthalmopathy): Bulging eyes (exophthalmos), eyelid swelling, and double vision – a complication specific to Graves disease
Muscle weakness and tremor
Menstrual irregularities in women

Diagnosis

Diagnosis is based on a combination of clinical examination, laboratory tests, and imaging:

Blood tests: Low TSH levels, elevated free thyroid hormones (fT3, fT4), and the presence of TSH receptor antibodies (TRAb)
Thyroid ultrasound: Assessment of the size, structure, and blood flow of the thyroid gland
Thyroid scintigraphy: Imaging of thyroid activity using a small amount of radioactive material
Ophthalmological examination: Performed when thyroid eye disease is suspected

Treatment

Graves disease can be managed with several treatment approaches. The choice depends on the severity of the disease, the patient's age, and the presence of other health conditions:

Drug Therapy

Antithyroid drugs (e.g., methimazole, carbimazole, propylthiouracil) reduce the production of thyroid hormones. They are the first-line treatment and are typically prescribed for 12 to 18 months. If the disease recurs, more definitive options are considered.

Radioiodine Therapy

Radioactive iodine (iodine-131) is taken orally and selectively destroys overactive thyroid tissue. This approach is particularly suitable for older patients or in cases of relapse. It is contraindicated during pregnancy.

Surgery (Thyroidectomy)

Surgical removal of the thyroid gland (thyroidectomy) is considered when the goiter is large, malignancy is suspected, or the disease is severe. Lifelong thyroid hormone replacement therapy is required after the procedure.

Treatment of Thyroid Eye Disease

When the eyes are affected, treatment options include corticosteroids, orbital radiation, or surgery. An interdisciplinary approach involving endocrinologists and ophthalmologists is recommended.

Prognosis and Outlook

Graves disease follows a relapsing-remitting course in many patients. Approximately 50% of those treated with antithyroid drugs experience a relapse. With appropriate management, the condition can be well controlled. Left untreated, severe hyperthyroidism can lead to life-threatening complications such as a thyroid storm (thyrotoxic crisis).

References

European Thyroid Association (ETA): Guidelines for the Management of Graves' Hyperthyroidism. Eur Thyroid J, 2018.
Ross DS et al.: 2016 American Thyroid Association Guidelines for Diagnosis and Management of Hyperthyroidism. Thyroid, 2016.
Jameson JL et al. (eds.): Harrison's Principles of Internal Medicine, 21st edition, McGraw-Hill, 2022.

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