Prognosis

Among patients over age 40, Graves hyperthyroidism is associated with increased mortality (primarily cardiovascular) when biochemical control of Graves hyperthyroidism may be suboptimal (i.e., during active treatment with antithyroid drugs, or after radioiodine but before achieving a hypothyroid state).[154] Prompt treatment of hyperthyroidism, irrespective of modality used, reduces long-term cardiovascular complications.[84] Prognosis of hyperthyroidism is excellent following therapy with antithyroid medications for control of hyperthyroidism.

There is, however, a high degree of relapse. Remission rates of 45.3%, 81.5%, and 96.3% have been reported for first-line therapy with antithyroid drugs, 131-I, and surgery, respectively.[98]

About 50% of patients achieve remission after an initial course of antithyroid drugs, with most relapses occurring within 4 years.[155]​ At 10 years, the remission rate is about 30% to 40%. Approximately 27% are estimated to achieve permanent remission.[155]

Risk factors for relapse

Several risk factors appear to be associated with relapse in Graves disease patients treated with antithyroid drugs:[156][157]​​

  • Orbitopathy

  • Younger age

  • Larger thyroid volume

  • Goiter size

  • High free T4 and free T3 levels

  • Smoking.

Thyroid-stimulating hormone (TSH) receptor antibody levels are less useful in predicting relapse risk in older patients with Graves disease.[54] When radioactive iodine is used and an appropriate dose is given, 90% of patients develop hypothyroidism within 3-6 months and need levothyroxine therapy.

Patients with orbitopathy and/or atrial fibrillation

Mild cases of Graves orbitopathy often settle down spontaneously. A significant proportion of patients with moderate-to-severe orbitopathy require immunosuppressive treatment and rehabilitative surgeries. Sight-threatening orbitopathy is an emergency, but the prognosis is excellent provided it is treated promptly by an experienced team.[60]

If the patient has atrial fibrillation, anticoagulant therapy may be required due to risk of thromboembolism. There is a lack of studies comparing anticoagulants in thyrotoxic atrial fibrillation. Direct oral anticoagulants (DOACs) may be associated with fewer bleeding events.[158]

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