1. Graves’ Disease

2. The Case (1) 55 F Graves’ disease diagnosed at 彰基 one year ago Initial presentation: sweating, good appetite, easy nervousness Physical examination: enlarged thyroid gland about 5 cm in diameter at both lobes PTU 1# bid

3. The Case (2) 95/7/17: MVP, TVP 7/22: Af i RVR (HR 220) → Amiodarone 7/23: Bradycardia, conscious change → Pericardiocetesis, 580mL 7/24: Re-op PTU 1# qd during 7/19-7/24, then DC HR ↑, free T4: 4.53, TSH<0.15 on 8/11 Newmazole 1# tid since 8/15

5. Graves’ disease 60 to 80% of hyperthyroidism Autoimmune disorder Common between 30 and 40 years Woman, 0.5 per 1000 Family history

6. Clinical Presentation Manifestations of hyperthyroidism: hypermetabolic state Manifestations of Graves’ disease: Ophthalmopathy Localized dermopathy Thyroid acropachy

8. Diagnostic Modality Decreased TSH Increased free T4 and increased T3 TSHR-Ab Thyroid radioactive iodine uptake and scan

9. Treatment Anti-thyroid drugs Radioactive iodine therapy (RAI) Surgery

10. Anti-thyroid drugs Propylthiouracil Carbimazole → Methimazole Both inhibit thyroid peroxidase PTU also inhibits T4 to T3 conversion Immunomodulatory action?

11. Adverse effects Rash Arthralgias Urticaria GI symptoms Agranulocytosis

12. Drug Therapy The Titration regimen is just as effective as the Block-Replace regimen with a significantly lower incidence of adverse effects. The optimal duration of anti-thyroid drug therapy for the Titration regimen is 12–18 months. There is no benefit from continued T4 replacement after a course of anti- thyroid treatment.

13. Radioactive Iodine Therapy 131 I Long latency period Contraindication: pregnancy, lactation, ophthalmopathy? Only slight increased risk of mortality from thyroid cancer but no other malignancies Nausea, pain

14. ATD vs. RAI (1)

15. ATD vs. RAI (2)

16. Surgery Young age Male sex Pregnancy/lactation Patient preference Large or nodular goiter Inability to tolerate ATDs

17. Complications Thyroid storm or thyrotoxic crisis Hypothyroidism Recurrent hyperthyroidsim Recurrent laryngeal nerve injury Hypoparathyroidism

18. Conclusions Current treatment for Graves’ disease is effective, but the ideal treatment is still not available. Further understanding about immunologic processes involved should allow better diagnostic methods and treatments.