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Treatment of Hyperthyroidism in Children and Adolescents: Approaches and Considerations

Learn about the causes and treatment methods for hyperthyroidism in children and adolescents, including the use of antithyroid drugs, radioiodine therapy, and surgery. Understand the factors influencing relapse and indications for different treatment modalities.

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Treatment of Hyperthyroidism in Children and Adolescents: Approaches and Considerations

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  1. درمان پركاري تيروئيد در كودكان و نوجوانان دكتر فريدون عزيزي پژوهشكده علوم غدد درون ريز و متابوليسم دانشگاه علوم پزشكي شهيد بهشتي

  2. Causes of Hyperthyroidismin children and adolescents Diffuse toxic goiter Toxic adenoma

  3. Introduction Treatment of basic pathogenic factors in thyrotoxicosis is only possible in rare conditions, such as thyrotropin secreting pituitary tumors, iatrogenic thyrotoxicosis and struma ovarii; existing therapies are only palliative. Treatment of thyrotoxicosis is designed to restrain thyroid hormone synthesis (antithyroid drugs) or to reduce the quantity of thyroid tissue (radioiodine and surgery).

  4. Selected Pharmacologic Features of ATD

  5. Duration of therapy with thionamides 1. Preparation for ablation of the thyroid: the duration of therapy is up to the time that patient attains euthyroidism. Methimazole is the preferred agent for attaining euthyroidism before radioiodine therapy. 2. Treatment of diffuse toxic goiter.

  6. Use of Thionamides Compared to propylthiouracil, methimazole induces more speedy improvement in serum levels of T4 and T3. This effect, added to once or twice daily doses and better patient adherence, make this drug more desirable than propylthiouracil.

  7. Frequently seen adverse reactions to thionamide agents* • Adverse reactions to methimazole are dose related; those of propylthiouracil are less clearly related to dose Azizi F. Exper Opin Drug Saf 2006; 5: 107-116

  8. شيوع عوارض داروهاي ضدتيروئيددر كودكان و نوجوانان

  9. Comparison of various properties of common thianomid drugs Azizi F. Exper Opin Drug Saf 2006; 5: 107-116

  10. Factors favoring relapse of thyrotoxicosis after treatment of Graves disease with thionamides More consistent factors: • Severe degree of thyrotoxicosis • Large goiter • Lack of decrease of goiter size during therapy • High T3 to T4 ratio in the serum • Higher baseline levels of anti-TSH receptor antibodies • Lack of normalization of serum TSH Inconsistent factors: • Sex, age, cigarette smoking, duration of symptoms before diagnosis, presence of ophthalmopathy, Psychiartic disorders, (depression, hypochondriasis, paranoia, mental fatigue) and problems of daily life Azizi F. Exper Opin Drug Saf 2006; 5: 107-116

  11. انديكاسيون هاي درمان با يد راديواكتيو در كودكان و نوجوانان • عدم موفقيت درمان دارويي • عوارض داروها • عدم تمكين به درمان دارويي • تمايل به درمان قطعي بيماري Krassas GE. Europ J Endocrinol 2004; 150: 407-14. Kraiem Z, Newfield RS. J Pediatr Endocrinol Metab 2001; 14: 229-43.

  12. درمان با يد راديواكتيو • تجويز Gy 200 در بزرگسالان 40% و در كودكان 70% كم كاري تيروئيد ايجاد مي كند. • پاسخ به يد درماني در تيروئيدهاي حجيم كمتر است. • تشديد افتالموپاتي در كودكان كمتر از بزرگسالان است. • احتمال خطر بروز بدخيمي با دوزهاي كم يد راديواكتيو وجود دارد. • با مقادير µCi/g 200-150 يد راديواكتيو, 5-20% هيپر و 90-60% هيپومي شوند. Patel et al. Thyroid 2006; 16: 593-8. Rivkees SA. J Clin Endocrinol Metab 2004; 89: 4227-8. Read CH et al. J Clin Endocrinol Metab 2004; 89: 4229-33. Rivkees SA, Cornelius EA. Pediatrics 2003; 111: 745-9.

