2022 European Thyroid Association Guideline for the management of pediatric Graves’ disease

Abstract

Hyperthyroidism caused by Graves’ disease (GD) is a relatively rare disease in children. Treatment options are the same as in adults – antithyroid drugs (ATD), radioactive iodine (RAI) or thyroid surgery, but the risks and benefits of each modality are different. The European Thyroid Association guideline provides new recommendations for the management of pediatric GD with and without orbitopathy. Clinicians should be alert that GD may present with behavioral changes or declining academic performance in children. Measurement of serum TSH receptor antibodies is recommended for all pediatric patients with hyperthyroidism. Management recommendations include the first-line use of a prolonged course of methimazole/carbimazole ATD treatment (3 years or more), a preference for dose titration instead of block and replace ATD, and to avoid propylthiouracil use. Where definitive treatment is required either total thyroidectomy or RAI is recommended, aiming for complete thyroid ablation with a personalized RAI activity. We recommend avoiding RAI in children under 10 years of age but favor surgery in patients with large goiter. Pediatric endocrinologists should be involved in all cases.

Asymmetrical Graves’ disease in children: potential usefulness of potassium iodide monotherapy

“…Four patients (4.5%) had germline TSHR mutations, and nine patients (10.3%) developed TRAb-positive GD during the follow-up. The 2022 ETA guideline states that if the clinical picture is suggestive of GD but TRAbs are absent, they should be repetitively evaluated a few weeks later 7. Our study illustrates the need for continuous measurement of TRAb level, as conversion to TRAb positivity may occur after a few weeks or even more, thus confirming the diagnosis of GD in patients who are initially TRAb-negative.…”

“…Owing to significant improvements in immunoassay laboratory methods, TRAb-negative GD has become rare. In addition, as stated in the 2022 European Thyroid Association (ETA) guideline, it is recommended that if the clinical picture is suggestive of GD but thyroid antibodies are absent, immunoassays should be repeated a few weeks later 7. This suggests that there are certain patients with GD who are initially TRAb-negative.…”

“Lymphocyte population in peripheral blood in children and adolescents with graves disease. Potential predictive tool for severity of the disease”

“…Longer periods of ATD may be considered if remission likelihood is low. Definitive treatment should be considered when patients remain thyrotoxic despite the use of high doses of ATD, in patients who develop serious ATD-related side effects and in subjects with relapse [ 3 ].…”

Graves’ disease: moving forwards

“…Imaging should, however, be considered in cases where thyroid antibodies are negative or where there is a nodule or nodularity apparent on thyroid gland palpation. Ultrasonography is preferred over scintigraphy to avoid radiation exposure 6. Thyroid ultrasonography with Doppler blood flow assessment often displays an enlarged, hyperechoic, hypervascular thyroid gland, while scintigraphy shows uniform uptake of isotope and diffuse enlargement of both thyroid lobes.…”

“…In the absence of TRAb, the presence of TPO antibodies can suggest underlying thyroiditis which can be self-limiting. Hence, it may be appropriate to monitor thyroid function tests for a few weeks before intervening with ATD treatment if the young person is not significantly unwell in the context of a low TRAb titre 6. If the child has GD then ATD should be commenced to avoid the negative physical and psychological effects of prolonged thyroid hormone excess.…”