Overactive thyroid: Graves disease and your three treatment choices

What is hyperthyroidism?

Your thyroid gland sits at the front of your neck and controls your metabolic rate by releasing thyroid hormones, chiefly T4 (thyroxine) and T3 (triiodothyronine). When it overproduces these hormones, every system in your body runs faster than it should. Your heart beats faster, your gut moves more urgently, and your nervous system stays on high alert even when you are trying to sleep.

Your doctor confirms the diagnosis by measuring TSH (thyroid stimulating hormone) in your blood: in hyperthyroidism, TSH is very low because your pituitary gland detects the excess and switches off its own signal. A 2024 review in The Lancet by Chaker and colleagues described hyperthyroidism as affecting roughly 1 to 2% of the general population worldwide, with significant variation in how it is managed depending on local resources.

A survey published in Endocrine Practice in 2017 examined practice specifically across the Middle East and North Africa, finding that Graves disease is the dominant cause in the region and that the treatment options available to patients vary considerably between countries. The condition is far more common in women than in men, roughly seven to one, and it can appear at any age though the peak is between 30 and 60 years.

Without treatment, persistent hyperthyroidism raises the long-term risk of atrial fibrillation, an irregular heart rhythm that increases stroke risk, and of osteoporosis, because excess thyroid hormone accelerates bone breakdown. These are reasons to take the condition seriously and follow through with treatment even when symptoms seem manageable.

What causes an overactive thyroid?

Graves disease accounts for around 80% of cases. It is an autoimmune disorder where your immune system produces antibodies that attach to TSH receptors on the thyroid and keep telling it to produce hormones continuously, bypassing the normal feedback loop entirely. The antibodies are called TSH receptor antibodies (TRAb) and a blood test that detects them confirms the diagnosis of Graves disease specifically. The condition has a clear genetic component and is more common in people with a family history of thyroid or other autoimmune conditions.

Toxic nodular goitre accounts for most of the remaining cases. One or more nodules in the thyroid develop the ability to produce hormone independently, without waiting for TSH signals. This form is more common in older patients and in regions where iodine intake has historically been low, which gives it some relevance in parts of the Arab world where dietary patterns vary.

Other causes include thyroiditis, an inflammation of the gland that can release a burst of stored hormone and cause transient hyperthyroidism over a few weeks before the gland burns out. Some medicines trigger overactivity: amiodarone, widely used for heart rhythm disorders and containing a large amount of iodine, is the most common culprit. Excess iodine from dietary sources such as very large amounts of seaweed can also occasionally push a borderline gland into overactivity.

Your doctor will determine the underlying cause before deciding on treatment, because the right approach differs between causes. This usually involves a blood panel for TSH, free T4 and T3, and sometimes TRAb antibodies. Ultrasound of the thyroid is widely available across the region and shows nodules clearly. Radioactive thyroid scanning, which helps distinguish Graves disease from nodular disease, requires a nuclear medicine facility and is available in major centres in Saudi Arabia, Egypt and the UAE.

What does hyperthyroidism feel like?

The symptoms reflect a body running at full throttle with no off switch. The most common are a rapid or pounding heart rate even at rest, unexplained weight loss despite eating normally or more than usual, feeling too warm when others are comfortable, sweating more than expected, and a fine tremor in the hands when you hold them out flat. Many people also feel persistently anxious, irritable or unable to concentrate, and sleep becomes difficult despite exhaustion.

Other symptoms include frequent bowel movements or loose stools, thinning or brittle hair, irregular or lighter menstrual periods in women, and muscle weakness particularly in the shoulders and thighs. Getting up from a chair without using your arms, or climbing stairs, can feel harder than it should. Some patients first notice a rapid or fluttering heartbeat and see a cardiologist before the thyroid diagnosis is reached.

