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Health condition · Clinically reviewed

Graves disease, antithyroid drugs, radioactive iodine and eye care.

The most common cause of hyperthyroidism in the UK. A structured plan across endocrinology, ophthalmology and surgery is what makes the difference.

A radiographer guides a patient onto the bed of an advanced 3 Tesla MRI scanner in a London imaging suite

Why trust this guide

  • 01

    Clinically reviewed

    Written by our editorial team and reviewed by a registered UK clinician before publication.

  • 02

    Sourced from guidance

    Checked against NICE NG145, the British Thyroid Association and European Thyroid Association standards.

  • 03

    Current for 2026

    Reflects modern UK practice on antithyroid drugs, radioactive iodine, thyroidectomy and thyroid eye disease.

Key facts

Graves disease at a glance.

The essentials in plain English: what it is, who it affects and the three definitive pathways UK clinicians use.

  • What it is

    An autoimmune condition in which TSH-receptor antibodies (TRAb) drive the thyroid to overproduce hormone.

  • How common

    The most common cause of hyperthyroidism in the UK, responsible for around 60 to 80 per cent of cases.

  • Who it affects

    Peak onset 30 to 50, with women affected 5 to 10 times more often than men.

  • Classic features

    Weight loss, tremor, palpitations, heat intolerance and anxiety, often with a diffuse goitre and a thyroid bruit.

  • Eyes and skin

    Thyroid eye disease affects 25 to 50 per cent, pretibial myxoedema about 5 per cent. Both need specialist input.

  • How it is treated

    Three definitive pathways: antithyroid drugs, radioactive iodine or total thyroidectomy. Choice is individual.

Why this guide matters

One diagnosis, three real choices.

Antithyroid drugs, radioactive iodine or thyroidectomy: each has trade-offs. The three points below shape the rest of this page.

  • TRAb makes the diagnosis

    TSH-receptor antibodies are highly specific for Graves. A positive TRAb with suppressed TSH usually confirms things without imaging.

  • Definitive treatment is a choice

    Radioactive iodine and total thyroidectomy both cure the hyperthyroidism. The right pick depends on age, eyes, goitre and plans for pregnancy.

  • The eyes deserve their own plan

    Thyroid eye disease is common, sometimes serious and needs its own ophthalmology-led pathway. Smoking cessation is central.

How the diagnosis is made

From first symptoms to a definitive plan.

The steps a UK GP, endocrinologist and, where needed, ophthalmologist will normally follow in Graves disease.

  1. 01

    Assessing

    History and examination

    Symptoms of thyrotoxicosis, family history of autoimmunity, smoking status and a careful look at the neck and eyes.

  2. 02

    Assessing

    Thyroid function tests

    Suppressed TSH with raised free T4 and free T3 confirms biochemical hyperthyroidism per NICE NG145.

  3. 03

    Assessing

    TRAb antibody testing

    TSH-receptor antibodies are highly specific for Graves and often make the diagnosis without further imaging.

  4. 04

    Confirming

    TPO and thyroglobulin antibodies

    Supportive markers of thyroid autoimmunity, useful when TRAb is equivocal or the picture is mixed.

  5. 05

    Confirming

    Radioiodine uptake and ultrasound

    Specialist-led when needed: diffuse increased uptake and a hypervascular gland on Doppler support Graves.

  6. 06

    Planning

    Thyroid eye disease assessment

    Werner NOSPECS grading and a Clinical Activity Score guide ophthalmology referral for moderate or active disease.

  7. 07

    Planning

    Multidisciplinary planning

    Endocrinology, ophthalmology and surgery agree the definitive plan, drawing on specialist commissioned services.

Typical timeline: from suppressed TSH to a definitive plan in a few weeks.

Symptoms

What Graves actually looks like.

The classic mix of thyrotoxic symptoms, a diffuse goitre and, in a significant minority, thyroid eye disease.

