AACE Conference Coverage

Modern Management of Graves’ Disease: Revisiting Longstanding Therapies

Anthony Calabro, MA

Key Highlights

  • Antithyroid drugs, particularly methimazole, have overtaken radioactive iodine as the preferred first-line treatment for Graves' disease in the United States.
  • This shift is largely driven by patient preference to preserve thyroid function and avoid lifelong hormone replacement.
  • All treatment options—antithyroid drugs, radioactive iodine, and surgery—carry distinct risks and benefits that must be weighed individually.

The management of hyperthyroidism due to Graves’ disease has remained clinically stable for over 75 years, yet there has been a substantial evolution in treatment preference, according to David S. Cooper, MD, professor of medicine and radiology at the Johns Hopkins University School of Medicine.1

In his presentation at the American Association of Clinical Endocrinology Annual Meeting in Orlando, FL, Dr Cooper discussed why a notable shift toward patient-centered approaches has emerged particularly in the United States. Indeed, while the core treatment modalities for Graves’ disease—antithyroid medications, radioactive iodine (RAI), and surgery—have not changed since the mid-20th century, methimazole, an antithyroid medication, has become the leading treatment option, preferred by both patients and increasingly by physicians.

Historically, RAI was favored by US physicians as a definitive, low-maintenance therapy, while many other countries leaned toward antithyroid drugs as first-line treatment. During the last 10 to 20 years, according to Dr Cooper, US treatment trends have aligned more closely with global standards. This pivot stems primarily from patient desire to preserve natural thyroid function and the potential for remission without lifelong hormone replacement therapy—benefits unique to antithyroid medications.

This shift in clinical practice is substantiated by survey data and insurance claims. Recent US physician surveys, including one published in The Journal of Clinical Endocrinology & Metabolism,2 reveal that 88% of respondents now recommend methimazole as the first-line therapy, compared with only 11% favoring RAI and 1% surgery. These surveys reflect physician attitudes, but Dr Cooper emphasized the strong influence of patient preference in this transition.

Methimazole offers the possibility of remission and avoids destruction of the thyroid gland, preserving endogenous function. However, it is not without drawbacks. Patients must undergo regular monitoring, and there is a rare risk of serious side effects such as agranulocytosis or hepatotoxicity, particularly within the first 90 days of treatment. RAI and surgery provide definitive resolution but require lifelong thyroid hormone replacement. RAI also involves radiation precautions and has been linked in some studies to increased risks of secondary malignancies and worsened thyroid eye disease. Surgery, while effective, carries operative risks such as permanent vocal cord paralysis or hypoparathyroidism, even in experienced hands.

Looking ahead, Dr Cooper noted that while the management algorithm remains unchanged, future therapies may address the autoimmune root of the disease. He highlighted ongoing research into immunomodulatory agents akin to those used in rheumatoid arthritis and inflammatory bowel disease.

References

  1. Cooper DS. Contemporary management of hyperthyroidism due to Graves’ disease. Presented at: American Association of Clinical Endocrinology (AACE) Annual Meeting; May 15-17, 2025; Orlando, FL. https://aace2025.d365.events/directory/sessions/61ec6189-e0ac-4b3f-a8d2-3348d5136d52
  2. Villagelin D, Cooper DS, Burch HB. A 2023 international survey of clinical practice patterns in the management of Graves Disease: a decade of change. J Clin Endocrinol Metab. 2024;109(11):2956-2966. doi:10.1210/clinem/dgae222