What is the evidence behind the evidence-base? The premature death of block-replace antithyroid drug regimens for Graves’ disease

Hyperthyroidism is characterised by increased thyroid hormone synthesis and secretion from the thyroid gland, whereas thyrotoxicosis refers to the clinical syndrome of excess circulating thyroid hormones, irrespective of the source. The most common cause of hyperthyroidism is Graves’ disease, followed by toxic nodular goitre. Other important causes of thyrotoxicosis include thyroiditis, iodine-induced and drug-induced thyroid dysfunction, and factitious ingestion of excess thyroid hormones. Treatment options for Graves’ disease include antithyroid drugs, radioactive iodine therapy, and surgery, whereas antithyroid drugs are not generally used long term in toxic nodular goitre, because of the high relapse rate of thyrotoxicosis after discontinuation. β blockers are used in symptomatic thyrotoxicosis, and might be the only treatment needed for thyrotoxicosis not caused by excessive production and release of the thyroid hormones. Thyroid storm and hyperthyroidism in pregnancy and during the post-partum period are special circumstances that need careful assessment and treatment.

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“…67 Therefore, the titration regimen should be the first-line approach, 44 even if some authors regard both approaches as equally safe. 68 …”

Section: Treatmentmentioning

confidence: 99%

Hyperthyroidism

2016

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“…However, evidence that this type of long-term combination therapy improves the remission rate is not convincing, and this regimen was reported to significantly increase the incidence of adverse reactions. Therefore, the use of this therapy is not recommended (92,93,94,95,96). …”

Section: Drug Therapies For Graves’ Diseasementioning

confidence: 99%

Guidelines for the treatment of childhood-onset Graves’ disease in Japan, 2016

Minamitani¹,

Sato

Ohye

et al. 2017

Clin Pediatr Endocrinol

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Abstract.Purpose behind developing these guidelines: Over one decade ago, the “Guidelines for the Treatment of Graves’ Disease with Antithyroid Drug, 2006” (Japan Thyroid Association (JTA)) were published as the standard drug therapy protocol for Graves’ disease. The “Guidelines for the Treatment of Childhood-Onset Graves’ Disease with Antithyroid Drug in Japan, 2008” were published to provide guidance on the treatment of pediatric patients. Based on new evidence, a revised version of the “Guidelines for the Treatment of Graves’ Disease with Antithyroid Drug, 2006” (JTA) was published in 2011, combined with the “Handbook of Radioiodine Therapy for Graves’ Disease 2007” (JTA). Subsequently, newer findings on pediatric Graves’ disease have been reported. Propylthiouracil (PTU)-induced serious hepatopathy is an important problem in pediatric patients. The American Thyroid Association’s guidelines suggest that, in principle, physicians must not administer PTU to children. On the other hand, the “Guidelines for the Treatment of Graves’ Disease with Antithyroid Drug, 2011” (JTA) state that radioiodine therapy is no longer considered a “fundamental contraindication” in children. Therefore, the “Guidelines for the Treatment of Childhood-Onset Graves’ Disease with Antithyroid Drug in Japan, 2008” required revision.

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“…Rather than titrating the MMI dose lower when circulating thyroid hormone levels fall, some physicians prefer the block-and-replace approach and add levo-thyroxine while not changing the MMI dose, however, there is a greater risk of adverse events using block and replace vs. dose reduction [21,22]. Recognizing that there is a potential dose–response relationship for some MMI-related complications [23,24], it is preferable to use the lowest MMI dose that achieves control, rather than using the block and replace approach.…”

Section: Antithyroid Drugsmentioning

confidence: 99%

Pediatric Graves’ disease: management in the post-propylthiouracil Era

Rivkees

2014

Int J Pediatr Endocrinol

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The most prevalent cause of thyrotoxicosis in children is Graves’ disease (GD), and remission occurs only in a modest proportion of patients. Thus most pediatric patients with GD will need treatment with radioactive iodine (RAI; 131I) or surgical thyroidectomy. When antithyroid drugs (ATDs) are prescribed, only methimazole (MMI) should be administered, as PTU is associated with an unacceptable risk of severe liver injury. If remission does not occur following ATD therapy, 131I or surgery should be contemplated. When 131I is administered, dosages should be greater than 150 uCi/gm of thyroid tissue, with higher dosages needed for large glands. Considering that there will be low-level whole body radiation exposure associated with 131I, this treatment 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 are operated on. Most importantly, the care of children with GD can be complicated and requires physicians with expertise in the area.

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What is the evidence behind the evidence-base? The premature death of block-replace antithyroid drug regimens for Graves’ disease

Cited by 43 publications

References 21 publications

Hyperthyroidism

Hyperthyroidism

Guidelines for the treatment of childhood-onset Graves’ disease in Japan, 2016

Pediatric Graves’ disease: management in the post-propylthiouracil Era

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