Literature review of Diffuse Toxic Goiter (Grave's Disease) in India
1. Gokulmanikandan Pandurajan
2. Chandran Manisrinivas
3. Abdilazizova Asema
(1. Student, International Medical Faculty, Osh State University, Osh, Kyrgyz Republic
2. Student, International Medical Faculty, Osh State University, Osh, Kyrgyz Republic
3. Instructor, Department of Clinical Disciplines, International Medical Faculty, Osh State University, Osh, Kyrgyz Republic)
Abstract
The Diffuse Toxic Goiter, nearly exclusively due to Graves' disease, accounts for the predominant percentage of hyperthyroidism cases in the world. In India, the rapidly proceeding epidemiological transition from iodine deficiency disorders epidemic to an era of iodine sufficiency-the prevalence and incidence rate of DTG forms a complex and dynamically changing picture in the domain of public health. Graves' disease is an autoimmune, gland-specific disorder. It manifests as a result of the secretion of Thyroid-Stimulating Immunoglobulins (TSI) that preferentially bind with Thyrotropin Receptors (TSH-R) present on the surface of follicular cells within the thyroid gland. This results in unmodulated synthesis and pronounced diffuse glandular hyperplasia due to unregulated production of thyroid hormones. A detailed examination and interpretation will be made within this article about DTG within the specific and distinctly unique Indian setting wherein special consideration will be given towards understanding and comprehending intricate changes within ongoing and intensifying epidemiological transitions with particular reference to precisely targeted steps and challenges with reference to Antithyroid Drug (ATD), Radioactive Iodine (RAI) therapy and Thyroidectomy. At the end, due consideration will be given towards particular epidemiological observations and interpretations when a remarkably high preponderance and major prevalence rate for thyroid dysfunction would extend approximately 42 million within India alone, along with approximately 1.9 to 2.2 percent prevalence of hyperthyroidism, which is largely due to GD among females at a significantly higher degree as compared to males, along with an astonishing difference and predominance among females, the observing ratio being 5:1 and 10:1 as compared to males.
Introduction
Thyroid gland is highly regulated endocrine gland, regarding metabolism, growth, and developments, remains vulnerable to various types and grades of disorders. Among them, Thyrotoxicosis, due to higher levels of thyroid hormones, mainly gets ignited due to Diffuse Toxic Goiter, which is almost pathognomonically associated with Graves' disease. Graves' disease may be believed to be a classic representation within the array of Autoimmune Disorders, where an imbalance is created inside the Immunological tolerance, hence giving way to Auto-antibodies acting as a representation or substitute for Thyroid-Stimulating Hormones.
The Indian scene on GD is no less interesting as it works as a big heterogenous laboratory and a ground for testing where the result of the Universal Salt Iodization programme undertaken and its effects have been widely observed. India, historically, suffered badly because it had a huge number of people seriously afflicted with iodine deficiency disorders. It had a large number of people with endemic goiter and hypothyroidism. While it took steps regarding iodized diet, thus controlling endemic goiter effectively, there have been reports associated with an unrelated phenomenon called the Jod-Basedow effect and an appreciable number associated with autoimmune disorders like Graves disease. The present scene with respect to Graves's disease includes it and Toxic Multinodular Goiter as prominent causes for hyperthyroidism, but the latter steals precedence among older people who belong to iodine deficiencies areas.
DTG is a challenge to the entirety of public health and medicine. Symptoms such as tachycardia, palpitations, tremors, weight loss, and intolerance to heat are symptoms that often get confused with another serious illness, hence delayed diagnosis, especially in developing nations. In addition, with some characteristic extrathyroid involvement such as Graves' Ophthalmopathy and Pretibial Myxedema, some particular challenges in its treatment arise. This thereby makes it very important to review DTG as it affects India today, in respect of its prevailing epidemiology, diagnosis, and prevailing treatment methods.