  13. انديكاسيون هاي جراحي در پركاري تيروئيد كودكان و نوجوانان • عدم موفقيت درمان دارويي • عوارض داروها • پركاري تيروئيد شديد • افتالموپاتي شديد • ترس از يد راديواكتيو • گواتر بزرگتر از 100 گرم (30!؟) • شك به بدخيمي گره تيروئيد Sherman J et al. Surgery 2006; 140: 21056-62 (با تغييرات) Rivkees SA. Pediatr Endocrinol Rev 2003; 1 (Suppl 2): 212-22

  14. تجربيات درمان پركاري تيروئيد در 304 كودك و نوجوان بين سال هاي 1370-1383 دانشگاه علوم پزشكي شهيد بهشتي- تهران

  15. There were 245 females and 59 males . All patients and their parents were given the option of selecting from the three principal modalities of therapy after a full discussion of advantages and disadvantages. Methimazole (MMI) was the principal medication prescribed. The usual dose of MMI was 0.5 mg/kg/day and the maintenance was 2.5-10 mg daily. For those with persistent hyperthyroidism, ablation therapy with radioiodine was proposed and if patient refused, surgical treatment was advised and if rejected, continuous MMI therapy was chosen.

  16. When relapse of hyperthyroidism occurred following MMI withdrawal, radioiodine therapy was employed, unless patients and/or family preferred thyroidectomy or continuous antithyroid therapy. Clinical evaluation and thyroid function tests were done every 6 months; quality of life, bone mineral density, cardiac evaluation and total cost of treatment were evaluated at the end of the study (median 6.4 yr).

  17. Mean age of patients was 15.6±2.6 yr and 81% were females. Of 304 patients , 76.6, 18.8 and 4.6% were 15-19, 11-14 and below 11 years of age .Five and 3 patients chose radioiodine and surgery as the initial treatments. The remaining 296 patients were treated with antithyroid medications.

  18. Course of treatment in patients with juvenile thyrotoxicosis

  19. Summary of final outcome in 304 patients with juvenile thyrotoxicosis 76 after 1.5 yr treatment with antithyroid drugs, 46 following radioiodine, 3 after surgery and 29 with continuous antithyroid treatment † 90 after radioiodine therapy, 9 following surgery and 8 spontaneously while on antithyroid herapy.

  20. Final results of treatment in 304 patients with juvenile hyperthyroidism * Numbers in parenthesis represent percent of patients treated with antithyroid drugs who completed 18 months of therapy † NA: not applicable because of inadequate number of patients 0

  21. Continuous ATD treatment Twenty nine patients chose continuous ATD therapy and they received ATD for 5.7±2.4 yr. Except for minor allergic symptoms, no serious complications occurred. Mean MMI maintenance dose was 4.6±1.2 (range 2.5-10 mg) daily.

  22. Comprison of abnormal TSH values, goiter rate and TPOAb levels between continuous antithyroid and radioiodine treated hypothyroid patients on levothyroxine

  23. Conclusion • Attaining euthyroidism with levothyroxine in radioiodine treated hypothyroid patients may be difficult. • Long-term continuous ATD treatment of juvenile thyrotoxicosis is safe and may be recommended for those with relapse after full course ATD therapy.

  24. Algorithm for the Use of Antithroid Drugs among Patienta with throtoxicosis Juvenile Hyperthyroidism Small or moderately enlarged thyroid Very large diffuse goiter, multinodular goiter, toxic adenoma Antithyroid- drug therapy ATD thenRadioidine therapy or surgery Start methimazole, 0.5-1.0 mg/kg/day, after discussing side effects and obtaining CBC and differential count Normalization of thyroid function With antithyroid drugs before therapy in elderly patients and those with heart disease Monitor thyroid function every 4-8 wk until euthyroid state achieved Discontinue drug therapy after 18 mo Monitor thyroid function every 2-3 mo for 6 mo, then less frequently Relapse Remission Monitor thyroid function every 12 mo indefinitely Definitive radioiodine therapy Second course of antithyroid drug therapy in children and adolescents Countineous MMI therapy

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