Graves' disease, a common form of hyperthyroidism, is an autoimmune disorder with an unclear etiology. Various treatment approaches exist, with Antithyroid Drugs (ATD) being a fundamental and globally recognized method targeting the immune factors for the ultimate cure of Graves' hyperthyroidism. ATD treatment is considered foundational, non-damaging to the thyroid, and a preferred option before surgery or radioiodine therapy.

Constituting approximately 90% of all hyperthyroid cases, Graves' disease is characterized by organ-specific autoimmune responses, notably the presence of Thyroid Receptor Antibodies (TRAb) in the serum. The interaction of TRAb with TSH receptors stimulates thyroid tissue, leading to hyperplasia and increased thyroid function.

The pathogenesis of Graves' hyperthyroidism remains incompletely understood, involving a complex network of immune molecules, cytokines, and chemokines triggered, in part, by antigenic stimulation such as viruses or bacteria. Research suggests that an increase in peripheral dendritic cells, particularly the pDC subgroup, plays a role, along with elevated interferon-alpha secretion. This process induces the differentiation of thyroid follicular cells, presenting the TSH receptor to T and B cells, ultimately resulting in the production of TRAb.

Treatment options for Graves' hyperthyroidism include Antithyroid Drugs (ATD), Radioactive Iodine (RAI), and surgery. ATD treatment, primarily based on thionamide derivatives, prevents thyroid hormone synthesis by inhibiting iodination of tyrosine residues in thyroglobulin. Beyond its primary action, ATD treatment also includes blocking T4-to-T3 conversion, immunosuppressive effects, and induction of apoptosis in thyroid lymphocytes.

Key features of ATD treatment include its status as the foundational therapy for all Graves' hyperthyroidism cases, its preference globally (excluding the United States), safety, reversibility of drug effects, and preservation of thyroid follicular structure.

ATD treatment serves not only as a standalone choice but also as a preferred option before surgery or radioiodine therapy. Studies suggest that using ATD before RAI significantly reduces complications like new-onset atrial fibrillation and mortality. Additionally, pre-treatment with ATD decreases the likelihood of hyperthyroid crises caused by radioactive inflammation.

ATD is suitable for all hyperthyroid cases, especially in mild cases with slight to moderate thyroid enlargement. Its use is favored in individuals under 20 years old, those with pregnancy-related hyperthyroidism, and elderly or frail patients. For children with hyperthyroidism, ATD is the preferred choice due to its convenience, minimal impact on learning, and avoidance of permanent, irreversible damage.

Comparatively, Radioactive Iodine (RAI) therapy has absolute contraindications in pregnant and breastfeeding women, and caution is advised in individuals under 20, those with severe heart, liver, or kidney dysfunction, active pulmonary tuberculosis, low peripheral white blood cell counts, or neutrophil counts.

The drawbacks of RAI therapy include its destructive nature, leading to permanent hypothyroidism requiring lifelong replacement therapy, the risk of radioactive thyroiditis, potential induction of hyperthyroid crises without prior ATD optimization, and exacerbation of infiltrative ophthalmopathy.

The choice between ATD and RAI treatment also considers cost implications. ATD treatment has lower drug expenses, with higher costs associated with laboratory tests. In the long term, ATD maintenance lasts for 2-3 years, providing a curative outcome. RAI treatment, on the other hand, incurs ongoing costs for replacement therapy and frequent laboratory tests, potentially surpassing the expenses of ATD treatment.

Due to variations in medical conditions across regions in China, the lack of routine measurement of antibodies like Thyroid Receptor Antibodies (TRAb) can lead to misdiagnoses and unnecessary RAI treatments, resulting in permanent hypothyroidism. RAI treatments can cause additional complications, increasing psychological stress and healthcare costs. In the United States, the preference for RAI treatment is influenced by appointment-based healthcare systems, hindering optimal adjustment of ATD medications.

In conclusion, Antithyroid Drug (ATD) treatment has been a longstanding and clinically proven approach for Graves' hyperthyroidism. It effectively treats the condition without damaging the thyroid, offering a cure without the need for continuous medication. Therefore, ATD treatment should remain the preferred choice for Graves' hyperthyroidism, with other supportive methods considered for managing additional symptoms.