In Graves disease specifically, a proportion of patients develop eye changes collectively called Graves ophthalmopathy. The eyes may appear to protrude, feel dry or gritty, become sensitive to bright light, or the eyelids may not fully close during sleep. These changes are caused by an immune reaction in the tissues behind the eye and are separate from the thyroid itself. They need specialist eye review and can sometimes continue or even temporarily worsen after the thyroid has been treated. If you notice any changes in your vision or eye comfort, mention them to your doctor.

Treatment choice one: antithyroid medicines

Antithyroid medicines block the thyroid from making new hormone without damaging the gland itself. The most commonly used are carbimazole or its active breakdown product methimazole, sold as thiamazole in some countries, and propylthiouracil (PTU), which is preferred in the first trimester of pregnancy because it crosses the placenta less than the alternatives. Symptoms typically begin to improve within two to four weeks as the stored hormone already in the blood is used up, and blood levels usually normalise within two to four months.

A 2024 paper in the Journal of Clinical Endocrinology and Metabolism by Azizi and colleagues reviewed the evidence for long-term antithyroid drug therapy in Graves disease and concluded that a course of 12 to 24 months is appropriate for most patients, with evidence that longer courses achieve higher remission rates. A 2023 large cohort study published in the European Thyroid Journal confirmed that a substantial proportion of patients maintain normal thyroid function for years after stopping treatment, though regular follow-up remains important.

The most serious side effect is agranulocytosis, a dangerous drop in the white blood cells that fight infection. It occurs in roughly 0.1 to 0.3% of patients and is most likely in the first few weeks of treatment. If you develop a sudden high fever or a severe sore throat at any point during treatment, go to an emergency department or clinic that day, not the next morning. Tell them you are on an antithyroid medicine and ask for an urgent white blood cell count.

Milder and more common side effects include a skin rash, joint aches or a raised liver enzyme on blood tests. These usually resolve with a dose adjustment or switch to an alternative drug. Tell your doctor about any new symptoms rather than stopping the medicine on your own, because abrupt discontinuation can trigger a rapid return of thyroid overactivity.

Treatment choice two: radioactive iodine

Radioactive iodine (RAI) is taken as a single capsule or liquid. The thyroid gland is unique in its ability to absorb iodine from the bloodstream, and the radioactive form destroys thyroid cells from the inside over several weeks to months. The targeting is remarkably precise: surrounding structures in the neck and other organs receive a very small radiation dose.

RAI has been in use since the 1940s and has an excellent long-term safety record. A 2023 review in JAMA by Lee and Pearce noted that RAI is effective and leads to resolution of hyperthyroidism in the majority of patients after one or occasionally two doses. The most common outcome is that the thyroid becomes underactive, which is then managed simply with a daily tablet of levothyroxine. Most people find this easy to live with.

The main concern specific to Graves disease is that RAI may worsen Graves ophthalmopathy in patients who already have eye involvement. Your doctor will assess your eye situation before recommending this treatment. RAI is absolutely contraindicated in pregnancy and breastfeeding, and pregnancy should be delayed for at least six months after treatment. A short course of antithyroid medicine is usually given first to normalise thyroid levels, and RAI is administered once that is achieved.

Availability varies across the region. Major nuclear medicine centres in Saudi Arabia, Egypt, Jordan and the UAE offer this treatment. It may not be accessible in Yemen, Syria or Sudan, and this is a practical reality that affects which treatment options are feasible for a given patient.

Treatment choice three: surgery

Total or near-total thyroidectomy removes the thyroid gland entirely or almost entirely. It is the fastest route to definitive treatment and is particularly suitable when the gland is very large and causing swallowing or breathing difficulty, when nodules need pathological examination to exclude malignancy, when a patient has Graves ophthalmopathy and wants to avoid the potential worsening associated with RAI, or when the other two treatments are contraindicated or have already failed.

The outcome of surgery depends heavily on the experience of the surgical team. The main risks are damage to the parathyroid glands, four tiny structures behind the thyroid that regulate calcium in the blood, and injury to the recurrent laryngeal nerves, which control the voice box. Temporary calcium problems are fairly common immediately after surgery and are managed with supplements. Permanent changes to the voice are rare in experienced hands. Choosing a hospital or surgeon who performs thyroid surgery frequently is important.

