The effects of cigarette smoking on the development of thyroid eye disease in patients with Graves’ disease: A clinical review
* Thyroid eye disease (TED) is thought to be caused by the stimulation of retro-orbital TSH receptors by thyrotropin receptor stimulating antibodies.
* There is a strong association between cigarette smoking and the development and progression of thyroid eye disease.
* Cigarette smoking has adverse effects upon treatments for Graves’ disease and thyroid eye disease.
* Optimum management of thyroid eye disease is multidisciplinary and early referral is vital.
* Advice and support for smoking cessation is important and should be provided by those managing the patients with thyroid eye disease and Graves’ disease.
Graves’ disease (GD) is a relatively common form of hyperthyroidism. It is the most common form of hyperthyroidism in young women and makes up around 85% of cases. It is due to an autoimmune process in which the thyroid stimulating hormone (TSH) receptors on thyroid follicular cells are stimulated by thyrotrophin receptor antibodies (TRAb) resulting in excess production of the thyroid hormones, tri-iodothyronine (T3) and thyroxine (T4). 1,2,3 The Wickham Study carried out in the United Kingdom found the incidence in the general population to be 100-200 cases per 100,000 individuals per year. Like many autoimmune diseases GD is more common in women than in men.4 Thyroid eye disease is the most frequent extra-thyroidal manifestation of GD with 25-50% of those affected showing a degree of eye involvement.5 The impact of tobacco smoking upon the development of TED and the management of patients suffering from TED is an area of much debate. This essay will explore the effect of tobacco smoking on the incidence and disease progression of TED in those with GD as well as on challenges surrounding patient management. Appropriate interventions that may benefit future management of patients with GD will then be discussed.
To write this report the databases Metalib and Medline were searched using the terms ‘Graves’ Disease, ‘thyroid eye disease and smoking’, ‘Graves’ Orbitopathy’ and ‘Graves’ Opthalmopathy’ in various combinations to find evidence based papers written in the English language. Papers written before 1995 and not cited since were discounted. The Cochrane Library was also searched for clinical trials and specialist textbooks were used to find other relevant and reliable information. Knowledge gained through personal clinical experience was used along with a patient account of their own personal experience of TED.
Mrs H is a 59 year old lady who suffers from Graves disease (anti-thyrotrophic receptor stimulator antibodies +) complicated by thyroid eye disease. She was diagnosed with Graves disease in 2008 when she presented with palpitations and leg swelling. She had been previously taking carbimazole 20mg per day until May 2010 when her Thyroid function tests showed her to be thyrotoxic once again. With consideration of Mrs H’s smoking habit and the risks involved in radioiodine treatment it was decided that she would undergo a total thyroidectomy which was carried out in June 2010. The operation was a success; since this time she has been taking 100mcg of levothyroxine OD and currently remains euthyroid. Mrs H has suffered from thyroid eye disease for 2 years and presented in 2010 with blurred vision, obvious swelling and redness of the external eye and retro-orbital pain. The diagnosis of thyroid eye disease was made based on symptoms, clinical findings and a history of Graves disease. Her active eye disease at the time of presentation was treated with high dose IV methylprednisolone. The disease is currently in the inactive phase although she still suffers from excessive lacrimation and there is obvious protrusion of both eyes. She is currently awaiting orbital decompression....
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