Autoimmune disease basics - Graves' Disease

For the next few weeks I'd like to focus on the basics of common autoimmune disorders. Some of these disorders you may be surprised to learn are autoimmune problems.

Graves' Disease

In Graves' disease, the victim of the autoimmune attack is the thyroid - specifically the TSH receptors located within the gland, causing a condition where the thyroid is running too fast - hypERthyroidism. TSH receptors are also located in many other areas of the body as well, and they too can be under attack by Graves' antibodies, but the attack on the thyroid is what causes the most severe of Graves' Disease symptoms. Other common sites of Graves' Disease battle grounds are less often mentioned:

** The skin - especially the skin of the lower legs/shins
** The eyes. Graves' ophthalmopathy is one of the most visible signs of the disease
** The brain

Understanding how the thyroid works is paramount to understanding Graves' Disease so I'll give a few basics here:

The Pituitary (master gland) is like a thermostat and senses how much thyroid your body needs. It sends a signal to the thyroid via a special hormone that turns the thyroid on. That hormone is called TSH (Thyroid Stimulating Hormone). TSH is like a key, and there are special 'locks' (called receptors) in the thyroid gland and elsewhere in the body. When the TSH receptor is occupied, it turns the thyroid on and more hormone is produced. When the pituitary senses that enough thyroid is circulating, it will tone down the TSH production. This is called a negative feedback system.

In Graves' Disease, this feedback system is altered by antibodies that act like TSH and fit into the TSH receptor and turn the thyroid on. The pituitary senses the overactivity and tries to shut the thyroid down by stopping the production of TSH, but because antibodies are occupying the TSH receptor, the gland continues to overproduce.

When Graves' antibodies begin to attack other tissues, it is the antibodies doing the evil work. When it attacks the lower legs, the skin begins to look like a very bad rash, and it will sometimes itch. If it is very bad it can begin to look like tissue destruction is occuring, and indeed it can.

When Graves' disease attacks the brain, it swells. When this happens, it is called Graves' Encephalopathy and you may have severe headaches and neurological problems including movement disorders, psychotic episodes, depression etc.

When Graves' Disease attacks the eyes, it causes the muscles and tissues behind the eye to swell. This pushes the eyeball forward and causes a wide-eyed look. There is usually, although not always, white visible around the iris of the eye all the time. When severe, the patient may be unable to completely close the eye and severe damage can result. There is significant pain with Graves' ophthalmopathy.

Because the thyroid controls every cell in your body, the signs of Graves' Disease can be very severe, indeed, life threatening. The adrenal system may be effected, causing anxiety and a feeling that adrenaline is pumping through your system all day and night. When it affects the heart you may begin to have a racing heart, palpitations (irregular beats) and the beat may become so strong you hear it inside your head. Blood pressure rises, your body temperature may be difficult to control and you lose heat tolerance. Migraines and chronic headache are common in Graves' patients. Hair may fall out, or become thin and fine. Nails become thin and may break easily. Skin may become oily and breakouts a problem. Most people with Graves' Disease lose weight uncontrollably, leading some to resist treatment. Some with Graves' gain weight which is not yet fully understood. Malabsorption may become an issue, as will vitamin deficiency, causing a whole host of other system-wide problems. Psychologically, Graves' Disease is hard on the patient as well as those around them. They may not understand that Graves' is the reason for anxiety and abrupt change of moods. Some of this is due to the antibodies and the disease, but some is due to the feeling of having an adrenaline rush all day every day. Some damage by Graves' Disease is permanent, and death can occur, so seeking help quickly is vital. Because the thyroid controls every cell in the body, symptoms can vary wildly between patients, and the list of possibilities is nearly endless. Long standing Graves' Disease can exhibit symptoms similar to Hashimoto's Thyroiditis - a hypOthyroid condition - which can be confusing to both doctors and patients.

Basic testing for Graves includes bloodwork: TSH Free T3, Free T4, TPOabs and TPIabs.

Treatment for Graves' is different depending on where you live. In the US, most endocrinologists will treat with medicines that shut the thyroid down by blocking it's use of iodine. These are called Anti Thyroid Drugs (ATD's). Usually treatment is continued for 2 years, then the meds are withdrawn to see if remission has occurred. If there is still a problem, it is usually recommended that the thyrod either be removed via surgery, or radiation via I-131, termed Radioactive Iodine Ablation (RAI).

In other countries, Anti-thyroid drug therapy is often continued indefinitely, preserving the thyroid and often inducing remission at a later time.

Controlling the iodine in your diet is also vital, as iodine is the fuel for your thyroid gland. This does NOT mean eliminating iodine, but simply controlling it in all the foods you eat to no more than 150 mcg's. Keeping a consistent iodine level is a very important key to feeling well during treatment after a Graves' Disease diagnosis.

Additionally, the use of caffeine and other stimulants is usually a bad idea with Graves' Disease. Heart palpitations, high blood pressure and anxiety can be treated effectively with Beta Blockers. Atenolol is usually the BB of choice, as it targets more specifically and has fewer side effects than other beta blockers. Other symptoms are treated as they arise.

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