  • Heat intolerance and sweating

    Feeling warm when others are comfortable, with sweaty palms and a preference for cooler rooms.

  • Weight loss with appetite preserved

    Unintentional weight loss despite eating normally, driven by a raised basal metabolic rate.

  • Palpitations and tachycardia

    A racing or forceful heartbeat, sometimes atrial fibrillation, especially in older adults.

  • Tremor and muscle weakness

    A fine tremor of the outstretched hands and proximal muscle weakness climbing stairs.

  • Anxiety, irritability, insomnia

    Mood changes, restlessness and poor sleep are common and often the first thing partners notice.

  • Diffuse goitre with bruit

    A smooth, symmetrical thyroid enlargement, sometimes with an audible bruit over the gland.

  • Thyroid eye disease

    Proptosis, lid retraction, diplopia or, rarely, optic neuropathy: a red flag for urgent ophthalmology.

  • Red flag: thyroid storm

    Fever, delirium, severe tachycardia or heart failure: a medical emergency needing hospital care.

Treatment

How Graves disease is treated in the UK.

Antithyroid drugs to bring things under control, then a considered choice between long-term medication, radioactive iodine or thyroidectomy.

  • Carbimazole

    First-line antithyroid drug in the UK, typically 10 to 40 mg daily for 12 to 18 months under specialist review.

  • Propylthiouracil (PTU)

    Preferred in the first trimester of pregnancy. Watch for agranulocytosis and hepatotoxicity.

  • Block and replace

    An alternative regimen combining a fixed dose of antithyroid drug with levothyroxine. Simpler monitoring for some patients.

  • Beta-blockers

    Propranolol controls tremor, palpitations and anxiety while definitive treatment takes effect.

  • Radioactive iodine (I-131)

    Specialist-commissioned definitive treatment. Often preferred: hypothyroidism afterwards is expected and easy to manage.

  • Total thyroidectomy

    Considered for large goitres, active eye disease, pregnancy plans or when rapid control matters. Lifelong thyroxine follows.

  • Selenium and TED supportive care

    Selenium for mild eye disease, plus preservative-free lubricants, prisms and eye taping to protect the cornea.

  • Steroids and teprotumumab

    Oral or IV methylprednisolone for moderate-to-severe active thyroid eye disease. Teprotumumab is an option in specialist centres.

Related specialist clinics

Definitive treatment is delivered through specialist commissioned pathways. See our guides to radioactive iodine, thyroidectomy and the teprotumumab clinic for thyroid eye disease.

What this guide is based on

The sources behind every claim on this page.

UK national guidance and specialist society standards, current at the time of last review.

Key references

Guidelines and standards we relied on.

A quiet reminder

This guide is for information, not medical advice.

Your GP, endocrinologist or ophthalmologist knows your history and can tell you which parts apply to you. If in doubt, get seen.

  • NICE. Thyroid disease: assessment and management (NG145).

  • British Thyroid Association (BTA). Guidelines on the management of primary hyperthyroidism.

  • European Thyroid Association (ETA). Guideline for the management of Graves hyperthyroidism.

  • MHRA. Carbimazole and propylthiouracil safety updates, including congenital malformation and pancreatitis warnings.

Red flags

When Graves needs urgent attention.

Most Graves is stable once treatment starts. These are the situations that are not, and where specialist input is needed quickly.

  • Thyroid storm

    Fever, agitation, severe tachycardia or heart failure in untreated or poorly controlled hyperthyroidism. Call 999.

  • Optic neuropathy in TED

    Loss of colour vision, blurring or a visual field defect in thyroid eye disease needs same-day ophthalmology review.

  • New atrial fibrillation

    AF in a younger adult or unexplained AF at any age should prompt a check for hyperthyroidism.

  • Neutropenic sepsis on carbimazole or PTU

    Sore throat, mouth ulcers or fever on antithyroid drugs. Stop the drug, check FBC and seek urgent care.