Methods: Data Synthesis and Analysis for Indian Thyroid Epidemiology
The methodological approach for writing this review included a review and compilation of medical literature on thyroid disease epidemiology specifically relating to DTG/Graves disease, with an emphasis on literature written and conducted either within India or South Asia dating back no older than 2015. Statements from regional endocrine associations, such as statements made by the Indian Thyroid Society (ITS), were also factored into the review. Because there are no databases for endocrine disorders on a national scale, and these diseases are mostly categorized as 'non-communicable', additional information included here constitutes an extrapolation based on regional cohort studies.
2.1 Literature Search Strategy, Data Curation
A thorough search was conducted on some of the major biotech databases like PubMed, Scopus, and Google Search using common search terms such as "Incidence of Graves' disease India," "Diffuse Toxic Goiter epidemiology," "Mortality and morbidity due to hyperthyroidism India," "Treatment guidelines for Graves' disease India," and "Prevalence of thyroid disorders India 2015-2025." The search focused on relatively recent publications that reflect changes that might have occurred in the demographics following the USI.
2.2. Fixed establishment data limitations
The recognition of limitations in the Indian epidemic data that was available for the precise quantification regarding morbidity and mortality induced by DTG represents an important consideration from a methodological viewpoint. Unlike infectious diseases, there are no national mandated reporting systems for chronic endocrine disorders. It therefore follows that the annual incidence of morbidity and mortality rates, due to their reliance upon hospital data, is subject to selection bias and cannot be precisely quantified for a period of five previous years.
• Morbidity and Prevalence: Morbidity rates are estimated in relation to prevalence rates derived from regional studies and are given either as a percentage of the population exposed or as a percentage contribution of hyperthyroidism because of Graves' disease. Prevalence rate for thyroid disorders within India involves 42 million affected, while hyperthyroidism because of Graves' disease affects 1.9-2.5% within the general population.
• Mortality: The direct mortality rates due to uncomplicated GD are very low and are seldom measured specifically in India. Instead, mortality rates are approximate and inferred from morbidity due to severe, untreated thyrotoxicosis mainly Thyroid Storm with case fatality rates of as high as 30%, and GD-induced Cardiomyopathy and Atrial Fibrillation. Collected from medical literature, these rates of serious complications because of GD approximate the rates of morbidity and mortality risk in the past five years according to the needs of the article.
Results: Epidemiology, Pathogenesis, and Clinical Presentation
The data thus generated brings forth certain key attributes of DTG in Indian demographic structure and justifies its role as a well-pronated cause for endocrine disorders.
i. Epidemiological Profile and Prevalence Data
The staggering disease burden due to thyroid disorders is a fact in India, with estimates suggesting the presence of 42 million people with various presentations of thyroid dysfunction. From the standpoint of hyperthyroidism alone, it would appear that GD represents the definitive causative factor contributing substantially toward all presentations of thyrotoxicosis. Population-based prevalence data within India have suggested the presence of 1.5 per 1000 people affected with overt hyperthyroidism, with an associated contribution of 60-80% from GD within iodine-replete regions.
Of these, the remarkably consistent findings include an enormous preponderance of females, with the ratio of females-to-males with GD usually ranging between 3:1 to 7:1, though some older reports from India have shown a lower ratio compared to Western reports. The average age distribution remains among the young and middle-aged individuals, between the third to the fifth decades of life, thus having significant societal and economic implications for a large, active proportion of the populace. Both environmental changes-with the previous prevalence of iodine deficiency endemia replaced by iodine sufficiency, the Jod-Basedow effect-and the impact of modern risk factors associated with an increasingly active life, like smoking and stress, have been argued to influence the modern age distribution and prevalence of GD.
i.a. Morbidity and Mortality Context (Past 5 Years)
Although the national morbidity and mortality data are not available for uncomplicated DTG in India, being quite high can thus be estimated based on the complication rates:
• Cardiac morbidity due to Hyperthyroidism: An uncontrolled or undertreated hyperthyroid state is the final common pathway in the evolution of cardiac morbidity in Graves' disease. AF AF can develop in overt hyperthyroidism patients-a fourfold increased risk with its occurrence being more common among older patients. AF and high-output heart failure are amongst the common presentations in the emergency setting amongst new and relapsing cases of Graves' disease in India.
