What is Grave’s Disease?

Graves’ disease is an autoimmune disorder that causes the thyroid gland to be overactive – causing hyperthyroidism & an enlarged thyroid.

– Its name comes from the Irish physician, Robert Graves, who first described the condition in 1835.

– Also called Basedow’s disease or thyrotoxicosis.

– It is more common in women, usually presenting between the ages of 30 and 40.

Hyperthyroidism refers to elevated serum thyroid hormone levels – when thyroid hormone levels are high, the pituitary decreases thyroid-stimulating hormone (TSH) production.

Hyperthyroidism may be due to several causes -Graves’ disease is the most common cause, accounting for more than 60% of all cases.

It is also the most common type of autoimmune disease in the U.S.

It is seen more commonly in patients with other autoimmune diseases such as type 1 diabetes, lupus, rheumatoid arthritis, or Addison’s disease.

Signs & symptoms resulting from HYPERTHYROIDISM:

   Increased metabolic rate

   Increased activity of the sympathetic nervous system

   Irritability

   Hyperactivity

   Hand tremor

   Hair loss

   Muscle weakness

   Insomnia

   Excessive sweating

   Fast heartbeat

   Heat intolerance

   Diarrhea

   Weight loss despite increased appetite

In addition to the signs & symptoms of hyperthyroidism, Graves’ disease has some specific characteristics.

– Goiter (abnormal enlargement of the thyroid gland) – smooth & diffuse
– Graves’ ophthalmopathy – bulging eyes
– Pretibial myxedema – thickening of skin on the shins

Graves’ ophthalmopathy is specific only to Graves’ disease and is an autoimmune inflammatory disorder that affects the orbit around the eye, seen as upper eyelid retraction, lid lag, edema, redness, conjunctivitis, & bulging eyes (proptosis).

For unknown reasons, eye problems occur much more often & are more severe in patients with Graves’ disease who also smoke cigarettes.

Mild cases are treated with lubricant eye drops or nonsteroidal anti-inflammatory drops. Severe cases are treated with steroids or orbital decompression surgery.

Thyroid storm is a rare, severe manifestation of hyperthyroidism, usually seen in a patient with Graves’ disease. It is a medical emergency manifested by a severe increase in metabolism, usually precipitated by a major stressor such as infection, trauma, or surgery. It can also occur when a patient is inadequately treated or stops taking prescribed therapy. S/S include elevated temperature, increased tachycardia or onset of dysrhythmias, elevated BP, worsening tremors & restlessness, worsening mental status – delirious or psychotic state or coma.

Cause of Graves’ disease

– Exact cause unclear

– Genetic predisposition – some people are more prone to develop TSH receptor activating antibodies – but there is no clear genetic defect found to point to a single gene cause.

– In other words, some people inherit a problematic immune system in which their blood cells (lymphocytes) make antibodies that bind to the surface of thyroid cells, stimulating those cells to overproduce thyroid hormones.

– Because it is an autoimmune disease that appears suddenly, a viral or bacterial infection may trigger the antibodies that cross-react with the human TSH receptor.

– Some evidence points to stress causing an aggravation of the autoimmune response that leads to Graves’ disease.

How is Graves’ disease diagnosed?

– Hyperthyroidism is diagnosed with a blood test to measure thyroid-stimulating hormone (TSH), which will be low, & the amount of thyroid hormone (T4 or T3), which is usually elevated. Thyroid stimulating immunoglobulin (TSI) is also tested to verify an obscure diagnosis – it is an autoantibody that mimics TSH by stimulating the thyroid cells to secrete extra hormone – and would be positive.
– Ultrasound – define the size & condition of the thyroid gland.
– The evidence that the hyperthyroidism is caused by Graves’ disease:

     Disease-specific Graves’ ophthalmopathy

     Goiter (enlarged thyroid)

     Family members with thyroid or autoimmune problems

Treatment for Graves’ disease includes:

    Antithyroid drugs

    Radioactive iodine or

    Surgery - thyroidectomy

*Generally, hyperthyroidism due to Graves’ disease is easily controlled and almost always successful.

Antithyroid Medications
– The two commonly used antithyroid medications include methimazole (Tapazole) and propylthiouracil (PTU). These drugs reduce the production of thyroid hormone.

– Treatment must be given for 6 months to 2 years to be effective, and after cessation of the drug, the hyperthyroid state may recur, or in some cases, the patient may go in remission.

Radioactive iodine (RAI) treatment

– Advantage of having a much higher success rate than medications
– Major side effect is the development of lifelong hypothyroidism requiring daily treatment with thyroid hormone.

Surgery for hyperthyroidism is usually reserved for:

    Failure of antithyroid drug therapy

    Failure or contraindication for RAI therapy

    Large goiters that are compressive

    Simultaneous thyroid cancer

All types of treatment for hyperthyroidism usually lead to the eventual development of hypothyroidism, in which a thyroid hormone tablet is given daily & thyroid function blood tests need to be done annually.

Nursing Care of patient with Graves’ disease:
– Reducing metabolic demands & supporting cardiovascular function.

    Monitor vital signs

    Administer medications as ordered

– Preventing complications

    Protect eyes during sleep

    Monitor nutrition & weight loss

– Providing psychological support

    Reduce anxiety

    Maintain healthy sleep patterns

– Providing education about the disease process & therapy needs