Graves’ disease: moving forwards

Abstract

Graves’ disease is a rare disorder that continues to present clinicians and families with a series of challenges. There are no new established treatments for children or adolescents, but the outcomes of recent clinical trials and meta-analyses have helped clinicians to prepare families for the road ahead. We have a more refined understanding of how to administer antithyroid drugs, which one to use and how long to treat the young person. We also have a greater insight into how best to reduce any risks associated with surgery and radioiodine. We understand more about long-term outcomes and their determinants and have greater awareness about the impact of the disease and its treatment on quality of life. A holistic approach to management is key to supporting and counselling young people and their families about the diagnosis and management options. In this review, we will discuss the recent literature and reflect on how this should be translated into clinical practice.

Notes for the general paediatrician: managing thyrotoxicosis in children and young people

“…It is worth noting that both hypothyroidism and hyperthyroidism are detrimental to cognitive functioning, reiterating the need to achieve an euthyroid state during examinations. Furthermore, perception of the quality of life can be low with antithyroid treatment 3 and this might adversely influence adherence and expectations from treatment in young people. Once carbimazole is stopped, relapse is most likely to occur within 6–12 months.…”

“… 6 In mild cases, attention span and school performance can be affected due to the cognitive and psychosocial impact of excess thyroid hormones. 3 7 While accelerated growth 8 does not usually lead to early puberty and reduced final height, 9 the long-term risk of osteopaenia through suboptimal bone mineralisation remains pertinent. 10 Children often present with irritability, weight loss, excessive sweating and heat intolerance; these features should prompt investigation for thyroid status without delay.…”

“… 10 Children often present with irritability, weight loss, excessive sweating and heat intolerance; these features should prompt investigation for thyroid status without delay. 3 It is critical to act early to prevent deterioration into more severe forms of thyrotoxicosis, such as a thyroid storm. This is a medical emergency with potential for life-threatening cardiovascular instability and a high mortality rate, estimated at 10%.…”

“…At present, consensus treatment guidelines for childhood thyrotoxicosis are emerging and intended mainly for specialist review. 3 12 Given the common practice of managing children with hyperthyroidism in a non-specialist setting, we have adopted a general paediatric perspective to discuss the diagnostic and therapeutic management of thyrotoxicosis in children and young people (excluding neonates) in shared care with specialist paediatric endocrine services. Our aim has been to review and assimilate information from an up-to-date evidence base with practice insights from specialists in endocrinology and biochemistry to provide recommendations for general paediatricians.…”

“…The most common cause is Graves’ disease, resulting from TSH receptor stimulation by autoantibodies 1. Thyrotoxicosis can occur at any age, but frequency increases with age and peaks during adolescence, with an incidence of Graves’ disease reported as 1 per 100 000 in children under the age of 16 years 2 3. Less commonly, thyrotoxicosis could be due to subacute thyroiditis, early Hashimoto’s thyroiditis, chronic lymphocytic thyroiditis, autonomous functioning nodules, amiodarone induced thyrotoxicosis and activating TSH receptor mutations.…”