Indications for surgical thyroidectomy for Graves’ disease include which of the following?

b. Symptomatic large goiter

c. Women of childbearing age

d. Concomitant thyroid nodule

Antithyroid drugs are the initial therapy in most patients with Graves’ disease, either as a definitive therapy or in preparation for 131I therapy or surgical ablation. Because of the high failure rate of long-term treatment with thionamides, the use of these drugs as definitive treatment has decreased. Drawbacks include the important 0.5% incidence of agranulocytosis and a recurrence rate as high as 43% during the first year when the drug is stopped. Five years after treatment only 25% of patients remain in remission. Unlike other definitive treatments, hypothyroidism does not occur as a result of thionamide treatment if an appropriate dosage is used. 131I has been used as definitive treatment for patients with Graves’ disease for many years with predictable and long-lasting good results in most patients. It has few, if any, serious side effects. It is ablative to the thyroid gland and hypothyroidism is a nearly inevitable result of effective therapy, although it may take years to become clinically apparent. About 70% of patients treated with 131I are hypothyroid within 10 years of treatment. The risk of recurrence of hyperthyroidism after an initial response is less than 5%. Most adult patients in the United States are treated with 131I as definitive treatment for Graves’ disease. Exceptions are women in the childbearing years where a subsequent fetus would be affected, patients with concomitant thyroid nodules where carcinoma is a concern, those with extremely large glands and, increasingly, those who are opposed to 131I therapy. Thyroidectomy is an important alternative in selected patients with Graves’ disease. Although controversial in the past, it now appears that ocular involvement does not respond more favorably to thyroidectomy than to 131I ablation.