Intended for healthcare professionals

Clinical Review

Diagnosis and management of thyrotoxicosis

BMJ 2014; 349 doi: (Published 21 August 2014) Cite this as: BMJ 2014;349:g5128
  1. Bijay Vaidya, consultant endocrinologist and honorary associate professor1,
  2. Simon H S Pearce, professor of endocrinology and honorary consultant physician2
  1. 1Department of Endocrinology, Royal Devon and Exeter Hospital, and University of Exeter Medical School, Exeter EX2 5DW, UK
  2. 2Endocrine Unit, Royal Victoria Infirmary and Newcastle University, Newcastle upon Tyne, UK
  1. Correspondence to: B Vaidya b.vaidya{at}

Summary points

  • It is important to determine the causes of thyrotoxicosis as some are self limiting

  • The test for antibodies to thyroid stimulating hormone receptor is more sensitive and specific than the test for antibodies to thyroid peroxidase for the diagnosis of Graves’ disease

  • Stratification of the severity of Graves’ disease is good practice, allowing patients with a low probability of remission from treatment with antithyroid drugs to be considered for radioiodine or thyroidectomy at an early stage

  • The block-replace regimen of antithyroid drugs must not be used to treat hyperthyroidism in pregnancy

  • Radioiodine treatment should be avoided in patients with active thyroid eye disease

Thyrotoxicosis is a common condition associated with excess circulating thyroid hormones that may present in myriad ways and thus will be encountered by practitioners in all medical disciplines. In Europe, it affects around 1 in 2000 people annually.1 Although thyrotoxicosis typically presents with weight loss, heat intolerance, and palpitations, there are a large variety of additional features, which manifest more variably with advancing age and in people with milder disease. It is important to determine the cause of the thyrotoxicosis, as this determines treatment. Some experts distinguish between thyrotoxicosis and hyperthyroidism by restricting the latter term to describe the conditions associated with excess synthesis and secretion of thyroid hormones from the thyroid gland.

This clinical review summarises the current evidence for the diagnosis and management of adults with thyrotoxicosis.

Sources and selection criteria

We searched Medline, Clinical Evidence, and the Cochrane library using various combinations of terms: “thyrotoxicosis”, “hyperthyroidism”, “Graves’ disease”, “subclinical hyperthyroidism”, “thyroiditis”, “antithyroid drugs”, “carbimazole”, “methimazole”, “propylthiouracil”, “amiodarone”, “radioiodine”, and “thyroidectomy”. We gave preference to high quality observational studies, randomised controlled trials, and systematic reviews published in the past 10 years.

What are the causes of thyrotoxicosis and who gets it?

Table 1 lists the important causes of thyrotoxicosis and the underlying pathogeneses. Graves’ disease is the …

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