What is the best definitive treatment for graves' disease? A systematic review of the existing literature

Background: The management guidelines of the American Thyroid Association and American Association of Clinical Endocrinologists for Graves' disease (GD) include any of the following modalities: ¹³¹I therapy, antithyroid medication, or thyroidectomy. No in-depth analysis has been performed comparing the treatment options, even though a single treatment option seems to be universally accepted. Methods: A systematic review of the literature was performed to examine contemporary literature between 2001 and 2011 evaluating the management options of GD. We compiled retrospective and prospective studies analyzing surgery and radioactive iodine. Outcomes of interest included postoperative hypothyroidism, euthyroidism, and persistent or recurrent hyperthyroidism without supplementation. Success was defined as postoperative euthyroidism or hypothyroidism. Failure was defined as persistent or recurrent hyperthyroidism. Results: Of the 14,245 patients, 4,546 underwent surgery [3,158 patients had subtotal thyroidectomy (STT) and 1,388 had total thyroidectomy (TT)] and 9,699 had radioactive iodine. The radioactive iodine group consisted of 2,383 patients receiving 1-10 mCi, 1,558 patients receiving 11-15 mCi, 516 patients receiving >15 mCi, and 5,242 patients receiving an unspecified amount. Surgery was found to be 3.44 times more likely to be successful than radioactive iodine (p < 0.001). STT and TT were found to be 2.33 and 94.45 times more likely to be successful than radioactive iodine (p < 0.001), respectively. Conclusions: On the basis of the outcomes analyzed, surgery appears to be the most successful in the management of GD, with TT being the preferred surgical option.