Treatment and prognosis of Graves' disease in children and adolescents
- Stephen LaFranchi, MD
Stephen LaFranchi, MD
- Professor of Pediatrics
- Oregon Health & Sciences University
Hyperthyroidism in children and adolescents has unique effects on growth and development in addition to causing many of the same symptoms that it does in adults. Graves' disease is by far the most common cause of hyperthyroidism in this age group, accounting for more than 95 percent of cases . Nearly all children with Graves' disease have a diffuse goiter; Graves' ophthalmopathy also may be present, but is less severe than in adults.
The treatment and prognosis of Graves' disease in childhood and adolescence will be discussed here. The clinical manifestations and diagnosis are presented separately. (See "Clinical manifestations and diagnosis of hyperthyroidism in children and adolescents".)
Rarely, conditions other than Graves' disease may cause hyperthyroidism in children. These include chronic lymphocytic thyroiditis, subacute granulomatous thyroiditis (de Quervain's disease), solitary hyperfunctioning thyroid nodules or toxic multinodular goiter, pituitary thyroid-stimulating hormone (TSH)-secreting adenoma, and hyperthyroidism induced by iodine, neck trauma, or radiation. Treatment of these conditions is similar to that for adults, except that children with nodular goiters are generally treated with surgery rather than radioactive iodine (RAI). (See "Clinical manifestations and diagnosis of hyperthyroidism in children and adolescents".)
Children and adolescents with Graves' hyperthyroidism can be treated with an antithyroid drug, radioactive iodine (RAI), or thyroidectomy. The choice of therapy is determined by individual consideration of the risks and benefits of the three treatment modalities (table 1). Regardless of the choice of treatment, all patients will require lifelong monitoring. An overview of treatment is shown in the algorithm (algorithm 1).
Selection of treatment — Most pediatric endocrinologists recommend antithyroid drug therapy as initial treatment in the hope that the patient will have a remission of the Graves' disease and therefore will remain euthyroid after treatment is discontinued. RAI therapy is generally used for children who do not achieve a permanent remission after a period of treatment with an antithyroid drug, or for those who experience serious adverse effects necessitating discontinuation of antithyroid drug treatment. RAI also may be used as initial treatment for children older than 10 years. . Surgical near-total thyroidectomy is an equally effective and safe treatment.
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- TREATMENT APPROACHES
- Selection of treatment
- Antithyroid drugs
- - Initiating and adjusting therapy
- - Side effects
- - Adding beta blockers
- - Thyroxine ("block and replace")
- - Stopping therapy
- - Remission rate
- - Management of patients who do not enter remission
- - Management of patients who relapse
- Radioactive iodine
- - Patient selection and dose
- - Hypothyroidism
- - Other side effects
- LIFELONG MONITORING
- SUMMARY AND RECOMMENDATIONS