5
Graves' Disease
Table 3. Clinical Situations That Favor a Particular Modality
as Treatment for Graves' Hyperthyroidism
Clinical situations RAI ATD Surgery
Pregnancy
a
X
P ! A !
Comorbities w/ increased surgical risk
and/or limited life expectancy
P A X
Inactive Graves' orbitopathy (GO) A A A
Active GO
b
P P
Liver disease P
!
A
Major adverse reactions to ATDs P X A
Patients with previously operated or
externally irradiated necks
P A
!
Lack of access to a high-volume thyroid
surgeon
P A
!
Patients with high likelihood of remission
(especially women, with mild disease,
small goiters, and negative or low-titer
thyrotropin receptor antibodies [TRAb])
A P A
Patients with periodic paralysis P A P
Patients with right pulmonary
hypertension, or congestive heart failure
P A
!
Elderly with comorbidities A A
!
yroid malignancy confirmed or suspected X – P
Large thyroid nodule (s) – A P
Coexisting primary hyperparathyroidism
requiring surgery
– – P
P, preferred therapy; A, acceptable therapy; !, cautious use; –, not first line therapy but
may be acceptable depending on the clinical circumstances; X, contraindication.
a
For women considering a pregnancy within 6 months, see discussion under Pregnancy.
b
Table 14 describes the use of RAI in GO in detail, considering disease activity, severity and other
risk factors for GO progression.
Graves' Disease
3. Patients with overt Graves' hyperthyroidism should be treated with
any of the following modalities: Radioactive iodine (RAI) therapy,
antithyroid drugs (ATDs), or thyroidectomy. (S-M)
