Reduction of the Risk of Relapse After Withdrawal of Medical Therapy for Graves' Disease

Abstract

It has been a continuing challenge to try and identify those patients with hyperthyroid Graves' disease likely to remain in remission after an antithyroid drug course or to manage the medical treatment so as to increase the chance of remission. On average, the overall relapse rate is approximately 50% and any significant reduction of this figure would be of practical as well as theoretical value. The numerous controlled prospective studies performed in many parts of the world, with varying iodine intakes, have all confirmed that the main initial features related to the subsequent risk of relapse are: young age, male gender, goiter larger than 40 mL, hypoechogenic and hypervascular gland, high level of anti-thyrotropin receptor antibody (TRAb), detected either with radioreceptor assay (TBII: >40 U/L) or the biologic stimulation assay (thyroid-stimulating antibodies [TSAb]; >300%), severity of hyperthyroidism, and possibly the presence of ophthalmopathy. Alone, each of these has a low predictive value, but together they allow evaluation of the risk of relapse, thus helping treatment choice. As to the modalities of antithyroid drug treatment, dose of the drug or addition of levothyroxine does not affect posttreatment outcome. In contrast, significantly fewer relapses occur for drug courses longer than at least 1 year. Persistence of high levels of TRAb after medical treatment is strongly predictive of relapse but this is of limited value because in most patients, TRAb levels are low or even undetectable at the end of treatment, which does not indicate for further outcome. Smoking is a significant independent risk factor for relapse. In conclusion, reduction of the risk of relapse in patients with medically treated hyperthyroid Graves' disease relies on clinical competence and appropriate management taking into account an array of factors none of which alone has definite predictive value.

Effect of High Dose Methylprednisolone Pulse Therapy Followed by Oral Prednisolone Administration on the Production of Anti-TSH Receptor Antibodies and Clinical Outcome in Graves' Disease

“…On the contrary, Vitti et al reported that the relapse rate of Graves' disease with ophthalmopathy was higher than that of Graves' disease without ophthalmopathy (71.9% vs 57.8%; p = 0.08) [24]. Although the presence of ophthalmopathy is a possible high risk factor of relapse, it has a low predictive value alone [25]. In our study, the remission rate of Graves' disease in the 2 groups was not significantly different.…”

Prognostic Value of Thyrotropin Receptor Antibodies (TRAb) in Graves' Disease: A 120 Months Prospective Study

“…Conservative therapy with ATD is the first choice treatment in Europe and it is proven to be effective in achieving euthyroidism in Graves' patients [3], even if long-term remission after therapy withdrawal is unsatisfying with relapse rates of 30-50% [9,[16][17][18][19][20]. However, if the great rate of relapse(s) may be related to TRAb levels and/or other parameters, such as gender, age, fT4 levels or goiter size is still controversial [13,14,[20][21][22][23].…”

The environment and autoimmune thyroid diseases

“…The association between smoking and Graves' disease is further underscored by the fact that smoking increases the risk for a relapse of Graves' hyperthyroidism (103,104). Smoking also increases the chances of an exacerbation of the eye disease after treatment with 131 I, and it reduces the efficacy of radiotherapy and corticosteroid treatment of the ophthalmopathy (105,106).…”