Challenges in the Diagnosis and Management of Graves' Disease in an Elderly Female With Antithyroid Drug Intolerance

Graves' Disease (GD) is uncommon in the elderly. This report explores the case of an 87-year-old female diagnosed with Graves' Disease following a non-specific decline and new-onset atrial fibrillation (AF). Incidental blood tests on admission revealed severe thyrotoxicosis with a thyroid-stimulating hormone (TSH) level of <0.0005mu/L and free thyroxine (fT4) level of 72 pmol/L, with positive TSH-receptor antibodies confirming Graves' Disease. Initial management with carbimazole achieved some biochemical control but led to hepatotoxicity. Reduced dosing caused similar hepatic derangement. Propylthiouracil also did not adequately control thyroid function and caused mild liver function derangement. The patient re-presented with decompensated thyrotoxicosis, including hypotension, fast AF, and confusion. The endocrinology multidisciplinary team (MDT) decided the patient was unsuitable for definitive treatments; hence, Lugol's iodine was commenced. Thyroid function gradually stabilised on a combination of Lugol's iodine, propranolol, steroid and low-dose propylthiouracil. This case was challenging due to anti-thyroid drug intolerance in conjunction with limited definitive management options, with our endocrinology team resorting to non-standard therapies to stabilise the patient. This case ultimately demonstrates the diagnostic and therapeutic challenges of managing Graves' hyperthyroidism in the elderly. .