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Grave's Disease

The Merck Manual Home Edition
states:
"Hyperthyroidism is overactivity of the thyroid gland that leads to high levels of thyroid hormones and speeding up of vital body functions. This occurs 20 times more frequently in women.

Graves' disease is the most common cause of hyperthyroidism. Heart rate and blood pressure may increase, heart rhythms may be abnormal, and people may sweat excessively, feel nervous and anxious, have difficulty sleeping, and lose weight without trying. Blood tests can confirm the diagnosis.[Editor: low levels of TSH <.01 and elevated T4 and T3 free].

Hyperthyroidism affects about 1% of people in the United States. It can occur at any age but is more common in women during menopause and after childbirth.

Causes
The most common causes include:
*Graves' disease
*Thyroiditis

Graves' disease, the most common cause of hyperthyroidism, is an autoimmune disorder caused by an abnormal protein (antibody) in the blood that stimulates the thyroid to produce and secrete excess thyroid hormones into the blood. This cause of hyperthyroidism is often hereditary and almost always leads to enlargement of the thyroid.

Thyroiditis is inflammation of the thyroid gland. Hypothyroidism usually follows because the levels of stored hormones are depleted.

Drugs and iodine can cause hyperthyroidism. Drugs include amiodarone, interferon-alpha, and, rarely, lithium.

Symptoms
Most people with hyperthyroidism have an enlarged thyroid gland (goiter). The entire gland may be enlarged, or nodules may develop within certain areas. The gland may be tender and painful. Symptoms of hyperthyroidism, regardless of the cause, reflect the speeding up of body functions: increased heart rate and blood pressure, abnormal heart rhythms (arrhythmias), excessive sweating and feeling too warm, hand tremors (shakiness), nervousness and anxiety, difficulty sleeping (insomnia), weight loss despite increased appetite, increased activity level despite fatigue and weakness, and frequent bowel movements, occasionally with diarrhea. Older people with hyperthyroidism may not develop these characteristic symptoms but have what is sometimes called apathetic or masked hyperthyroidism, in which they become weak, confused, withdrawn, and depressed. Hyperthyroidism can cause changes in the eyes. A person with hyperthyroidism may appear to be staring.

If the cause of hyperthyroidism is Graves' disease, eye symptoms include puffiness around the eyes, increased tear formation, irritation, and unusual sensitivity to light. Two distinctive additional symptoms may occur: bulging eyes (exophthalmos or proptosis—see Symptoms) and double vision (diplopia— Vision, Double). The eyes bulge outward because of inflammation in the orbits behind the eyes. The muscles that move the eyes become inflamed and unable to function properly, making it difficult or impossible to move the eyes normally or to coordinate eye movements, resulting in double vision. The eyelids may not close completely, exposing the eyes to injury from foreign particles and dryness. These eye changes may begin before any other symptoms of hyperthyroidism, providing an early clue to Graves' disease, but most often occur when other symptoms of hyperthyroidism are noticed. Eye symptoms may even appear or worsen after the excessive thyroid hormone secretion has been treated and controlled."

Medications Used in Treatment:
1. Antithyroid Drugs: Tapazole®/methimazole, propylthiouracil
2. Thyroid surgery: removal of the thyroid gland cures the problem 90% of the time leaving the patient to take thyroid supplements for life for hypothyroidism.

Suggested Links:
*Medscape
*N.H.S. Choices (with Video)
*Nation Grave's Disease Foundation


*[Editor] The trouble is that no therapy for hyperthyroidism is superior: all have about a 50% relapse rate after 12 to 18 months. Options reviewed in the Abraham publication were either 1)block with antithyroid drugs and replace thyroxine, or 2)titrate anti-thyroid medication and titrate thyroxine replacement. Adding back thyroxine does not appears to provide any benefit. Immuno-suppressive therapies need further evaluation.

*[Editor] TSH and dosage of thyroxine are reduced in patients on metformin. This is thought to be do to the effects of the medications, implying that patients on metformin are [less than adequately] under treated.

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