After complete removal you will need lifelong levothyroxine. The dose is adjusted by periodic TSH blood tests, usually every six to twelve months once a stable dose is found. Most people reach a good level and feel completely normal on their replacement dose. Surgery is immediately definitive: there is no waiting months for the gland to wind down as there is with RAI.

Thyroid storm: the emergency that cannot wait

Thyroid storm is an extreme and sudden worsening of hyperthyroidism, usually triggered in someone with undiagnosed or untreated overactivity by a physical stress such as a severe infection, an operation, trauma, or even childbirth. The thyroid floods the body with hormones at a rate that overwhelms every compensatory mechanism simultaneously. It is rare but it is one of the most dangerous conditions in endocrinology.

A comprehensive review in Missouri Medicine in 2022 described thyroid storm as carrying a mortality rate above 10% even with prompt treatment in an intensive care unit. Recognising the warning signs and acting immediately is potentially life-saving. The condition needs intravenous medicines to block hormone production and release, beta-blockers to protect the heart, and treatment of whatever triggered the crisis, all given simultaneously in a hospital setting.

Anyone with known or suspected thyroid disease who develops the combination of high fever, very fast heart rate and mental confusion needs emergency care that same hour. Do not wait to see if the fever settles with paracetamol.

Living with Graves disease: monitoring, eyes and everyday life

If you are taking antithyroid medicines, your doctor will check your TSH and free T4 every three to six months to adjust the dose and confirm you are remaining in the normal range. Do not stop the medicine based on how you feel. Normal symptoms can return within a few weeks of discontinuation if the autoimmune process is still active, and restarting is straightforward but avoidable.

If you have Graves ophthalmopathy, your eyes need a separate review from a specialist, ideally an ophthalmologist experienced in thyroid eye disease. Lubricating eye drops relieve the dry and gritty sensation. Wearing wraparound glasses outdoors reduces wind irritation. Sleeping with the head of the bed slightly elevated helps reduce morning puffiness. In moderate to severe cases, systemic treatments including corticosteroids and orbital radiation or decompression surgery are available in regional centres.

Smoking is one of the strongest known risk factors for worsening Graves ophthalmopathy. Studies consistently show that smokers with Graves disease have more severe and more treatment-resistant eye involvement than non-smokers. If you smoke, stopping is the single most effective action you can take to protect your eyes.

There is no special diet that treats Graves disease. Very high iodine intake, for example from daily consumption of large amounts of seaweed supplements, is best avoided during antithyroid drug treatment because it can interfere with the medicine. Otherwise, normal regional foods including fish, dairy and iodised salt in ordinary amounts are fine. Moderate regular exercise, sleep and stress management support overall wellbeing and may reduce the frequency of autoimmune flares.

Sources

• Chaker L, Cooper DS, Walsh JP et al: Hyperthyroidism, Lancet (London, England), 2024
• Lee SY, Pearce EN: Hyperthyroidism: A Review, JAMA, 2023
• Beshyah SA, Khalil AB, Sherif IH et al: A SURVEY OF CLINICAL PRACTICE PATTERNS IN MANAGEMENT OF GRAVES DISEASE IN THE MIDDLE EAST AND NORTH AFRICA, Endocrine practice, 2017
• De Almeida R, McCalmon S, Cabandugama PK et al: Clinical Review and Update on the Management of Thyroid Storm, Missouri medicine, 2022
• Azizi F, Mehran L, Abdi H et al: Approach to the Patient Considering Long-term Antithyroid Drug Therapy for Graves' Disease, The Journal of clinical endocrinology and metabolism, 2024
• Jin M, Jang A, Kim CA et al: Long-term follow-up result of antithyroid drug treatment of Graves' hyperthyroidism in a large cohort, European thyroid journal, 2023