Patient Preferences Drive Modern Management of Graves’ Disease
In this expert conversation, David S. Cooper MD, professor of medicine and radiology at the Johns Hopkins University School of Medicine, explores how antithyroid medications, particularly methimazole, became the dominant first-line therapy for Graves’ disease in the United States over radioactive iodine and surgery, discusses the risks and benefits of each treatment option, and more. Dr Cooper presented on this topic at the 2025 American Association of Clinical Endocrinology Annual Meeting in Orlando, FL.
Additional Resources
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
Consultant360: Can talk about the key themes of your presentation, entitled "Contemporary Management of Hyperthyroidism Due to Graves’ Disease," presenting at the American Association of Clinical Endocrinology Annual Meeting?
David S. Cooper, MD: That's kind of an ironic title, because the treatment for Graves’ disease has not changed in more than 75 years. There's really nothing new. And so, it's interesting that people still want to hear about it and still have questions about it, because even though there's nothing new in terms of the actual treatments, there are new things that we're learning about the old treatments, if you will.
Obviously, I think everybody knows that the original first treatment for Graves’ disease was surgery. This was done at the end of the 19th and early 20th centuries and into the middle of the 20th century, really. But then radioactive iodine was discovered and has been used since the 1940s. Subsequently, the antithyroid drugs that we use now—methimazole is the main one—were also discovered in the late 1940s. So honestly, there's nothing new, although there are treatments being developed by pharmaceutical companies. But right now, the treatments we have are the same that a doctor would have used 50 years ago.
And so, the question is, why are we having this contemporary management? And I think the reason is because the choices in terms of how doctors and patients think about which treatment would be best have shifted a lot over the last 20 to 25 years, especially in the United States. It used to be that, even as recently as 15 years ago, radioactive iodine was the main treatment doctors would recommend to their patients as the best and most trouble-free way of dealing with Graves’ disease.
Consultant360: That kind of leads to my next question—which you already started to answer—why this shift?
Dr. Cooper: Over the last decade or so, the thinking has shifted, especially among patients, and then doctors have kind of caught up. Now, antithyroid drugs—specifically methimazole—are the preferred treatment. The main reason is that patients want to maintain the possibility of having a normal thyroid. Some patients who take antithyroid drugs go into remission. They take the drug for a few years and then stop, and they seem to be cured and have normal thyroid function. If a patient has radioactive iodine or surgery, they’ll be cured, but must remain on lifelong thyroid medication.
That preference has shifted in the United States. In the rest of the world, most doctors and patients have long preferred antithyroid drugs. The United States has now aligned with global trends. This is based on surveys of thousands of doctors and insurance claims data documenting the shift from radioactive iodine to methimazole therapy.
Consultant360: What are the key takeaways from your presentation for primary care physicians?
Dr. Cooper: No treatment is perfect. Every treatment has pros and cons. The pros of antithyroid drug treatment are that the person may go into remission and maintain normal thyroid function. Even if they’re on methimazole, at least they have their own thyroid. The downside is that they must take the medication and be monitored closely, especially in the first 30 to 90 days, when rare but serious side effects like liver damage or agranulocytosis can occur.
There’s also more follow-up involved—blood tests and doctor visits. By contrast, with radioactive iodine or surgery, the person is cured and on lifelong thyroid hormone therapy, usually managed by a primary care doctor. Fewer specialists are involved. But with radioactive iodine, there are radiation safety protocols—patients must avoid close contact for a few days. This is often a problem for women with small children. There's also some evidence of increased risk of secondary cancers and thyroid eye disease.
Surgery, though definitive, carries a 1% risk of complications such as hypoparathyroidism or permanent hoarseness. So the advantage is you’re cured quickly, but the disadvantage is lifelong medication and potential complications.
Future treatments are promising—immunomodulatory therapies, like those used in rheumatoid arthritis or psoriasis, may provide alternatives in the future. In 10 to 20 years, we may have treatments that induce remission without destroying the thyroid.
Consultant360: Is the shift toward methimazole complete or still evolving?
Dr. Cooper: A recent survey published in the Journal of Clinical Endocrinology and Metabolism in 2024 showed that only 11% of US doctors now recommend radioactive iodine, and 1% surgery. So, 88% prefer antithyroid drugs. But much of this is patient driven. Patients are well-informed about risks and want to avoid surgery or radiation. So, while doctors are adapting, this change is also fueled by patient preference.