ESPE Abstracts

Background: The incidence of Graves’ disease in patients aged <15 years is estimated at 0.9 per 100,000. Parental anxiety around definitive treatment, timing of this around schooling and clinician confidence in long-term medical treatment often results in prolonged medical management. This audit aimed to assess the rates of remission, timing of definitive treatment and long-term medical management in children managed for Graves’ at a UK tertiary centre.

Methods: The electronic medical records at Great Ormond Street Hospital were searched for patients reviewed with a diagnosis of Graves’ disease between 2018 and 2022.

Results: 51 patients were identified in this time window (median age at diagnosis: 9.71 [1.95-16.85] years). Nine patients were treated by block and replace (BR) and 42 with dose titration (DT)(5 switched to BR). Two patients required treatment with propylthiouracil (liver toxicity and severe neutropenia on carbimazole respectively); the remainder received carbimazole. 1/18 children remitted after a first trial off therapy (mean treatment duration: 2.75 [1.17-4.75] years). 2/6 remitted after a second trial off (mean treatment duration: 4.42 [3-7] years). 20 children had definitive treatment (18 thyroidectomies, 2 radioactive iodine treatment (RAI) with a further 5 referred for definitive treatment (mean treatment duration: 3.25 [0.33-10] years). 27 patients remain on medical therapy (median treatment duration: 4.25 [0.3-14.4] years). 37 patients received medical treatment exceeding three years. 7 were diagnosed at <5 years (mean treatment duration: 6.7 [3.16-10] years), 3 received definitive treatment and 4 long term medical therapy. 12 were diagnosed at 6-10 years (mean treatment duration: 6.6 [3.46-14.24] years), with 3/12 undergoing definitive management and 1/12 remitting. 8 were diagnosed at 10-15 years (mean treatment duration: 5 [3.25-8.25] years), all remaining on long-term therapy.

Conclusions: The remission rate in paediatric Graves’ is estimated to be 20-30% after 3 years. The remission rate is much lower in our group, with the majority of patients remaining on long-term therapy. The practicalities of thyroidectomy and RAI become simpler with age but teenagers may choose to defer this decision during critical school exam years and further prolong medical management. The variable and short-lived nature of remission in this group, alongside evidence suggesting that paediatric thyroidectomy does not negatively impact quality of life, may support earlier definitive treatment, rather than delaying the inevitable. Additionally, thyroxine replacement is safer and requires less monitoring. Further understanding of the young person’s wellbeing and quality of life throughout Graves treatment would be valuable.