Should radioiodine be the first-line treatment for paediatric Graves’ disease?

AbstractDebate exists regarding the optimal treatment strategy for paediatric Graves’ disease with radioiodine (RAI), and surgery, usually reserved for failure of medical therapy. We present our own experience to introduce a review of the published literature focussing on the predictors of remission after antithyroid drug (ATD) therapy from diagnosis, and discuss whether RAI should be considered as a first-line therapy.A retrospective analysis of all diagnosed cases of paediatric Graves’ disease presenting to a large District General Hospital.Thirteen patients were diagnosed with Graves’ disease between February 2004 and May 2013. The median age at diagnosis was 13.7 years (range 7.2–17.1 years) with a female:male ratio of 11:2. Some nine patients completed a 2-year course of carbimazole out of which 8 relapsed after a mean duration of 0.82 years (range 0.08–1.42 years); the ninth currently remains in remission. Of the eight patients who relapsed, three have undergone RAI treatment. Two patients failed to tolerate carbimazole treatment, one of whom received RAI treatment because surgery was contraindicated and one patient with severe autism proceeded to RAI treatment due to poor compliance and persistent hyperthyroidism.Prognostic factors at presentation predicting a low likelihood of remission following ATD treatment include younger age, non-Caucasian ethnicity, and severe clinical and/or biochemical markers of hyperthyroidism. Psycho-social factors including compliance also influence management decisions.In specifically selected patients presenting with paediatric Graves’ disease, the benefits and risks of radioactive iodine as a potential first-line therapy should be communicated allowing families to make informed decisions.

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INCREASED RISK OF RADIOIODINE TREATMENT FAILURE ASSOCIATED WITH GRAVES DISEASE REFRACTORY TO METHIMAZOLE

Endocrine Practice ◽

10.4158/ep-2020-0164 ◽

2020 ◽

Vol 26 (11) ◽

pp. 1312-1319

Author(s):

Jennifer J. Kwak ◽

Rola Altoos ◽

Alexandria Jensen ◽

Basel Altoos ◽

Michael T. McDermott

Keyword(s):

Risk Factors ◽

Treatment Failure ◽

Potential Risk ◽

Radioactive Iodine ◽

Antithyroid Drug ◽

Graves Disease ◽

First Line ◽

Line Therapy ◽

Potential Risk Factors ◽

Iodine 131

Objective: Iodine 131 (I-131) radioactive iodine (RAI) therapy has been the preferred treatment for Graves disease in the United States; however, trends show a shift toward antithyroid drug (ATD) therapy as first-line therapy. Consequently, this would favor RAI as second-line therapy, presumably for ATD refractory disease. Outcomes of RAI treatment after first-line ATD therapy are unclear. The purpose of this study was to investigate treatment failure rates and potential risk factors for treatment failure, including ATD use prior to RAI treatment. Methods: A retrospective case control study of Graves disease patients (n = 200) after I-131 RAI therapy was conducted. Treatment failure was defined as recurrence or persistence of hyperthyroidism in the follow-up time after therapy (mean 2.3 years). Multivariable regression models were used to evaluate potential risk factors associated with treatment failure. Results: RAI treatment failure rate was 16.5%. A majority of patients (70.5%) used ATD prior to RAI therapy, predominantly methimazole (MMI) (91.9%), and approximately two-thirds of patients used MMI for >3 months prior to RAI therapy. Use of ATD prior to RAI therapy ( P = .003) and higher 6-hour I-123 thyroid uptake prior to I-131 RAI therapy ( P<.001) were associated with treatment failure. MMI use >3 months was also associated with treatment failure ( P = .002). Conclusion: More patients may be presenting for RAI therapy after failing first-line ATD therapy. MMI use >3 months was associated with RAI treatment failure. Further studies are needed to investigate the association between long-term first-line ATD use and RAI treatment failure. Abbreviations: ATD = antithyroid drug; BMI = body mass index; EMR = electronic medical record; I-123 = iodine 123; I-131 = iodine 131; MMI = methimazole; PTU = propylthiouracil; RAI = radioactive iodine; TRAb = TSH receptor antibody; TSH = thyroid-stimulating hormone

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Plasmapheresis as First Line Therapy for Thyrotoxicosis in a Critically Ill Patient

Journal of the Endocrine Society ◽

10.1210/jendso/bvab048.1937 ◽

2021 ◽

Vol 5 (Supplement_1) ◽

pp. A948-A948

Author(s):

Rachel Sheskier ◽

Alen Sajan ◽

Priyanka Mathias ◽

Vafa Tabatabaie

Keyword(s):