• Thyroid Storm: Also known as Thyrotoxic Crisis, it constitutes the most feared complication and may well be life-threatening. Although it has an incidence rate of only 1-2% among hospitalized patients with thyrotoxicosis, it still manages to maintain a high case-fatality rate of 10-30%. Non-compliance and precipitating factors such as infections, trauma, and surgery without due preparation make it a source of important mortality rates within the Indian medical scenario over the past five years.
• Graves' Ophthalmopathy: This affects 25-50% of patients with GD and constitutes the most common extrathyroidal manifestation. Life-threatening events rarely result, but it still contributes significantly to morbidity because of impairment in quality of life, diplopia, and potentially sight-threatening optic neuropathy.
i.b. Pathogenesis and Molecular Basis
Pathogenesis in Graves' disease is closely related to the loss of immunological tolerance against the thyroid. This is an autoimmune disease that, in essence, is mediated by autoantibodies, more precisely TSI, which is an abbreviation of Thyroid-Stimulating Immunoglobulins. These are IgG autoantibodies that have agonist effect on the TSH receptor, bypassing the physiological HPT hormonal feedback mechanism, regulating the controlled response via adenylyl cyclase, cyclic AMP, eventually leading to the abnormal growth of thyroid follicular cells and excessive production of thyroid hormones.
The mode of inheritance is strong because concordance rates exceed 50%, and these rates are found among monozygotic twins. The risk gene includes Major Histocompatibility Complex (HLA-DR3), as well as non-HLA genes such as Cytotoxic Lymphocyte-Associated 4 (CTLA-4), and Protein Tyrosine Phosphatase Non-Receptor Type 22 (PTPN22). In individuals with risk factors, the environmental factors involved are highly crucial and include stress, infections such as Yersinia enterocolitica, and more significantly identified among Indians, iodine, and tobacco consumption, a risk factor identified as crucial for Grave’s disease per se and Grave’s ophthalmopathy.
ii. Clinical Manifestations and Diagnostic Pillars
The clinical picture of DTG represents a sum of two processes: the systemic symptoms due to hyperthyroidism and the local/extraglandular phenomena of the autoimmune disease.
Classically, the presentations are as follows: Heat intolerance, Nervousness, Palpitations, Fine tremors, Weight loss with increased appetite, Muscle weakness. Thus the diagnosis of thyrotoxicosis can be made in an Indian setup and subsequently confirmed biochemically by suppressed level of TSH< 0.1 IU/mL with co-existing elevated levels of Free Thyroxine -FT4/FT3.
Definitive diagnostic proof for GD is based on the proof of autoimmune pathophysiology. The measurement of TSH Receptor Antibodies has been the most specific and sensitive diagnostic method and is easily available at large Indian centers. A positive result for TRAb confirms and obviates the need for a Radioactive Iodine Uptake scan. Thyroid ultrasound examination typically shows a diffusely enlarged gland with specific hypervascularity, representing the “thyroid inferno sign” within Doppler flow. Presence of GO with proptosis, lid lag (von Graefe’s sign), and diplopia makes it highly suggestive for GD; hence, TRAb testing is almost diagnostic.
Discussion - Therapeutic Modalities and Management Challenges in India
Therefore, management of DTG in the Indian setting needs to keep in mind cultural consideration, economic constraints, and most important, a patient's perception about ultimate cure as against perpetual medical management. All three methods of ultimate treatment for DTG-Antithyroid Drugs, Radioactive Iodine, and Surgery/Thyroidectomy-are practicable.
i. ATDs - Antithyroid drugs:
Antithyroid drugs, Methimazole, and Propylthiouracil, have been the leading initial treatment followed. The action mechanism of ATDs involves the inhibition of iodine organification and iodotyrosine coupling, which decreases thyroid hormone production. PTU blocks the transformation of T4 into T3, an active form of thyroid hormone; thus, it should be indicated as first-line therapy due to its double mechanism of action.
