Patient handout

Hyperthyroidism / thyrotoxicosis (Graves / toxic nodule / thyroiditis — standalone core)

PRODUCTION

1. Your condition

This handout is for hyperthyroidism / thyrotoxicosis (graves / toxic nodule / thyroiditis — standalone core). Your care team identified this based on: suppressed/undetectable tsh on screening or opportunistic testing (ata 2016 ross).

Other reasons your team may use this plan: heat intolerance / weight loss / palpitations / tremor / anxiety / oligomenorrhoea (ata 2016 ross); new atrial fibrillation / unexplained sinus tachycardia → screen thyroid (ata 2016 ross); proptosis / lid retraction / diplopia / periorbital oedema — graves orbitopathy (eugogo 2021 bartalena).

2. Your medications

Take these medications exactly as prescribed. Do not stop or change a dose without talking to your provider.

Medication	Starting dose	How	When	What it does
radioiodine uptake & scan + TRAb + thyroglobulin + thyroid Doppler	—	—	—	ATA 2016 Ross — master MECE pivot: diffuse↑RAIU=Graves, focal↑=toxic nodular, LOW=thyroiditis/factitious/iodine-induced; low thyroglobulin=factitious; Doppler separates amiodarone type 1 vs 2 (Tanda 2008)
supportive only — no thionamide (destructive thyroiditis / factitious / iodine-induced low-RAIU)	—	—	—	ATA 2016 Ross — destructive/exogenous thyrotoxicosis is self-limited; thionamide is ineffective and harmful; treat symptoms only and retest (hypothyroid phase expected in thyroiditis)
NSAID then short oral glucocorticoid taper for painful subacute thyroiditis	—	—	—	ATA 2016 Ross — NSAID first for pain; prednisone taper if severe/unresponsive pain; NOT a thionamide indication

Plan: Thyrotoxicosis aetiology gate → beta-blocker → methimazole first-line → definitive (RAI vs surgery) → Graves-orbitopathy ladder → pregnancy → amiodarone-induced (ATA 2016 Ross; ETA 2018 Kahaly; ATA 2017 Alexander; EUGOGO 2021 Bartalena)

3. Your action plan

Use these zones to know what to do based on how you feel.

GREEN — Stable, symptoms controlled, no danger signs

If you have:

Heart rate, tremor and weight stable on your current treatment (ATA 2016 Ross)
No fever, sore throat, jaundice or eye changes
Taking your antithyroid medicine exactly as prescribed

Do this:

Take methimazole (or your prescribed antithyroid drug) every day as directed (ATA 2016 Ross)
Keep your blood-test appointments (thyroid levels every 4–6 weeks until stable) (ATA 2016 Ross)
Do not smoke — smoking worsens thyroid eye disease (EUGOGO 2021 Bartalena)
If you are planning a pregnancy, contact your provider FIRST — the medicine plan changes (ATA 2017 Alexander)

YELLOW — Warning — contact your provider promptly

If you have:

New or worsening eye bulging, double vision or eye pain (EUGOGO 2021 Bartalena)
Symptoms returning (palpitations, tremor, weight loss) or becoming sluggish/cold (over-treatment)
A positive pregnancy test while on an antithyroid drug
Mild rash or joint aches after starting the drug

Do this:

If newly pregnant on an antithyroid drug, contact your provider NOW — the drug usually needs changing (ATA 2017 Alexander)
Do not change your own dose; arrange a thyroid blood test (ATA 2016 Ross)
Report new eye symptoms the same week — early thyroid eye disease is treatable (EUGOGO 2021 Bartalena)

Call your provider if:

Newly pregnant on an antithyroid drug (same day) (ATA 2017 Alexander)
New or worsening eye bulging / double vision (EUGOGO 2021 Bartalena)
Symptoms of too much OR too little thyroid hormone (ATA 2016 Ross)

RED — Emergency — stop the drug / seek urgent care

If you have:

Fever with a sore throat or mouth ulcers (possible agranulocytosis) (ATA 2016 Ross)
Yellow skin/eyes, dark urine or severe upper-abdominal pain (liver injury) (ATA 2017 Alexander)
High fever + confusion + racing heart + vomiting (possible thyroid storm) (ATA 2016 Ross)
Sudden vision loss or severe eye pain (EUGOGO 2021 Bartalena)

Do this:

STOP the antithyroid drug and get an urgent blood count for fever + sore throat (ATA 2016 Ross)
Go to the emergency department now for confusion + high fever + racing heart — this can be thyroid storm (ATA 2016 Ross)
Seek emergency eye care for sudden vision loss (EUGOGO 2021 Bartalena)
Bring your medication list including your antithyroid drug and dose

Call your provider if:

Always seek emergency care for fever + sore throat on a thionamide, jaundice, thyroid-storm features, or sudden vision loss (ATA 2016 Ross; ATA 2017 Alexander; EUGOGO 2021 Bartalena)

4. When to seek emergency care

Call 911 or go to the nearest emergency room right away if you have:

Hyperthermia + altered mental status + cardiac failure / GI-hepatic dysfunction in a thyrotoxic patient (Burch-Wartofsky high) — thyroid storm (ATA 2016 Ross)(life-threatening)
Fever + sore throat / mucosal ulceration on methimazole or PTU — agranulocytosis (~0.2–0.5%) (ATA 2016 Ross; ETA 2018 Kahaly)(life-threatening)
Jaundice / RUQ pain / transaminase surge on propylthiouracil (can be fulminant) or methimazole cholestasis (ATA 2017 Alexander)
Dysthyroid optic neuropathy / corneal breakdown / rapidly progressive proptosis in Graves orbitopathy (EUGOGO 2021 Bartalena)(life-threatening)
Pregnant or pre-conception woman with Graves/overt thyrotoxicosis, or elevated TRAb in pregnancy (ATA 2017 Alexander)
Thyrotoxicosis on/after amiodarone (AIT) requiring a thionamide — ATD-agranulocytosis risk is ~6× the background thyrotoxicosis risk (conditional-on-drug dependency) (Gershinsky Thyroid 2019)

5. Follow-up

Graves: assess remission after 12–18 mo MMI (TRAb-guided) — relapse → definitive therapy or long-term low-dose MMI (Azizi: long-term recurrence 17% vs conventional 56%; juvenile 4-yr cure 88% vs 33%). Lifelong levothyroxine after RAI/thyroidectomy (route to endo.hypothyroidism.core.v1). Pregnancy: TRAb in pregnancy → fetal/neonatal thyrotoxicosis surveillance; pre-conception counselling (switch to PTU plan / consider definitive before pregnancy). RAI long-term modest solid-cancer-mortality counselling (Kitahara). Return precautions: fever/sore throat, jaundice, eye pain/vision change, palpitations, pregnancy (ATA 2016 Ross; ETA 2018 Kahaly; ATA 2017 Alexander)

6. Sources

Guideline: ATA 2016 Guidelines for Diagnosis and Management of Hyperthyroidism and Other Causes of Thyrotoxicosis (Ross, Thyroid 2016) + ETA 2018 Graves Hyperthyroidism (Kahaly, Eur Thyroid J) + ATA 2017 Thyroid Disease in Pregnancy (Alexander) + EUGOGO 2021 Graves Orbitopathy (Bartalena, EJE); reconciled with OPTIC (Douglas NEJM 2020), the 2025 EUGOGO-vs-ATA/ETA-2022 comparison, long-term-ATD recurrence RCTs, the Danish nationwide ATD-embryopathy cohort (Andersen JCEM 2013), the AIT-amplified ATD-agranulocytosis cohort (Gershinsky Thyroid 2019), and the Thyroid Studies Collaboration fT4-AF IPD (Baumgartner Circulation 2017)