Managing Graves' disease (GD) should be simple. Stop the immune system from targeting the TSH receptor and the disease is cured. Unfortunately this is not yet feasible in most young people and GD is not a trivial condition for those affected. There are significant advantages and disadvantages of all current treatments with no easy way forwards for many and the family's decisions will reflect their perceptions of medical, radiation and surgical risk. The fact that two of the three standard treatments remove the thyroid gland (radioiodine ablation or total thyroidectomy) underlines the fact that what is simple in theory is not so simple in clinical practice.
Where are we in 2019?
1. Anti-thyroid drug (ATD): There is no data from clinical trials in the young to show that a block and replace (BR) ATD regimen has advantages over dose titration (DT). However larger doses of ATD will render the patient euthyroid more quickly and there are clinical scenarios where BR is useful. Longer term 'low dose' ATD is an attractive option for some families but how should we manage the small risk of agranulocytosis in those on anti-thyroid drug for several years? Perhaps not the best choice for those young people intent on travelling the world.
2. Surgery (total thyroidectomy): is a useful treatment in patients who fail to tolerate ATD or who relapse following an ATD course. Forging good links with an appropriately skilled and experienced surgical team is important and the nature of the discussions about surgical risk will impact on patient and family choice. Small risk of voice-change even in the best hands.
3. Radio-iodine: A key component of radioiodine treatment is parent and adolescent understanding of relative risk and how they manage associated uncertainty. What are the underlying reasons for the different 'national' approaches to this treatment modality? Theoretical risk of harm due to exposure to ionising radiation is increased in those young people who are still growing and developing.
New treatment strategies for GD are needed and an evolving clinical experience with immune modulation is heralding the start of a new era in Graves' disease research and management.
19 - 21 Sep 2019
European Society for Paediatric Endocrinology