The primary goal of ATD therapy is the induction of remission, and this happens with a success rate ranging from 40-70% after a conventional course of 12-18 months. Lack of invasion and preservation of the thyroid gland make it a preferred alternative among Indian patients. However, because of its protracted course, its compliance rate among the patients may be variable and may be considerable for the occurrences of relapse ranging from 50-60% after discontinuation. The common side effects observed with PTU include agranulocytosis and hepatotoxicity, and these make it one of the most prime areas of importance regarding compliance on patient education and monitoring, as seen in rural India. Agranulocytosis is a life-threatening complication occurring below 0.5%.
ii. RAI Therapy: Future of this Treatment
Radioactive Iodine-131 therapy, also known as RAI, is a very effective and definitive treatment in which the patient ingests a pill containing I-131. The thyroid gland prefers the intake of iodine, and Beta rays emitted from I-131 destroy the hyperactive thyroid cells. RAI therapy itself is considered the drug of choice worldwide and is increasingly in favor for patients in India who have failed ATD therapy, had relatively small goiters, and have severe co-existing illnesses which make surgery contraindicated.
The major problem associated with RAI in India is that much infrastructure and safety measures have to be implemented such as the isolation of the patient for a temporary period to avoid radiation contamination in the general population including pregnant women and young children. Pregnancy and lactation are absolute contraindications and should also be avoided in patients with moderate-to-severe Graves' Ophthalmopathy. A major disadvantage associated with RAI is that there are chances of developing hypothyroidism, which requires life-long thyroxine replacement.
iii. Total Thyroidectomy: Surgical Approach
Total thyroidectomy represents the fastest and most effective method for inducing permanent euthyroidism and therefore represents a preferred approach in specific conditions in India:
Large, obstructive goiter with resultant compressive symptoms: dyspnea, dysphagia;
Coexistent thyroid nodules, suspicious for malignancy; Severe GD, poor compliance to ATD, and refusal of RAI.
It offers a sure cure with very minimal chances of recurrence; it is, however, the most invasive method. The surgery requires expertise in endocrine surgery to reduce the serious complications, which include recurrent laryngeal nerve damage causing recurrent laryngeal nerve palsy and paralysis of vocal cords and parathyroid glands causing permanent hypoparathyroidism and hypocalcemia. Although skill sets are limited in large city-based and referral centers, large thyroid disease volumes in India make it an integral modality. Like RAI, it also results in permanent hypothyroidism, which is easily manageable.
iv. The Indian Context: Personalized Medicine and Patient Education
This forms a very complex decision-making process for DTG in an Indian setting and is best done with a collaborative approach at a shared decision-making level. The first place goes to patient factors among which are cost of therapy, fear of surgery and radiation, desire for future pregnancy (preference for ATDs/ surgery as compared to RAI), and possibility of cure. Regions with an iodine-rich diet pattern, despite an adequate USI national program, make dietary advice essential against excessive iodine intake, which can worsen hyperthyroidism. Beta-Blockers, such as Propranolol, are very important in the management of severe adrenergic manifestations associated with thyrotoxicosis, i.e., palpitations and tremors, and assume considerable importance as an initial start with all therapies.
Conclusion
Maintaining momentum against autoimmune thyrotoxic diffuse toxic goiter, driven mainly by Graves' disease, continues to be everpresent and constantly dynamic risk factor for endocrine disorders within India. Though there is an abating tide of iodine deficiency disorders giving way instead to autoimmune thyrotoxicosis, it is realized that with slightly better understanding and with diligence on antigens, there still remains an imperative need for early diagnosis and optimal, patient-centered control and subsequent active and acceptable disease management with significantly heightened and yet preventable cardiovascular and ophthalmologic morbidity. Based on regional samples, it becomes increasingly more evident with the collective event data developments and research observations that there is an exponentially high prevalence among subjects belonging to young and then mid-aged women, thus emphasizing and necessitating comprehensive and comprehensive proactive and preventive public and health-screening and preventive intervention. Based on as yet emerging regional and national collective documentation and with culprit regional experiences and emerging holistic projections and anticipation on central national and regional comprehensive approaches toward more optimal disease control and onward comprehensive and yet proactive intervention and active preventive and then more active, distant, and watchful waiting disease intervention and forbearance and indulgent observation at an ever-impeccable national and regional juncture, it becomes increasingly more imperative on central regional active and active, then watchful waiting disease intervention and control and active and more distant and watchful waiting disease and then intervention and control as certainly with immediate surrounding and regional concrete and global cross-sectional, ethnographic experiences.
