Differentiating Graves' disease from subacute thyroiditis using ratio of serum free triiodothyronine to free thyroxine

• The ideal treatment of thyrotoxicosis should be directed at its etiology.
• Serum total triiodothyronine (T3): thyroxine (T4) ratio (ng/ug) of >20 suggests Graves' disease.
• In the current practice, the measurement of free thyroid hormone is more commonly used.
• Serum free T3/free T4 ratio of >4.4 (10−2 pg/ng) may help in differentiating the cause of thyrotoxicosis.

BackgroundThe measurement of free thyroid hormone, instead of the total form, is more commonly used in current practice. We aimed to evaluate the usefulness of the ratio of serum free triiodothyronine (FT3, pg/mL) to free thyroxine (FT4, ng/dL) for differentiating Graves' disease from subacute thyroiditis.Materials and methodsMedical records of thyrotoxic patients aged >15 years who had measurement of FT3, FT4 and thyrotropin on the first diagnosis of thyrotoxicosis before initiating treatment were retrospectively reviewed. Data were collected from all clinics, and were not limited to the endocrine clinic. Pregnant women were excluded.ResultsA total of 548 patients (468 with Graves' disease, 40 with subacute thyroiditis and 40 with toxic adenoma/multinodular goiter) were recruited. Mean age was 43.9 ± 15.4 years. Most were female 434 (79.2%), and goiter was present in 55.3%. Prevalence of T3-toxicosis and T4-toxicosis were 5.6% and 6.6%, respectively. Mean FT3/FT4 ratios were 4.62 ± 2 (10−2 pg/ng) in patients with Graves' disease and 2.73 ± 0.5 in subacute thyroiditis. The area under the ROC curve of the FT3/FT4 ratio for diagnosis of Graves' disease was 0.83 (95%CI, 0.76–0.91). Cutoff level of this ratio >4.4 offered sensitivity of 47.2% and specificity of 92.8%.ConclusionsFT3/FT4 ratio of >4.4 (10−2 pg/ng) may help in differentiating the cause of thyrotoxicosis.