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Rate of remission is the most important determinant for treatment decision-making in Graves’ disease

CTFP October 2021

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Graves’ disease, the most common cause of hyperthyroidism or overactive thyroid, can be treated by one of three ways: antithyroid drugs (ATD), which are medications that slow the thyroid function), surgery or radioactive iodine therapy, a radioactive pill that targets the thyroid almost exclusively and slowly destroys thyroid cells. Each one of these treatments have different benefits and risks. For example, the chances of resolution of the hyperthyroidism (remission) for radioactive iodine therapy and surgery is more than 90%. In contrast, ATDs can produce a remission in only about 25-50% of the patients. On the other hand, the risks of complications are higher with surgery (low calcium, voice problems) and ATD (rash, liver problems). The choice of which treatment to use should be a shared one, between the clinician and the patient, and based on risks, benefits and patient’s preferences. This study was done to try to understand which factors affect the treatment preferences in patients and clinicians and compare both of them.

van Kinschot CMJ et al 2021 Preferences of patients and clinicians for treatment of Graves’ disease: A discrete choice experiment. Eur J Endocrinol 184:803–812.

This study was conducted in the Netherlands in 2019. The researchers asked 286 patients with Graves’ disease and 61 clinicians what treatment they would choose among two or more options offered. Each treatment given to the participants to choose from was associated with different characteristics: chances of remission, severe side effects, permanent voice changes and hypocalcemia (low calcium in blood). The responses were examined to find out which treatment characteristics influenced the most in making their final decision. Patients were in average 47 years old and 95% were women. The clinicians were in average 37 years old and 80% were internists.

The least chosen treatments were the ones characterized by having lower chances of remission and higher risks of severe side effects, hypocalcemia and permanent voice changes. In terms of how important those characteristics were for each group: remission rates: 37% for patients and 35% for clinicians; risk of side effects: 19% for patients and 24% for clinicians; hypocalcemia: 12% for patient and 16% for clinicians; permanent voice changes: 5% for patients and 11% for clinicians.

The ideal treatment choice was ATD for both, patients and clinicians. When choosing between surgery and radioactive iodine therapy, patients preferred surgery while clinicians preferred radioactive iodine therapy. A lower remission rate was acceptable as long as the choice was ATD over radioactive iodine therapy or surgery

In the past few years, ATDs have become the preferred choice for the treatment of Graves’ disease, even though the remission rates are significantly lower with this treatment as compared with both radioactive iodine therapy and surgery. This study shows that although remission rate was very important for the patients, other factors, such as avoidance of complications, were more valued when making their final decision. In this regard, it is important to communicate to the patients what their “individualized” chances of cure with ATD are in order for them to make a more informed decision. Even though radioactive iodine therapy has the lowest risk of complications, patients did not generally choose this treatment. This may be due to fear of radioactivity and its negative connotation. This is in contrast with the physician’s positive view of radioactive iodine therapy. Physicians should be aware of their patient’s attitudes and values towards the different treatments to better guide and counsel.

— Susana Ebner MD


Hyperthyroidism: a condition where the thyroid gland is overactive and produces too much thyroid hormone. Hyperthyroidism may be treated with antithyroid meds (Methimazole, Propylthiouracil), radioactive iodine or surgery.

Graves’ disease: the most common cause of hyperthyroidism in the United States. It is caused by antibodies that attack the thyroid and turn it on.

Total thyroidectomy: surgery to remove the entire thyroid gland.

Radioactive iodine (RAI): this plays a valuable role in diagnosing and treating thyroid problems since it is taken up only by the thyroid gland. I-131 is the destructive form used to destroy thyroid tissue in the treatment of thyroid cancer and with an overactive thyroid.