General Therapeutic Relationship of the Patient and Physician
The foregoing discussion explains several methods for specifically decreasing thyroid hormone formation. They are, in a sense, both unphysiologic and traumatic to the patient. As a good physician realizes in any problem, but especially in Graves' disease, attention to the whole patient is mandatory.
During the initial and subsequent interviews, the physician caring for a patient with Graves' disease must determine the nature of the psychic and physical stresses. Frequently major emotional problems come to light after the patient recognizes the sincere interest of the physician. Typically the problem involves interpersonal relationships and often is one of matrimonial friction. The upset may be deep-seated and may involve very difficult adjustments by the patient, but characteristically it is related to identifiable factors in the environment. To put it another way, the problem is not an endogenous emotional reaction but a difficult adjustment to real external problems. On the other hand, one must be aware that the emotional lability of the thyrotoxic patient may be a trial for those with whom he or she must live, as well as for the patient. Thus thyrotoxicosis itself may create interpersonal problems. From whatever cause they arise, these problems are dealt with insofar as possible by the wise physician.
We have been unimpressed by the benefits of formal psychiatric care for the average thyrotoxic patient, but are certain that sympathetic discussion by the physician, possibly together with assistance in environmental manipulation, is an important part of the general attack on Graves' disease. In other cases, personal problems may play a less important etiologic role but may still strongly affect therapy by interfering with rest or by causing economic hardship.
In addition to providing assistance in solving personal problems, two other general therapeutic measures are important. The first is rest. The patient with Graves' disease should have time away from normal duties to help in reestablishing his or her psychic and physiologic equilibria. Patients can and do recover with appropriate therapy while continuing to work, but more rapid and certain progress is made if a period away from the usual occupation can be provided. Often a mild sedative or tranquilizer is helpful.
Another important general measure is attention to nutrition. Patients with Graves' disease are nutritionally depleted in proportion to the duration and severity of their illness. Until metabolism is restored to normal, and for some time afterward, the caloric and protein requirements of the patient may be well above normal. Specific vitamin deficiences may exist, and multivitamin supplementation is indicated. The intake of calcium should be above normal.
This chapter has dealt with the diagnosis and treatment of Graves' disease. Diagnosis of the classic form is easy and depends on the recognition of the cardinal features of the disease and confirmation by such tests as TSH and FTI.
The differential diagnosis includes other types of thyrotoxicosis, such as that occurring in a nodular gland, accompanying certain tumors of the thyroid, or thyrotoxicosis factitia, and nontoxic goiter in a patient with symptoms that imitate those of thyrotoxicosis. Types of hypermetabolism not of thyroid origin must also enter the differential diagnosis. Examples are certain cases of pheochromocytoma, polycythemia, lymphoma, and the leukemias. Pulmonary disease, infection, parkinsonism, pregnancy, or nephritis may stimulate certain features of thyrotoxicosis.
Treatment of Graves' disease cannot yet be aimed at the cause because it is still unknown. One seeks to control thyrotoxicosis when that seems to be the major indication, or the ophthalmopathy when that aspect of the disease appears to be more urgent.
The available forms of treatment, including surgery, drugs, and 131I therapy, are reviewed. There is a difference of opinion as to which of these modalities is best, but to a large degree guidelines governing choice of therapy can be drawn.
Antithyroid drugs are widely used for treatment on a long- term basis. About one-third of the patients undergoing long-term antithyroid therapy achieve permanent euthyroidism. Drugs are the preferred initial therapy in children and young adults.
Subtotal thyroidectomy is a satisfactory form of therapy, if an excellent surgeon is available, but is used infrequently by many thyroidologists. The combined use of antithyroid drugs and iodine makes it possible to prepare patients adequately before surgery, and operative mortality is approaching the vanishing point. Many young adults, especially males, are treated by surgery if antithyroid drug treatment fails.
Currently, most endocrinologists consider RAI to be the best treatment, and consider the associated hypothyroidism to be a minor problem. Evidence to date after well over four decades of experience indicates that the risk of late carcinogenesis must be near zero. The authors advise this therapy in most patients over age 40, and believe that it is not contraindicated above the age of about 15. Dosage is calculated on the basis of 131I uptake and gland size. Most patients are cured by one treatment. The principal side effect is the occurrence of hypothyroidism. This complication occurs with a fairly constant frequency for many years after therapy and may be an inevitable complication in many patients if cure of the disease is to be achieved. Many therapists accept this as an anticipated outcome of treatment.
Thyrotoxicosis in children is best handled initially by antithyroid drug therapy. If this therapy does not result in a cure, surgery may be performed. Treatment with 131I is accepted as an alternative form of treatment by some physicians.
Neonatal thyrotoxicosis is a rarity. Antithyroid drugs, propranolol and iodide may be required for several weeks until maternally-derived antibodies have been metabolized.
The physician applying any of these forms of therapy to the control of thyrotoxicosis should also pay heed to the patient's emotional needs, as well as to his or her requirements for rest, nutrition, and specific antithyroid medication.