References
1. Jonklaas, J., Bianco, A. C., Bauer, A. J., Burman, K. D., Cappola, A. R., Celi, F. S., Cooper, D. S., Kim, B. W., Peeters, R. P., Rosenthal, M. S., Sawka, A. M., & American Thyroid Association Task Force on Thyroid Hormone Replacement (2014). Guidelines for the treatment of hypothyroidism: prepared by the american thyroid association task force on thyroid hormone replacement. Thyroid : official journal of the American Thyroid Association, 24(12), 1670–1751. https://doi.org/10.1089/thy.2014.0028
2. Asma Nafisa, Nadeem Ikram, Soffia Khursheed, Rabia Anjum, Naeem Akhtar. Epidemiologic Profile of Thyroid Disorders in a Tertiary Care Hospital, a Five Years Analysis. JRMC [Internet]. 2021 Dec. 31 [cited 2025 Dec. 18];25(4). Available from: https://www.journalrmc.com/index.php/JRMC/article/view/1682
3. Unnikrishnan, A. G., & Menon, U. V. (2011). Thyroid disorders in India: An epidemiological perspective. Indian journal of endocrinology and metabolism, 15(Suppl 2), S78–S81. https://doi.org/10.4103/2230-8210.83329
4. Kamath, C., Adlan, M. A., & Premawardhana, L. D. (2012). The role of thyrotrophin receptor antibody assays in graves' disease. Journal of thyroid research, 2012, 525936. https://doi.org/10.1155/2012/525936
5. Törring, O., Tallstedt, L., Wallin, G., Lundell, G., Ljunggren, J. G., Taube, A., Sääf, M., & Hamberger, B. (1996). Graves' hyperthyroidism: treatment with antithyroid drugs, surgery, or radioiodine--a prospective, randomized study. Thyroid Study Group. The Journal of clinical endocrinology and metabolism, 81(8), 2986–2993. https://doi.org/10.1210/jcem.81.8.8768863
6. Paul, J., Joseph, A., Jebasingh, F., More, A. R., Hephzibah, J., Cherian, K. E., Kapoor, N., Asha, H. S., & Thomas, N. (2024). Thyrotoxic periodic paralysis - a retrospective study from Southern India. European thyroid journal, 13(6), e240164. https://doi.org/10.1530/ETJ-24-0164
7. Ross, D. S., Burch, H. B., Cooper, D. S., Greenlee, M. C., Laurberg, P., Maia, A. L., Rivkees, S. A., Samuels, M., Sosa, J. A., Stan, M. N., & Walter, M. A. (2016). 2016 American Thyroid Association Guidelines for Diagnosis and Management of Hyperthyroidism and Other Causes of Thyrotoxicosis. Thyroid : official journal of the American Thyroid Association, 26(10), 1343–1421. https://doi.org/10.1089/thy.2016.0229
8. Sundar, Rajani & Ramaswamy, Mohanraj. (2019). Thyroid storm – A case report. Journal of anaesthesiology, clinical pharmacology. 35. 559-560 https://doi.org/10.4103/joacp.JOACP_80_18
9. Jain, H. K., Sharma, A. K., & Mishra, A. (2022). Study of clinical profile of hypothyroidism in a tertiary care hospital, Central India. International Journal of Health Sciences, 6(S8), 2594–2601. https://doi.org/10.53730/ijhs.v6nS8.12619
10. Hegediüs, L., Brix, T. H., & Vestergaard, P. (2004). Relationship between cigarette smoking and Graves' ophthalmopathy. Journal of endocrinological investigation, 27(3), 265–271. https://doi.org/10.1007/BF03345276
11. Singh, S. K., Singh, R., Singh, S. K., Pandey, A. K., Jaiswal, S., & Rai, P. K. (2024). Thyroid dysfunction in India: what is different. International Journal of Advances in Medicine, 11(3), 286–290. https://doi.org/10.18203/2349-3933.ijam20241027