  • Pregnancy on antithyroid drugs

    Carbimazole and PTU cross the placenta. Any pregnancy on treatment needs urgent specialist maternal medicine review.

  • Rapid goitre enlargement

    Sudden growth, hoarseness or difficulty swallowing needs urgent imaging to exclude other pathology.

  • Osteoporotic fracture in the untreated

    Long-standing untreated thyrotoxicosis accelerates bone loss. A low-trauma fracture is a call to assess bone health.

  • Severe muscle weakness or paralysis

    Thyrotoxic periodic paralysis, especially in men of East Asian heritage, is an emergency needing hospital care.

  • Suspected iodine-induced flare

    A flare after contrast imaging or high-iodine supplements deserves prompt biochemical reassessment.

Living with it

A treatable condition, with a clear plan.

Four things that make the biggest difference day to day: stopping smoking, regular monitoring, careful eye care and good specialist support.

A quiet reminder

Consistency beats intensity, every time.

Small, steady habits kept up for months do more than a heroic week that does not last.

  1. 01 Smoking

    Stopping smoking is not optional

    Smoking worsens Graves and, in particular, thyroid eye disease. Stopping is one of the highest-value things you can do.

  2. 02 Monitoring

    Regular blood tests matter

    TFTs are checked every four to six weeks while dosing is settled, then less often once stable. Relapse after antithyroid drugs is common, around 50 per cent.

  3. 03 Eyes

    Protect the eyes early

    Preservative-free lubricants, taping at night and prompt review of any change in vision, redness or double vision.

  4. 04 Support

    Get properly supported

    The British Thyroid Foundation and specialist nurses can help with pacing, work, pregnancy planning and thyroid eye disease.

Frequently asked

Everything we get asked about Graves disease.

Quick answers on diagnosis, antithyroid drugs, radioactive iodine, thyroidectomy and thyroid eye disease.

  • What is Graves disease?

    An autoimmune condition in which TSH-receptor antibodies stimulate the thyroid gland to overproduce hormone. It is the most common cause of hyperthyroidism in the UK, responsible for around 60 to 80 per cent of cases, and often produces a diffuse goitre and thyroid eye disease alongside classic thyrotoxic symptoms.

  • How is Graves disease diagnosed?

    By combining symptoms with thyroid function tests showing a suppressed TSH and raised free T4 and free T3, and a positive TRAb antibody test. TPO and thyroglobulin antibodies support the picture. Radioiodine uptake and thyroid ultrasound with Doppler are used in specialist settings where the diagnosis is not clear.

  • What treatments are available?

    Three definitive pathways: antithyroid drugs such as carbimazole for 12 to 18 months, radioactive iodine (I-131) as a specialist-commissioned definitive treatment, and total thyroidectomy. Beta-blockers control symptoms in the meantime. Choice depends on age, goitre size, plans for pregnancy and whether thyroid eye disease is active.

  • How is thyroid eye disease managed?

    Mild disease is managed with selenium, preservative-free lubricants and stopping smoking. Moderate-to-severe active disease is treated with intravenous methylprednisolone, sometimes teprotumumab in specialist centres, and later orbital decompression, strabismus and eyelid surgery. All of this is best coordinated by an ophthalmology-endocrinology multidisciplinary team.

  • Can I be treated with radioactive iodine?

    Yes, for most non-pregnant adults with Graves it is a well-tolerated and definitive option. Hypothyroidism afterwards is expected and easily managed with levothyroxine. It is not used in pregnancy or breastfeeding, and it is used cautiously with steroid cover in active thyroid eye disease as it can worsen the eyes.

  • What happens in pregnancy?

    Graves in pregnancy is managed by a specialist maternal medicine team. Propylthiouracil is preferred in the first trimester, with a switch to carbimazole for the rest. TRAb is checked as it can affect the baby. Radioactive iodine is contraindicated. Thyroidectomy is sometimes considered in the second trimester if drugs are not tolerated.

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