Clinical Utility of TSH Receptor Antibodies (TRAb)

[ling]

Incredible piece for those with Graves

ncbi.nlm.nih.gov/pmc/articl...

Copyright © 2013 by The Endocrine Society

1. In patients on methimazole, a positive TRAb is helpful in suggesting that it is not yet time to stop the medication.

2. TRAb tests are also used in the prediction of the rare neonatal transfer of GD, with the main purpose of reassuring most women with GD who will have negative or low titer and limiting the use of intensive fetal monitoring to the few others with persistent high-titer TRAb.

3. When tested with the newer assays, TRAb are emerging as a powerful marker (if not pathogen) of GO,

4. As with many autoimmune diseases, GD is characterized by remissions and flare-ups.

5. Because Graves' hyperthyroidism has a remitting and relapsing natural history, it is not surprising that the absence of TRAb at any time in the history of 1 single patient cannot guarantee that these will not return in the distant future, no matter how accurate the assay is.

6. Given the available data, we would like to suggest that testing TRAb in Graves' patients who are euthyroid while on methimazole is very useful in distinguishing patients with active disease and positive TRAb who are euthyroid only because of TH synthesis blocking of methimazole from patients in remission with negative TRAb.

a) Patients with negative or low-titer TRAb (in remission) can discontinue methimazole depending on the circumstances. Because a prolonged remission cannot be promised based on a currently negative TRAb level, patients at high risk of negative consequences from late relapses, such as patients with paroxysmal atrial fibrillation, may be best served by ongoing antithyroid drug treatment or RAI treatment.

b) Medium- to high-titer TRAb-positive patients should be counseled that a discontinuation would almost certainly be followed by a quick return of the hyperthyroidism and should be given the choice of continuation of methimazole treatment and repeat testing at biannual or annual intervals vs definitive treatment.

7. True GD hyperthyroidism cannot occur without TRAb. GD is almost unique among autoimmune diseases, in that the most important clinical manifestation of the disease, the hyperthyroidism, is entirely dependent on, and completely recapitulated by, the interaction of an autoantibody with its autoantigen. Hence, testing for the TSHR antibody should be particularly useful in the diagnosis of GD hyperthyroidism.

8. TRAb can accurately predict short-term relapses of hyperthyroidism after a course of antithyroid drugs but are less effective in predicting long-term relapses or remissions.

9. GD affects many organ systems either by the autoimmune process or as a complication of thyrotoxicosis. Systemic involvement of GD includes the eyes (Graves' ophthalmopathy [GO]) and skin (Graves' dermopathy), whereas bones, heart, liver, and other organs are affected by the excess thyroid hormone.

[Vbgr]

Thank you for this

[ling in reply to Vbgr]

You're welcome : )

[ling in reply to Vbgr]

Hi Vbgr, I saw your earlier post.

How are u doing now?

I too just had a major nasty attack after a stressful period. Reconsidering RAI. Depressing

[Vbgr in reply to ling]

Hi Ling, not too bad now, levels getting very reasonable. Saw my Endo today and he is pleased with me, he is a very nice person. Gave me two options to consider - long term carbimazole( I told him at my age I didn’t think anything would be long term- just for a laugh) or RAI . We didn’t discuss RAI as I side stepped it. Would not consider RIA, I have read this forum for three years or about and the risks with Graves would not be in my favour. If you are considering RAI please get advice as it’s a non return step, seems some people are lucky and some are not. That’s how it reads. Let me know how you get on. Val

[ling in reply to Vbgr]

Hi Vbgr. Thanks for sharing. It's great to hear you're doing well : ) It's always a struggle to come back from the brink.

What are the worst symptoms for u?

[pennyannie in reply to ling]

Please do not go down this route, if you must relinquish your thyroid consider surgery.

It is cleaner, it is contained and more complete. True it is an operation.

RAi is a quick fix 20 minute appointment in out patients, and then a discharge back out into primary care.

It is the hospitals treatment of choice because financially, it is the cheapest option, but it may not be in the patients best interest.

The RAI drink burns out your thyroid but also goes through your whole body and can cause long term consequences, you may not even have been told about.

It can also trigger thyroid eye disease, and there is no way of knowing who will be affected until it's too late.

Elaine Moore Graves Disease - A Practical Guide - is a very good book - this American lady has the disease and drank the RAI - hence why she wrote this book and has set up a Foundation for Graves patients to educate, research and freely discuss all that Graves Disease is and does.

Please take time to research this treatment thoroughly.

Why take this risk ?

I'm with Graves Disease post RAI in 2005.

[ling in reply to pennyannie]

Thank you my dear.

What do u know about the possible complications from surgery? Have had a cursory read about problems with the parathyroid, and in that article, hypoparathyroidism and recurrent laryngeal nerve palsy.

I've also watched a documentary on a case of parathyroidism. It severely affects mobility and causes debilitating daily pain.

In my case, one certainty is that thyroid eye disease will be triggered with RAI.

Whether surgery or RAI, it will be a headache deciding.

[pennyannie in reply to ling]

When you consider our disease is one of our immune system attacking our bodies, removal of the gland under attack, the thyroid, is simplistic in the first instance.

Swopping one set of symptoms, hyperthyroidism for hypothyroidism, is deemed the answer, as the medics believe they can manage an underactive thyroid more successfully than they can an overactive thyroid.

Either way the thyroid is the victim in all this and not the cause.

True Graves can be considered life threatening if it's not medicated, since the thyroid is such an important gland, and the conductor of our whole body orchestra, fine tuning our metabolism, physical, emotional, psychological, and spiritual well being.

I read Professor Toft, the eminent endocrinologist states :-

" I am so concerned about the state of advice on the management of primary hypothyroidism that I am increasingly reluctant to suggest ablative therapy with iodine 1-131 or surgery in patients with Graves disease, irrespective of age or number of reoccurrences of hyperthyroidism. "

The full article Thyroid Hormone Replacement - a counterblast to guidelines - December 2017 - The Journal of the Royal College of Physicians - Edinburgh :

True any medical intervention comes with a level of risk.

RAI does sound appealing, it is just a little pill - I know, I took it.

Back in 2003 sadly, there wasn't the availability of all this free information.

I now read up about my situation, in reverse : I wouldn't suggest anyone go through my last five years of dealing with the long term consequences of RAI.

[ling in reply to pennyannie]

Thank you again