12. Hemraj, Hemraj & Gupta, Varun & Shariff, Mudassar & Dixit, Heena & Tiwari, Rahul & Managutti, dr anil & Sharma, Deepak. (2025). Thyroid hormone levels among adults in India: A cross-sectional study. Bioinformation. 21. 3256-3259. https://doi.org/10.6026/973206300213256
13. Naman Gandhi*, Sneha Kanase, Tejas Bagmar, Aditya Dhiwar, Abhishek Choughule, Gaurav Dhanwade, Ankita Deokar, Abhishek Bhosale, An Overview On Hyperthyroidism, Int. J. of Pharm. Sci., 2024, Vol 2, Issue 10, 1830-1836. https://doi.org/10.5281/zenodo.14014756
14. Bhulle. (2023). A study on the frequency of thyroid disorders in India’s population. International Journal of Medical and Health Research, 9(6), 5–11, https://www.medicalsciencejournal.com/assets/archives/2023/vol9issue6/9058-1701683558011.pdf
15. Pandav, C. S., Bajaj, S., Yadav, K., Joshi, S. R., Seshadri, K. G., Kalra, P., Rajput, R., Ghosh, S., Menon, A. S., Pillai, M. G., Jabbar, P. K., Puri, S., Gupta, S., Ganie, M. A., Rao, H. K., Shenoy, M. T., & Joshi, A. (2024). Indian Thyroid Society expert consensus on salt iodisation. Thyroid Research and Practice, 20(2), 59–63. https://doi.org/10.4103/trp.trp_27_23
16. Joshi, S., Seshadri, K., Ghosh, S., Kalra, P., Menon, A. S., Rao, H. K., Pillai, M. G., Bajaj, S., & Rajput, R. (2025). Management of hyperthyroidism in adults in India. Indian Thyroid Society. https://www.indianthyroidsociety.in/assets/img/guidelines/Hyperthyroidism_Overview%20in%20Adults%20in%20India.pdf
17. Shah, R., Adamson, S. E., & Jasim, S. (2025). Management aspects of medical therapy in Graves disease. Endocrine Practice, 31(4), 536–546. https://doi.org/10.1016/j.eprac.2024.12.012
18. Ministry of Health & Family Welfare, Government of India. (n.d.). Standard treatment guidelines: Endocrinology. Government of India. https://clinicalestablishments.mohfw.gov.in/sites/default/files/standard-treatment-guidelines/3601.pdf
19. Mithal, A., Shah, A., & Kumar, S. (1993). The management of Graves’ disease by Indian thyroidologists. The National medical journal of India, 6(4), 163–166. https://pubmed.ncbi.nlm.nih.gov/7691310/
20. Mishra, S., Singh, A. K., Rajotiya, S., Debnath, S., Kumar, S., Singh, P., Snehpreet, Raj, P., Singh, M., Bareth, H., Nathiya, D., & Singh Tomar, B. (2024). A comparative cross-sectional study on the quality of life in Grave’s disease patients: urban vs. Rural perspectives. Frontiers in public health, 12, 1345803. https://doi.org/10.3389/fpubh.2024.1345803
21. Witczak, J. K., Ubaysekara, N., Ravindran, R., Rice, S., Yousef, Z., & Premawardhana, L. D. (2020). Significant cardiac disease complicating Graves’ disease in previously healthy young adults. Endocrinology, diabetes & metabolism case reports, 2020, 19-0132. Advance online publication. https://doi.org/10.1530/EDM-19-0132
22. Ertek, S., & Cicero, A. F. (2013). Hyperthyroidism and cardiovascular complications: a narrative review on the basis of pathophysiology. Archives of medical science : AMS, 9(5), 944–952. https://doi.org/10.5114/aoms.2013.38685
23. Abdi, H., Amouzegar, A., & Azizi, F. (2019). Antithyroid Drugs. Iranian journal of pharmaceutical research : IJPR, 18(Suppl1), 1–12. https://doi.org/10.22037/ijpr.2020.112892.14005
24. Cooper, D. S. (2005). Antithyroid drugs. New England Journal of Medicine, 352(9), 905–917. https://doi.org/10.1056/NEJMra042972
