Clinical Spectrum and Outcome of Patients with Graves’ Disease: A Single-Center Experience from a Tertiary Care Institution in the Kashmir Valley, India

Abstract

Objective: Graves' disease (GD) is a common autoimmune disorder with variable outcomes. We aim to study the clinical manifestations and treatment outcome of GD in the post-iodization scenario. Material and Methods: The present study was designed as a cross-sectional study, in which a total of 180 patients with GD (127 males and 53 females) attending our center were reviewed retrospectively. The demographic data, modes of treatment, comorbidities, remission, and recurrence rates were determined for the patients. All patients were initially treated with anti-thyroid drugs (ATDs), with the subsequent management depending on the course of the disease. Results: The mean (±SD) age at diagnosis was 38.30 (10.73) years and the lag period between the onset of symptoms and the diagnosis was 5.12 (2.69) months, with the male patients having a significantly shorter duration of illness compared to females (4.36 vs. 5.44 months; P=0.015). Majority of the patients presented with the typical symptoms and signs associated with hyperthyroidism and/or goiter, although the atypical presentations were not uncommon. ATDs were the most preferred treatment modality employed to achieve clinical and biochemical remission. The mean duration of achieving euthyroidism and the normalization of TSH levels were 3.31±1.51 and 7.45±3.35 months, respectively. On follow-up at three months, 46.1% of the patients were euthyroid, with normalization of the TSH levels in 15.6% of them. Failure to achieve early remission/disease control was significantly higher in males (p=0.003) and smokers (p=0.036). Among the 72 patients who completed medical therapy, 49 patients achieved remission, of whom 20 patients relapsed with a first-year relapse rate of 20.4%. Disease relapse was significantly associated with higher initial 99 mTechnetium (99 m Tc) uptake (p=0.022) and higher grade of goiter (p=0.026) at presentation. The logistic regression analysis revealed male gender (p=0.048) and orbitopathy (p=0.036) as the independent risk factors predicting relapse of the GD. Conclusion: Graves' disease manifests with varied clinical manifestations, including the atypical ones, warranting careful clinical assessment to ensure an accurate diagnosis. Gender and orbitopathy are the independent risk factors predicting the relapse of the disease.

Therapeutic Options in Graves’ Hyperthyroidism

“…Clinical and biochemical features associated with elevated levels of thyroid hormone, particularly of a long duration and/or orbitopathy, elevated levels of TSH-receptor antibodies (TRAbs) along with a diffuse increase in radioactive iodine or technetium uptake scan, confirm the diagnosis of GD. The association of GD with plethora of systemic manifestations, including typical and atypical, and a relatively prolonged course on account of higher rates of recurrences and relapse responsible for significant morbidity and an increased risk of mortality warrant proper management of the disease and the associated complications [10]. The treatment for GD comprises rapid control of the symptoms, generally with a beta adrenergic blocker, and reduction of thyroid hormone levels using one of the several modalities available, including ATDs to block thyroid hormone synthesis, destruction of the thyroid gland by RAI, and or removal of thyroid gland by surgery respectively; the selection of the optimal approach often varies according to the patient preference, different guidelines, clinical factors and local traditions.…”