Hyperthyroidism Assessment

Graves Disease, Toxic Nodular Disease & Thyroiditis

View Algorithm

Key Clinical Points

• TRAb sensitivity 97%, specificity 98-99% for Graves disease
• RAI uptake differentiates Graves (high) from thyroiditis (low/absent)
• Methimazole preferred over PTU (except first trimester pregnancy and thyroid storm)
• Counsel ALL patients on thionamides about agranulocytosis: seek care if fever/sore throat
• Thionamides do NOT induce remission in toxic nodular disease
• Beta-blockers for symptom control in ALL forms of thyrotoxicosis

Demographics

Patient age

Age affects presentation and management approach

Biological sex

Thyroid disease 4-8x more common in females

Is the patient pregnant or planning pregnancy?

Pregnancy significantly alters management approach

Symptoms

Palpitations

Present in 51-75% of thyrotoxic patients

Unintentional weight loss

Present in 61-68% of thyrotoxic patients

Heat intolerance or excessive sweating

Present in 55% of thyrotoxic patients

Tremor (especially fine hand tremor)

Present in 54% of thyrotoxic patients

Anxiety or nervousness

Present in 40% of thyrotoxic patients

Muscle weakness

Most common symptom (75%)

Increased bowel movements or diarrhea

GI hypermotility in 22%

Eye symptoms (dryness, grittiness, protrusion, double vision)

Pathognomonic for Graves disease (25% of patients)

Neck swelling or enlargement

Goiter present in 35-70%

Sleep disturbance or insomnia

Present in 42%

Neck pain or tenderness

Suggests subacute thyroiditis

Fever or recent viral illness

Suggests subacute granulomatous thyroiditis

Risk Factors

Family history of thyroid disease

Increased risk of autoimmune thyroid disease

Current smoker

Worsens Graves ophthalmopathy, reduces remission rates

Personal history of autoimmune disease

Associated with autoimmune thyroid disease

Iodine intake status

Affects etiology and management

Medications

Current medications affecting thyroid

Amiodarone

Lithium

Levothyroxine

Carbimazole/Methimazole

Biotin supplements

Tyrosine kinase inhibitors

Immune checkpoint inhibitors

Iodine-containing contrast

None

Multiple drugs affect thyroid function

Recent iodine-containing contrast (within 3 months)

Can cause thyrotoxicosis or interfere with RAI uptake