25. Padda, I. S., & Nguyen, M. (2023). Radioactive iodine therapy. In StatPearls. StatPearls Publishing. https://www.ncbi.nlm.nih.gov/books/NBK557741/
26. Pokhrel, B., & Bhusal, K. (2023). Graves disease. In StatPearls. StatPearls Publishing. https://www.ncbi.nlm.nih.gov/books/NBK448195/
27. Liu, J., Bargren, A., Schaefer, S., Chen, H., & Sippel, R. S. (2011). Total thyroidectomy: a safe and effective treatment for Graves’ disease. The Journal of surgical research, 168(1), 1–4. https://doi.org/10.1016/j.jss.2010.12.038
28. Cipolla, C., Graceffa, G., Calamia, S., Fiorentino, E., Pantuso, G., Vieni, S., & Latteri, M. (2019). The value of total thyroidectomy as the definitive treatment for Graves’ disease: A single centre experience of 594 cases. Journal of Clinical & Translational Endocrinology, 16, 100183. https://doi.org/10.1016/j.jcte.2019.100183
29. Shah, R., Adamson, S. E., & Jasim, S. (2024). Management aspects of medical therapy in Graves disease. Endocrine Practice. Advance online publication. https://doi.org/10.1016/j.eprac.2024.12.012
30. Sengupta, J., Das, H., Chellaiyan, V. G., Sasithra, S., & Britto, J. J. (2022). An observational study of incidence of metabolic syndrome among patients with controlled Grave’s disease. Clinical Epidemiology and Global Health, 15, 101010. https://doi.org/10.1016/j.cegh.2022.101010
31. Antonelli, A., Ferrari, S. M., Ragusa, F., Elia, G., Paparo, S. R., Ruffilli, I., Patrizio, A., Giusti, C., Gonnella, D., Cristaudo, A., Foddis, R., Shoenfeld, Y., & Fallahi, P. (2020). Graves’ disease: Epidemiology, genetic and environmental risk factors and viruses. Best practice & research. Clinical endocrinology & metabolism, 34(1), 101387. https://doi.org/10.1016/j.beem.2020.101387
32. Kalra, S., Selim, S., Shrestha, D. Et al. Best practices in the laboratory diagnosis, prognostication, prediction, and monitoring of Graves’ disease: role of TRAbs. BMC Endocr Disord 24, 274 (2024). https://doi.org/10.1186/s12902-024-01809-9
33. Yeung, S.-C. J., Habra, M. A., & Chiu, A. C. (2023, January 4). Graves disease. In R. Khardori (Chief Ed.), Medscape. https://emedicine.medscape.com/article/120619-overview
34. Shakya, R. K., Kumar, P., Khan, M. S., & G, A. (2024). Prevalence of thyroid dysfunction among young women in an Indian population: A prospective study. Journal of Cardiovascular Disease Research, 15(7), 3186. https://doi.org/10.48047/
35. Pandav, M., & Marwaha, R. (2022). An overview of Grave’s disease. Rep Thyroid Res, 6, 9. https://www.hilarispublisher.com/open-access/an-overview-of-graves-disease.pdf
36. George J Kahaly, Management of Graves Thyroidal and Extrathyroidal Disease: An Update, The Journal of Clinical Endocrinology & Metabolism, Volume 105, Issue 12, December 2020, Pages 3704–3720, https://doi.org/10.1210/clinem/dgaa646
37. Lee, S. Y., & Pearce, E. N. (2023). Hyperthyroidism: A Review. JAMA, 330(15), 1472–1483. https://doi.org/10.1001/jama.2023.19052
38. Lath, D., Nandipati, V. S., Jebasingh, F., Cherian, K. E., Kapoor, N., Asha, H. S., Paul, T. V., & Thomas, N. (2024). A Lower Prevalence of Central Nervous System and Higher Prevalence of Cardiac Symptoms Characterises Indian Patients with Thyrotoxic Storm: A Retrospective Analysis. Indian journal of endocrinology and metabolism, 28(3), 302–307. https://doi.org/10.4103/ijem.ijem_355_23