Clinical Thyroidology® for the Public
Summaries for the Public from recent articles in Clinical Thyroidology
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GRAVES’ DISEASE
Smoking and clinical outcomes in Graves’ disease
BACKGROUND
Graves’ disease is the most common cause of hyperthyroidism in the United States. Graves’ disease is an autoimmune condition in which the body produces antibodies that attack and turn on the thyroid, causing the gland to become hyperthyroid. Symptoms of Graves’ disease include weight loss, heat intolerance, insomnia, increased frequency of bowel movements, palpitations and tremors. Graves disease is treated with antithyroid medications, mainly methimazole. The goal of treatment with methimazole is for Greaves’ disease to go into remission.
Graves’ disease is also associated with thyroid eye disease (TED) which can cause eye bulging, irritation, and double vision. It is well known that smoking can make TED worse. However, several studies have suggested that smoking is also associated with worse outcomes of Graves’ disease, including decreased remission and relapse rates. This study sought to further clarify the effects of smoking on clinical outcomes in patients with Graves’ disease.
THE FULL ARTICLE TITLE
Forbes S et al. Cigarette smoking exposure and clinical outcomes in Graves’ disease. J Clin Endocrinol Metab 2026;111(7): e1805–e1812. doi: 10.1210/clinem/ dgag061. PMID: 41676894.
SUMMARY OF THE STUDY
This study conducted in the United Kingdom enrolled 991 patients with newly diagnosed Graves’ disease who were treated with antithyroid medications. They performed evaluations at study entry, 1 year and long term.
Graves’ disease was diagnosed by a suppressed TSH, elevated thyroid hormones, and positive thyrotropin receptor antibody (TRAb) or diffusely increased uptake on nuclear thyroid scan. The main outcome measures were baseline TRAb levels, TED activity and recurrence of active Graves’ disease at 1 year and long term after discontinuation of antithyroid medications.
Patients were separated by smoking status: non-smokers, ex-smokers and current smokers. Current smokers had higher TRAb levels at diagnosis, increased risk of developing TED and increased relapse of Graves’ disease 12 months after stopping antithyroid medications. Each 10 cigarettes smoked per day was associated with a 34 % higher risk of TED and 60% higher risk of relapse at 1 year suggesting a dose dependent effect. Ex-smokers and nonsmokers had comparable outcomes.
WHAT ARE THE IMPLICATIONS OF THIS STUDY?
This study indicates that smoking is associated with worse health outcomes in patients with Graves’ disease, including increasing the risk of developing or worsening of TED and increasing the relapse rates of Graves’ disease after stopping antithyroid drugs. Further, this study suggests stopping smoking returns these outcomes to the same as patients that have never smoked. There are many general health reasons to stop smoking. Adding to this is the recommendation that stopping smoking in patients with Graves’ disease improves clinical outcomes. All patients with Graves’ disease should be encouraged to quit smoking.
— Whitney Woodmansee MD
ATA RESOURCES
Graves’ Disease: https://www.thyroid.org/graves-disease/
Hyperthyroidism (Overactive): https://www.thyroid.org/hyperthyroidism/
ABBREVIATIONS & DEFINITIONS
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.
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.
Autoimmune thyroid disease: a group of disorders that are caused by antibodies that get confused and attack the thyroid. These antibodies can either turn on the thyroid (Graves’ disease, hyperthyroidism) or turn it off (Hashimoto’s thyroiditis, hypothyroidism).
Thyroid eye disease (TED): also known as Graves ophthalmopathy. TED is most often seen in patients with Graves’ disease but also can be seen with Hashimoto’s thyroiditis. TED includes inflammation of the eyes, eye muscles and the surrounding tissues. Symptoms include dry eyes, red eyes, bulging of the eyes and double vision.
TRAb: antibodies often present in the serum of patients with Graves disease that are directed against the TSH receptor, often causing stimulation of this receptor with resulting hyperthyroidism. OCTOBER
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