Respiratory Failure ◽

Critically Ill ◽

Laboratory Evaluation ◽

Critically Ill Patient ◽

Klebsiella Pneumonia ◽

Graves Disease ◽

First Line ◽

First Line Therapy ◽

Line Therapy ◽

Thyrotoxic Crisis

Abstract Introduction: The role of plasmapheresis (TPE) in thyrotoxicosis management is not well established. Its use may be determined on an individualized basis (1). We report a case of a critically ill patient where TPE was utilized as first-line therapy for refractory thyrotoxicosis. Clinical Case: A 33-year-old woman with Graves’ disease complicated by medication non-adherence presented with rapidly ascending paralysis and bulbar weakness. Primary work up was consistent with acute inflammatory demyelinating polyneuropathy (AIDP) based on EMG findings of motor fiber polyneuropathy with demyelinating features. Laboratory evaluation revealed uncontrolled hyperthyroidism (TSH <0.05 uU/mL, N 0.3-4.2 uU/mL; fT4 3.9 ng/dL, N 0.6-1.5 ng/dL; tT3 318, N 60-160 ng/dL). Initially, there was low concern for thyrotoxicosis based on a Burch-Wartofsky score of 15 (2). Standard dose methimazole and aggressive beta-blockade were initiated. Hospital course was complicated by hypoxic respiratory failure due to progressive paralysis requiring intubation and septic shock from Klebsiella pneumonia requiring initiation of pressors and broad-spectrum antibiotics. Biochemical evaluation showed increasing fT4 (3.8 ng/dL) and tT3 (419 ng/dL) levels. Burch-Wartofsky score increased to 55, consistent with a thyrotoxic crisis. Due to the patient’s critical condition, TPE was rapidly initiated along with standard therapy for thyrotoxic crisis (high dose methimazole, esmolol drip, stress dose corticosteroids, cholestyramine, and potassium iodide) as a bridge to definitive management with thyroidectomy. Rapid clinical improvement with a decline in fT4 levels (3.8 to 2.1 ng/dL) was noted after initiation of TPE with normalization in fT4 (1.5 ng/dL) and tT3 (54 ng/dL) after three sessions. Thyroidectomy was pursued after clinical stabilization. Surgical pathology showed diffuse papillary hyperplasia consistent with Graves’ disease. Due to persistent respiratory failure, the patient underwent tracheostomy placement. Repeat EMG revealed severe myopathic dysfunction without demyelinating features favoring a diagnosis of acute thyrotoxic myopathy over AIDP. Patient was ultimately discharged to a long term acute care facility due to slow neurological recovery. Conclusion: TPE should be considered as first line management in conjunction with conventional medical therapy in critically ill patients with thyrotoxicosis as a bridge to thyroidectomy due to rapid time to effect and patient stabilization. References: (1) Padmanabhan A, et al. J Clin Apher. 2019 Jun;34(3):171-354. (2) Bahn Chair RS, et al. Thyroid. 2011 Jun;21(6):593-646.

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Graves’ disease and toxic nodular goiter – radioiodine therapy

Nuklearmedizin ◽

10.1055/s-0038-1625641 ◽

2002 ◽

Vol 41 (02) ◽

pp. 63-70 ◽

Cited By ~ 4

Author(s):

M. Dietlein ◽

H. Schicha

Keyword(s):

Conservative Treatment ◽

Radioiodine Therapy ◽

Nodular Goiter ◽

Human Thyroid ◽

Definitive Treatment ◽

Graves Disease ◽

First Line ◽

First Line Therapy ◽

Line Therapy ◽

Benign Thyroid

SummaryAt the 15th conference on the human thyroid in Heidelberg in 2001 the following aspects of the radioiodine therapy of benign thyroid disorders were presented: General strategies for therapy of benign thyroid diseases, criterions for conservative or definitive treatment of hyperthyroidism as first line therapy and finally preparation, procedural details, results, side effects, costs and follow-up care of radioiodine therapy as well as legal guidelines for hospitalization in Germany.The diagnosis Graves’ hyperthyroidism needs the decision, if rather a conservative treatment or if primary radioiodine therapy is the best therapeutic approach. In the USA 70–90% of these patients are treated with radioiodine as first line therapy, whereas in Germany the conservative therapy for 1–1.5 years is recommended for 90%.This review describes subgroups of patients with Graves’ disease showing a higher probability to relapse after conservative treatment. Comparing benefits, adverse effects, costs, and conveniences of both treatment strategies the authors conclude that radioiodine therapy should be preferred as first line therapy in 60–70% of the patients with Graves’ hyperthyroidism.

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