A review by Cheethan and Bliss published in the August issue of Clinical Endocrinology provides guidance on therapeutic strategies for children with Grave’s disease.
Treatment for Grave’s disease has usually been the same for all age groups including an antithyroid drug (ATD), surgery (partial or total thyroidectomy) and radioiodine (a drug in either liquid or capsule form that destroys the thyroid gland and any other thyroid cells-including cancer cells-that take up iodine.
However the side effects of those standard treatments can have long term consequences. Particularly, the side effects of an ATD on younger patients who are still in their development phases are considered to be harmful. Many clinicians treating children with Grave’s find it more challenging than treating an adult because of the side effects that tend to develop.
Therapies may need to be adjusted due to the patient’s developing and changing body size.
Treatment options
Initial therapy and symptom relief: Beta-blockers are useful in the symptomatic patient. Oral iodine or glucocorticoid can be used to reduce thyroid hormone levels acutely but are rarely needed unless the thyrotoxic patient requires surgery.Radioiodine (RI): Radioiodine has been increasingly used as a second line therapy for thyrotoxicosis in young patients. Although a young child will receive relatively more radiation exposure because the body organs are closer together, RI is still a potential therapeutic option in the younger child with Graves' who cannot tolerate ATD and where surgery is unacceptable to the family. It is also promoted as a cost-effective way of treating Graves' disease.
Surgery: A thyroidectomy can be used to treat Grave’s disease. Most surgeons will suggest removing the entire gland because of the risk of hyperthyroidism recurrence if only part of the gland is removed. Patients who receive thyroidectomy are at risk for a thyroid storm. A Thyroid storm is a life-threatening health condition that is associated with untreated or undertreated hyperthyroidism.
Antithyroid drug (ATD): Generally, ATD are more effective in adults than in children. Remission rates of 40-50% are common in adults compared to only 20-30% in children. For children, it might be best to administer ATDs as part of a block and replace (BR) regimen, where endogenous thyroid hormone production is destroyed and thyroxine replaced or a smaller dose of ATD can be ‘dose-titrated’ (DT) to normalize thyroid hormone secretion. The longer the ATD is used, the more likely the disease is to remit. With that noted, an serious concern with ATD use in a younger patient is the risk of neutropenia. Other side effects include itching, rash, hives, joint pain and swelling, fever, changes in taste, nausea, and vomiting.
Which treatment option is best?
According to Cheetham and Bliss, treatment options will be dependent on a number of factors but in most patients, ATD will be the standard therapy. Below are some of the key considerations to make for the major treatment options that the authors provided.Key circumstances when ATD may be the most appropriate treatment for Graves' disease in the young
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Key circumstances when thyroidectomy may be the most appropriate treatment for Graves' disease in the young
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Key circumstances when radioiodine may be the most appropriate treatment for Graves' disease in the young
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About Grave’s Disease
Graves’ disease is a type of autoimmune problem that causes the thyroid gland to produce too much thyroid hormone.Thyroid-stimulating immunoglobulins (TSIs) bind to thyrotropin receptors resulting in increase release of T3 and T4.
Common symptoms may include Graves ophthalmopathy, enlarged thyrold gland (goiter), Graves’ dermopathy, rapid heartrate, anxiety and irritability, hand tremors, heat sensitivity, and frequent bowel movements.
Reference
Cheetham T, Bliss R. Treatment option in the young patient with Graves’ disease. Clin Endo. 2016;85:161-164. DOI: 10.1111/cen.12871source : http://www.raredr.com/
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