Intervention in Graves' disease. Choosing among imperfect but effective treatment options.

Graves' disease is an autoimmune disorder that comprises the triad of diffuse toxic goiter, ophthalmopathy, and infiltrative dermopathy, although all three are not necessarily present in a given patient. The manifestations of Graves' disease vary, depending on the patient's age and other factors. Choice of therapy is influenced by the patient's age, history of heart disease, pregnancy status, expectations, and preferences. Most patients are treated with either radioactive iodine (sodium iodide I 131 [Iodotope]) or the antithyroid drugs propylthiouracil or methimazole (Tapazole). Antithyroid drugs may be more effective in producing long-term remission if levothyroxine sodium (Levothroid, Levoxine, Synthroid) is added to the regimen after the patient becomes euthyroid. Hypothyroidism occurs in many patients following 131I therapy but is also seen in a substantial number of patients who have been treated with thyroidectomy and even in some who have taken antithyroid drugs. Long-term follow-up is necessary, regardless of type of initial treatment, and should include an annual physical examination and measurement of serum concentrations of thyrotropin and the free thyroxine index, both of which should be maintained in the normal range.