Graves’ disease accounts for 60% to 80 % of patients with hyperthyroidism. It is up to 10 times more common in woman, with the highest risk of onset between the ages of 40 and 60 years. Its prevalence is similar among whites and Asians and lowest among blacks.1

A classical clinical presentation for Graves’ hyperthyroidism includes diffuse goitre in up to 90%, ophthalmopathy in about 50 % and elevated FT4 and FT3 levels with a suppressed TSH. When Graves’ disease is suspected but the diagnosis remains uncertain, measurement of TSH receptor antibodies may be helpful.2 Radioiodine uptake should be performed before beginning antithyroid therapy. Increased uptake in a homogeneous pattern is seen in Graves’ disease.3
The therapeutic approach to Graves’ hyperthyroidism consists of decreasing thyroid hormone synthesis: the administration of a thionamide; radioiodine ablation; or surgery. RAI has been used for treatment of hyperthyroidism for over six decades.4 It is the preferred treatment modality worldwide because of its efficacy, safety and low cost. It is also a definitive treatment in most patients with Graves’ disease.5

The clinical manifestations of Graves’ disease as well as the diagnostic and therapeutic trends in managing Graves’ disease at King Abdulaziz University hospital in Jeddah are reviewed in this study.

The medical charts of all patients with a diagnosis of Graves’ disease at King Abdulaziz University Hospital during a period of two years (September 2002 to September 2004) were reviewed. The inclusion criteria for the diagnosis of Graves’ disease involved all of the following:

1. Diffuse goitre
2. Increased iodine uptake in homogeneous pattern
3. Suppressed TSH level

Patients seen in KAUH with thyrotoxicosis routinely have thyroid function test (FT4, FT3, TSH) using radioimmunoassay commercial kits, thyroid scans using radioactive iodine(I123) or (Tc99m) and antithyroid antibodies (anti-microsomal and anti-thyroglobulin antibodies) measured by indirect haemagglutination technique. Personal data such as age, sex, nationality and clinical presentation were reviewed. The mode of therapy, which was selected according to physician or surgeon preference or patient choice including (antithyroid medication, radioactive iodine treatment or surgery) and outcome of therapy (euthyroid, hypothyroid and hyper thyroid) were recorded. The SPSS (Statistical Analysis for Social Science) was utilized. The mean ± SD was determined for quantitative variables. Frequencies were adjusted on a basis and rates comparison tests were performed. A p-value of £0.05 was considered statistically significant.

A total of 115 cases of Graves’ disease were analyzed. The mean age were 34.36 ± 11.44 years (range 6-72 years) the female: male ratio was 2:1 (77: 38). Non-Saudi: Saudi ratio was 85:50; 1.7:1. One hundred and five patients (91%) were below 50 years of age, while 10 patients only (9%) were above 50 years of age. Forty patients (34.8%) below 50 years of age had exophthalmos and lid lag, versus zero patients above 50 with exophthalmos and lid lag. Four patients (3.4%) of those older than 50 years of age presented with atrial fibrillation.

The measurement of thyroid functions tests was done routinely in all patients with Graves’ disease by using radioimmunoassay method ELISA. The mean FT4 level was 66.95 ± 30.16 (range 12.5–120 pmole/L). FT3 was done in 90 patients with a mean level of 25.8 ± 15.83. The mean TSH level in all patients was 0.005 ± 0.01. The thyroid antibodies (anti-thyroglobulin and anti-microsomal antibodies) were positive in 42 cases (36.5%). However TSH receptor antibodies (TRABs) was not performed for any patient. Almost all patients with Graves’ disease were diagnosed by scintigraphy using Technetium (Tc99m), that is 93 %, followed by iodine 131 (I131) in 7 % of the cases.

Radioactive iodine treatment was recommended for 85 patients (73.9%) with a mean dose of 12.8 ± 4.3 Mci (range 8-25 Mci). The use of radioactive iodine as the initial mode of therapy was recommended for 47 cases (55.3 %) versus radioactive iodine treatment, which was used for recurrent hyperthyroidism after at least 6 months therapy with antithyroid drugs in 38 cases (44.7%) with a p-value of 0.54 that is statistically not significant.

The radioactive dose administration depended on the nuclear physician either by giving a fixed dose or a calculated dose on uptake and/or gland size. It was usually administered as a single dose of I 131. However, only one patient received two doses of radioactive iodine because of recurrence of hyperthyroidism. Medical treatment with carbimozole and b-blockers was administrated in 12 cases (31.5%) before I131 therapy versus 26 cases treated with b-blockers only before radioactive iodine therapy with a p-value of 0.009 which statistically significant. A nuclear medicine physicians followed up patients after radioactive iodine treatment in a nuclear medicine clinic. Thirty-one patients (36.4%) developed hypothyroidism during follow-up. The presence of a goitre increased the delay in the occurrence of hypothyroidism.

Thyrotoxicosis is an endocrine disorder that predominantly affects females. Graves’ disease accounts for 60% to 80 % of all patients with hyperthyroidism. It is up to 10 times more common in women, with the highest risk of onset between the ages of 40 and 60 years.1 Ninety-one per cent of our patients were below 50 years of age. Exophthalmos occurred in patients younger than 50 years old; however, atrial fibrillation occurred in patients above 60 years old, which is consistent with figures reported in the literature.6,7 However, several international surveys in the management of Graves’ disease from Saudi Arabia, North America, Europe and Japan reported remarkable progress in the diagnosis and treatment of Graves’ disease compared to those published a few years ago.8,9

The diagnostic approach of Graves’ disease begins with determination of free thyroxin, thyrotropin releasing hormone and TSH level by immunoradiometric assay. All our patients were diagnosed by a homogeneous increased uptake of isotope, 93% used TC99m isotope scan, and only 7 % of the cases used I123 isotope scan.3 The decreased use of thyroid ultrasound was observed in this study; only 21% had an ultrasound of the thyroid as part of the diagnostic work up of Graves’ disease.

Definitive therapies for hyperthyroidism include RAI, antithyroid drugs and surgery. A detailed analysis of several surveys demonstrate the wide variations among physicians of different countries in the treatment of Graves’ disease as well as several new developments in the treatment compared to that practiced in the last decade, which reflects tremendous progress in the knowledge of this disease.10

RAI has been used for the treatment of hyperthyroidism for over six decades.11 It is the preferred modality of treatment in the United States for patients with Graves’ hyperthyroidism, and it is commonly used throughout the world. RAI is effective, safe, of low cost and significantly reduces the thyroid volume.12 Yet, its major disadvantage is the development of permanent hypothyroidism in a significant proportion of patients requiring life long replacement with thyroid hormone.13 A similar trend towards the use of RAI has also been observed in Saudi Arabia where it was used in 9% of patients in a study conducted by Sulimani, et al in 1988.14 This figure increased to 36% in the study conducted by Akbar, et al in 2000 at KAUH,15 and increased to 40% in our study as the initial modality of treatment. The antithyroid medications (Carbimazole and propylthiouracil (during pregnancy) are the most frequently chosen modality, as reflected by 62% of cases in our study.16 The percentage of surgery decreased significantly to 3.5% only.17 Conversely, the use of RAI was the preferred choice for recurrence after failure of antithyroid medications to achieve euthyroidism.