ATA Guidelines Tools

8 Graves' Disease 21. Measurement of TRAb levels prior to stopping ATD therapy is suggested, as it aids in predicting which patients can be weaned from the medication, with normal levels indicating greater chance for remission. (S-M) 22. If MMI is chosen as the primary therapy for GD, the medication should be continued for approximately 12–18 months, then discontinued if the TSH and TRAb levels are normal at that time. (S-H) 23. If a patient with GD becomes hyperthyroid after completing a course of MMI, consideration should be given to treatment with RAI or thyroidectomy. (W-L) • Continued low-dose MMI treatment for longer than 12–18 months may be considered in patients not in remission who prefer this approach. Iodine 24. Potassium iodide may be of benefit in select patients with hyperthyroidism due to GD, who have adverse reactions to ATDs, and have a contraindication or aversion to RAI therapy (or aversion to repeat RAI therapy) or surgery. (N-In) • Treatment may be more suitable for patients with mild hyperthyroidism, or a prior history of RAI therapy. Thyroidectomy 25. If surgery is chosen as treatment for GD, patients should be rendered euthyroid prior to the procedure with ATD pretreatment, with or without β-adrenergic blockade. A potassium iodide- containing preparation should be given in the immediate preoperative period. (S-L) 26. Calcium and 25-OH-vitamin D should be assessed preoperatively and repleted if necessary, or given prophylactically. Calcitriol supplementation should be considered preoperatively in patients at increased risk for transient or permanent hypoparathyroidism. (S-L) 27. In exceptional circumstances, when it is not possible to render a patient with GD euthyroid prior to thyroidectomy, the need for thyroidectomy is urgent, or when the patient is allergic to ATDs, the patient should be adequately treated with β-blockade, potassium iodide, glucocorticoids, and potentially cholestyramine in the immediate preoperative period. (S-L) • The surgeon and anesthesiologist should have experience in this situation. 28. If surgery is chosen as the primary therapy for GD, near-total or total thyroidectomy is the procedure of choice. (S-M)

• Cover