s stopped, the RAIU in Graves’ patients usually returns to pre- treatment levels within a week . Because it is the most effective agent available in preventing conversion of T4 to T3, it has a useful role in managing thyroid storm. Immunosuppressive Therapy- Development of new targeted and relatively safe immune suppressive treatments has allowed their extension to Graves’ disease. Rituximab, an anti CD20 B cell lymphocyte depleting monoclonal antibody, was initially found to induce remission in Graves’ ophthalmopathy. It also mediates decreases in anti thyroid antibodies, and is currently employed in a Phase II trial for therapy of mild, relapsing Graves’ disease (175.1, 175.2). Significant adverse events during therapy with rituximab (“serum sickness”, mild colitis, iridocyclitis, polyarthritis) have been reported, andwill probably limit its usefulness (175.21) Use of agents of this type, that work by increasing function of regulatory T cells, will probably become common in the next few years. Another approach has been pioneered by Gershengorn and colleagues, who devised a small molecule that is an “allosteric inverse agonist” of TSHR, and inhibits stimulation of TSH receptor activation by TSAbs (175.3 )
Subtotal thyroidectomy is an established and effective form of therapy for Graves’ disease, providing the patient has been suitably prepared for surgery. In competent hands, the risk of hypoparathyroidism or recurrent nerve damage is under 1%, and the discomfort and transient disability attendant upon surgery may be a reasonable price to pay for the rapid relief from this unpleasant disease. In some clinics it is the therapy of choice for most young male adults, especially if a trial of antithyroid drugs has failed. Total thyroidectomy may be preferred in patients with serious eye disease or high TRAb levels, in order to help the eye disease and to keep down the incidence of recurrence . iAs with other effective methods available, it is necessary for the physician and the patient to decide on the form of therapy most suitable for the case at hand. Because of the potential but unproved risks of 131-I therapy, it is not always possible to make an entirely rational choice; the fears and prejudices of the physician and the patient will often enter into the decision.
Surgery is clearly indicated in certain patients. Among these are (1) patients who have not responded to prolonged antithyroid drug therapy, or who develop toxic reactions to the drug and for whatever reason are unsuitable for 131-I therapy; (2) patients with huge glands, which frequently do not regress adequately after 131-I therapy; and (3) patients with thyroid nodules that raise a suspicion of carcinoma. Stocker et al have reviewed the problem of nodules in Graves’ glands. They found that 12% of Graves’ patients had cold defects on scan, and among these half were referred for surgery. Six of 22, representing 2% of all Graves’ patients, 15% of patients with cold nodules, 25% of patients with palpable nodules, and 27% of those going to surgery, had papillary cancer in the location corresponding to the cold defect. Of these patients, one had metastasis to bone and two required multiple treatments with radioiodine. These authors argue for evaluating patients with a thyroid scintigram and further diagnostic evaluation of cold defects(201a). Subtotal or near total thyroidectomy is often the treatment of choice for patients with amiodarone induced thyrotoxicosis, since response to ATDs is typically poor, and RAIU can not be given. Surgery may also have a place in therapy of older patients with thyroid storm and/or cardio-respiratory failure, who do not respond rapidly to intensive medical therapy(202a).
Surgery in patients with ophthalmopathy
Contemporary data indicate that exophthalmos may be exacerbated by RAI therapy ,although in some studies appearance of progressive ophthalmopathy was about the same after treatment with 131-I as with surgery . Thus, in the presence of serious eye signs, treatment with antithyroid drugs followed by surgery is an important alte