An Effective Straightforward Protocol for the Treatment of Graves' Hyperthyroidism for Primary Care Providers

The prevalence of hyperthyroidism is very common in the United States (approximately 1.2%) with Graves' Disease (GD) being the most common non-iatrogenic cause. The limited number of endocrinologists and their concentration in larger cities means that primary care providers (PCPs) must treat a large number of these patients. This paper provides an effective, straightforward protocol for them to do so.

Patients with GD hyperthyroidism were referred to a county endocrinology clinic by PCPs in clinics that cared for medically underserved, mostly minority patients, a challenging population to treat. Hyperthyroidism was diagnosed by elevated free T₄ and/or free T₄ concentrations, euthyroidism by normal concentrations of both and hypothyroidism by low free T₄ or elevated TSH concentrations. Patients were treated with methimazole with initial doses and up-titration based on free T₄ and free T₃ concentrations and down-titration by free T₄ and TSH concentrations.

At the initial visit, 155 patients were, and 54 patients were not, respectively, taking an anti-thyroid drug. At the initial visit, patients either remained on methimazole, were started on the drug or were switched to it from propylthiouracil. The 209 patients were followed for up to 18 months. The protocol rapidly reversed the hyperthyroidism in most patients and at the end of the study, 72% were euthyroid, 19% were hyperthyroid and 9% were hypothyroid. Medication non-adherence probably accounted for those who were hyperthyroid at that time.

PCPs following this protocol will enable them to effectively treat patients with GD hyperthyroidism.