Synopsis
Confirm Graves autoimmunity, select antithyroid or definitive treatment with reproductive safeguards, and identify thyroid eye disease requiring urgent sight-saving specialist care.
- Graves disease is TSH-receptor-antibody-mediated hyperthyroidism and may cause diffuse goitre, thyroid bruit, eye disease, dermopathy and rarely acropachy.
- Confirm biochemical thyrotoxicosis with TSH, free T4 and free T3, then use TRAb as the NICE-recommended confirmatory test.
- A course of carbimazole is commonly used, with NICE describing 12 to 18 months when antithyroid medicine is chosen as definitive treatment in adults.
- Radioiodine, antithyroid medicine and surgery each have distinct trade-offs; eye disease, pregnancy plans, goitre size, compression, malignancy concern and relapse risk shape selection.
- Before carbimazole obtain baseline full blood count and liver tests; fever, sore throat, mouth ulcers or infection requires stopping the medicine and urgent blood-count assessment.
- Thyroid eye disease activity and severity are different: redness and pain indicate activity, whereas diplopia, exposure and optic neuropathy define consequences requiring specialist assessment.
- Check acuity, colour vision, pupils, eye movements, corneal exposure and lid closure, not just degree of proptosis.
- Smoking cessation and avoidance of second-hand smoke are high-value interventions because smoking worsens eye disease and treatment response.
- Radioiodine can worsen active thyroid eye disease and needs specialist selection, with prophylaxis or an alternative strategy when risk is significant.
- Pregnancy and planned conception require urgent specialist medication review; radioiodine is contraindicated, and carbimazole carries important MHRA reproductive warnings.
Key red flags
Reduced central or colour vision, new visual-field defect, relative afferent pupillary abnormality or optic-disc change can result from apical compression, sometimes without dramatic proptosis.
Lagophthalmos, severe pain, photophobia, epithelial defect, ulceration or a cloudy dry cornea indicates exposure-related threat and requires immediate ocular protection plus same-day ophthalmology.
Investigation priorities
Establish severity and follow biochemical response to treatment.
Management branches
Clinical and biochemical findings suggest Graves disease without storm.
- Measure TRAb, document cardiac and eye status, check pregnancy possibility and obtain baseline full blood count and liver tests before thionamide treatment.
- Use BNF-checked carbimazole and symptom control under the local pathway, with explicit infection, liver, pancreatitis and reproductive safety-netting.
- Monitor free hormones initially, then discuss a 12-to-18-month medicine course or definitive radioiodine or surgery according to relapse risk and patient priorities.
Key medicines
Carbimazole for Graves hyperthyroidismThe adult starting total is commonly 15 to 40 mg daily in the current BNF, selected by biochemical severity; subsequent titration or block-and-replace requires the agreed endocrine regimen.Baseline blood count and liver tests are required. Stop for infection symptoms pending urgent count; discuss pregnancy, effective contraception, hepatic injury and pancreatitis, and check live MHRA warnings.
Propranolol for short-term symptom reliefUse a BNF-verified oral regimen commonly within 10 to 40 mg three or four times daily, titrated to symptoms and pulse while monitoring blood pressure.Avoid in asthma, significant conduction disease, marked hypotension and decompensated low-output failure. It does not treat autoimmunity, prevent relapse or replace separate atrial-fibrillation management.