| The following vignette applies to the next 2 items. |
A 25-year-old man comes to the office with a 2-month history of fatigue, palpitations, sweating, and heat intolerance. The symptoms are becoming more distressing and are keeping the patient awake at night. The patient has no diplopia, eye pain or redness, decreased vision, neck pain, or proximal muscle weakness. Medical history is unremarkable, and he currently takes no medications. He smoked for approximately a year during college but quit after graduation. The patient drinks alcohol socially but does not use recreational drugs. Family history is positive for hypothyroidism in his mother. Temperature is 36.7 C (98 F), blood pressure is 130/70 mm Hg, pulse is 115/min (regular), and respirations are 18/min. Examination shows an anxious, thin man in no acute distress. There is mild lid lag but no conjunctival erythema or proptosis. Extraocular movements and pupillary reflexes are intact. Mild diffuse nontender enlargement of the thyroid gland is noted. The skin is warm and moist. Cardiac examination is unremarkable except for tachycardia. Neurologic examination shows a fine hand tremor and brisk symmetrical reflexes but is otherwise unremarkable. Laboratory tests show normal complete blood count, basic metabolic profile, and urinalysis. Thyroid function test results are as follows:
| TSH | <0.01 μU/mL |
| Free T4 | 2.5 ng/dL (normal: 0.8-1.9) |
| Total T3 | 250 ng/dL |
Radioactive iodine uptake at 24 hours is 36% (normal: 8%-25%), and scan shows a diffuse uptake pattern. Serum thyroid-stimulating immunoglobulin level is mildly elevated.
Item 1 of 2
Which of the following is the best next step in management of this patient?
Show Explanatory Sources
This patient has Graves disease with a positive thyroid-stimulating immunoglobulin assay and diffusely increased uptake on radioiodine scintigraphy. Patients with symptomatic hyperthyroidism should be started on a beta blocker (eg, propranolol) to reduce symptoms, with additional measures to decrease thyroid hormone production and achieve a euthyroid state. Modalities include antithyroid drugs (ATDs), radioactive iodine (RAI), and thyroidectomy; there is no gold standard treatment, and choice of therapy depends on the specifics of the case, clinician experience, and patient preference.
ATDs inhibit synthesis of thyroid hormone. They can be used in short courses to achieve remission in mild cases and for chronic management in poor operative candidates or those who wish to avoid surgery or RAI therapy. In patients with more significant symptoms (as in this patient), ATDs are useful to induce a euthyroid state in preparation for surgery or RAI therapy. Methimazole is usually preferred due to the risk of hepatotoxicity with propylthiouracil, although propylthiouracil is recommended in the first trimester of pregnancy due to the teratogenic effects of methimazole (Choice A).
RAI is appropriate for patients who cannot tolerate ATDs, those who wish to avoid surgery, or those in whom an ATD alone is unlikely to achieve remission. Due to diffuse injury to the gland, most patients treated with RAI for Graves disease develop residual hypothyroidism and require long-term thyroid replacement therapy. RAI is contraindicated in pregnancy and lactation. RAI could be considered for definitive therapy in this patient; however, due to his significant symptoms, a beta blocker should be administered first (Choice B).
Surgery is preferred for those with large goiters, obstructive symptoms, or suspected thyroid cancer and is also recommended for those with significant ophthalmopathy in whom RAI may cause an exacerbation of symptoms (Choice D).
(Choice C) Prednisone is recommended for patients with moderate to severe Graves ophthalmopathy (eg, exophthalmos, periorbital edema, vision changes) prior to definitive treatment with surgery or RAI. This patient's mild lid lag does not require prednisone. He should receive ATDs and a beta blocker given his symptoms.
Educational objective:
Patients with Graves disease should be started on a beta blocker to reduce hyperthyroid symptoms, followed by specific treatment to achieve a euthyroid state. Modalities include antithyroid drugs, radioactive iodine, and surgical thyroidectomy.