Treatment of Hyperthyroidism in Patients with Graves’ Orbitopathy

Abstract

Hyperthyroidism due to Graves’ disease can be treated by antithyroid drugs (ATDs), radioiodine (RAI), or thyroidectomy. None of the treatments targets pathogenetic mechanisms of the disease. Graves’ orbitopathy (GO), the most frequent extrathyroidal manifestation of Graves’ disease, is present in about 25 % of newly diagnosed Graves’ patients, and rarely progresses over time. Neither ATDs nor thyroidectomy appear to affect the natural course of GO. At variance, RAI may cause de novo occurrence or progression of preexisting GO in a minority of patients, especially if smokers. In patients with mild GO, all the treatments for hyperthyroidism can be used safely. However, in most patients receiving RAI treatment, steroid prophylaxis using low-dose prednisone for a few weeks is advisable to prevent RAI-associated progression of GO. In the few patients with sight-threatening eye disease, management of GO has an absolute priority, and hyperthyroidism should be conservatively treated with ATDs until GO is cured. In patients with moderate-to-severe and active GO, who must be treated as soon as possible by immunosuppression, the choice of a conservative approach (ATDs) or an ablative treatment (RAI, thyroidectomy, total thyroid ablation) for thyroid dysfunction remains an important and unsolved dilemma. In patients whose GO has been cured or inactivated, any treatment for hyperthyroidism can be safely used.