2022 European Thyroid Association Guideline for the management of pediatric Graves' disease

Abstract

Hyperthyroidism caused by Graves' disease (GD) is a relatively rare disease in children. Treatment options are the same as in adults - antithyroid drugs (ATD), radioactive iodine (RAI) or thyroid surgery, but the risks and benefits of each modality are different. The European Thyroid Association guideline provides new recommendations for the management of pediatric GD with and without orbitopathy. Clinicians should be alert that GD may present with behavioral changes or declining academic performance in children. Measurement of serum TSH receptor antibodies is recommended for all pediatric patients with hyperthyroidism. Management recommendations include the first-line use of a prolonged course of methimazole/carbimazole ATD treatment (3 years or more), a preference for dose titration instead of block and replace ATD, and to avoid propylthiouracil use. Where definitive treatment is required either total thyroidectomy or RAI is recommended, aiming for complete thyroid ablation with a personalized RAI activity. We recommend avoiding RAI in children under 10 years of age but favor surgery in patients with large goiter. Pediatric endocrinologists should be involved in all cases.

Keywords: Graves’ disease; antithyroid drugs; childhood; clinical practice guideline; management; pediatric; radioactive iodine; total thyroidectomy.

Figure 1

Remission rates in relation to duration of medical treatment (methimazole or carbimazole) in patients with pediatric Graves’ disease. Remission rates reported in the systematic review by van Lieshout et al. (40) (Table 2) evaluating studies on the efficacy of treatment with methimazole or carbimazole in relation to the treatment duration in pediatric Graves’ disease. Size of the bubble reflects the size of the patient population. Prospective studies comparing standard and long-term treatment durations are displayed twice in this figure (Azizi et al. (49) displayed in red, and Léger et al. and Kaguelidou et al. (47, 48) displayed in green).