**6. Therapy for Graves' Disease**

According to age, severity of hyperthyroidism, goiter size, presence and degree of ophthalmopathy, as well as patient's personal preference, GD treatment should be tailored in each individual patient. Medical treatment with anti-thyroid medicine (thionamides) is usually suggested in all patients to revive euthyroidism at first. Once euthyroidism is achieved, the long strategy comprises many choices, including relatively long-term (usually twelve to twenty four months) course of anti-thyroid drugs, radioactive iodine or surgery. Beta-blockers, if not inadvisable are time and again used prior to restoration of euthyroidism to reduce the symptoms of thyrotoxicosis. The thyroid hormone formation is blocked by specific thionamides or antithyroid drugs (propylthiouracil and methimazole). These drugs prevent the thyroid hormone production by inhibiting iodine organification and coupling of iodotyrosines. Treatment of this disease with these drugs is usually well tolerated. Some of the side effects like skin rash and, hardly Granulopenia, Hepatits and Arteritis may occur. Methimazole is currently most well liked over propylthiouracil, owing to the proof of a lower prevalence of severe side-effects, particularly hepatitis [73], with the exception of the first trimester of pregnancy, when propylthiouracil is preferred due to the increased rate of congenitalmal formations, especially aplasia cutis, which has been reported with the utilization of methimazole [74]. Due to the high probability of recurrence of hyperthyroidism after the withdrawal of therapy, this method is not suggested to individuals having large goiters. Contrary, in individuals with thyroid eye disease (ophthalmopathy), we tend to like a surgical removal of all or part of the thyroid gland (thyroidectomy), radioiodine ablation, or both owing to the pathogenetic role of crossreactive antigens between the thyroid and orbital tissues [75]. In some centers, the methimazole is used at higher doses than desirable amounts needed to correct hyperthyroidism in coalition with thyroid hormone for block and replacement treatment. This tactic relies on plausible immunosuppressive methimazole action, which still has not been incontestable in studies related to humans [76]. Radioiodine is ideally administered after the accomplishment of euthyroidism with the help of anti-thyroid drugs. Hypothyroidism is induced to attain a stable remission of GD, this is the goal of the treatment. To calculate the appropriate radioactive iodine dose to be given, 24 hour radioactive iodine uptake is usually performed before treatment and used together with gland volume. However, a fixed radioiodine dose may also be given without interfering with the outcome [77]. Radioiodine treatment, when using appropriate dose, within 1 to 6 months in the majority of patients (about 80%), it leads to hypothyroidism. Those Patients having large goiter the radioiodine therapy should not be used as it has low success rate unless repeated treatments are planned. It has been seen that radioiodine has acute side effects which are mild, well tolerated and generally self-limiting. Radioactive therapy for the treatment of hyperthyroidism sometimes causes a transitory pain and swelling of the neck and subsequently requires a treatment with oral glucocorticoids. During this process, for a short period of time the symptoms of thyrotoxicosis may exacerbate due to the release of preformed thyroid hormones. After radioiodine treatment, a transient worsening or more rarely, the fresh appearance of thyroid eye disease may occur, but it can be easily prevented by the administration of oral prednisone after radioiodine for 8–12 weeks. After radioiodine therapy in adults with Graves, there is no evidence of an increased risk of thyroid cancer and other solid tumors as well as of leukemia [78]. No major studies are available in children unfortunately. So, radioiodine treatment is not recommended before the age of 18–20 years. With the exception of a transitory decrease in testosterone levels in men, no effects on the reproductive system in male and female have been described [79]. A patient

with a large goiter has been indicated by Thyroidectomy. The surgical procedures most commonly recommended in patients with GD are near total thyroidectomy (NT) or total thyroidectomy (TT), consisting in the removal of most or all visible thyroid tissue, respectively. Both procedures result in hypothyroidism. Recurrence of hyperthyroidism is extremely rare. The rate of post-operative complications (e.g. surgical hypoparathyroidism, laryngeal nerve paralysis) is not increased compared with that observed using other less aggressive surgical procedures [80]. Briefly, the treatment of choice depends on the seriousness and activity of GD. In individuals with moderately severe thyroid eye disease, the usage of intravenous glucocorticoids is the first-line treatment and if this intravenous glucocorticoids treatment fails, orbital decompression is performed [81]. And this rehabilitative surgery (orbital decompression, muscle or eyelid surgery) must be considered when the eye disease is inactive. No major treatments are required for the majority of patients having a mild ophthalmopathy, and patients are given local measurement (e.g. eye lubricants, sun glasses) or, based on a recent study, selenium [82].
