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Published on: September 20, 2024
Controversies in the management of Graves' disease in children
1Department of Pediatrics, University of Florida College of Medicine, Pediatrics - Chairman's Office, 1600 SW Archer Road - Room R1-118, Gainesville, FL, 32610-0296, USA. srivkees@ufl.edu.
Insights
Graves' disease in children often requires treatment beyond medication. Radioactive iodine or surgery are common, but methimazole is preferred over propylthiouracil due to liver risks. Family preferences are key in decision-making.
Area of Science:
- Pediatric Endocrinology
- Thyroid Disorders
- Internal Medicine
Background:
- Graves' disease (GD) is the leading cause of thyrotoxicosis in pediatric populations.
- Spontaneous remission is rare, necessitating definitive treatment for most children.
- Previous reliance on propylthiouracil (PTU) is now discouraged due to severe liver toxicity risks.
Purpose of the Study:
- To review current treatment modalities for pediatric Graves' disease.
- To compare the efficacy and safety of radioactive iodine, surgery, and antithyroid drugs.
- To highlight considerations for optimizing treatment decisions in children with GD.
Main Methods:
- Review of existing literature on pediatric Graves' disease management.
- Analysis of treatment outcomes and side effect profiles for radioactive iodine (131I), methimazole (MMI), and thyroidectomy.
- Discussion of dosage guidelines and surgical recommendations.
Main Results:
- Methimazole (MMI) is the preferred antithyroid drug, with lower doses potentially minimizing side effects.
- Radioactive iodine (131I) requires higher dosages for effective treatment but carries radiation exposure concerns, especially in younger children.
- Thyroidectomy, preferably near-total or total, is recommended but associated with higher complication rates in children, necessitating experienced surgeons.
Conclusions:
- Treatment decisions for pediatric Graves' disease must balance efficacy, risks, and patient/family values.
- Methimazole (MMI) offers a safer medical option than PTU, though long-term remission rates vary.
- Radioactive iodine (131I) and surgery are effective but require careful consideration of risks and surgeon expertise.
Abstract:
Graves' disease (GD) is the most prevalent cause of thyrotoxicosis in children. Because spontaneous and lasting resolution of this condition occurs in only a minority of patients, most pediatric patients with GD will need radioactive iodine treatment (131I) or thyroidectomy. Whereas the medication propylthiouracil (PTU) had been used in the past, only methimazole (MMI) should be now used in children, as PTU is associated with an unacceptable risk of liver failure. However, MMI may be associated minor and major side effects, which may be minimized using lower doses. An area of controversy involves the optimal duration of antithyroid drug (ATD) therapy. For some children, the prolonged use of antithyroid drugs is a valid approach, but for most, this will not increase the chance of remission. When 131I is administered, dosages should be greater than 150 uCi/gm of thyroid tissue, with higher dosages needed for larger glands. Considering that there will be low-level whole body radiation exposure associated with 131I, this treatment is viewed as controversial by some and should be avoided in young children. When surgery is performed, near-total or total thyroidectomy is the recommended procedure. Complications for thyroidectomy in children are considerably higher than in adults. Thus, an experienced thyroid surgeon is needed when children have surgery. Overall, when different treatment options for GD are considered, the benefits, risks and viewpoints of the family need to be considered and discussed in full.
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