E. J. Graham1, J. Malinowski1, C. A. Dinauer1, E. R. Christison-Lagay1, C. E. Quinn1, T. Carling1, R. Udelsman1, G. G. Callender1 1Yale University School Of Medicine,Department Of Surgery,New Haven, CT, USA
Introduction: Graves disease (GD) is an autoimmune disease of the thyroid with an incidence of 0.79 cases per 100,000 person-years in children aged 0-14 years. In the United States, the pediatric GD population has not been well characterized due to its low prevalence and lack of comprehensive follow up. The American Thyroid Association recommends anti-thyroid drugs (ATD) for primary treatment of GD in pediatric patients, but no clear recommendation exists for definitive treatment, i.e. radioactive iodine (RAI) or thyroidectomy. This study aimed to characterize demographics and predictors of treatment selection in pediatric patients with GD at a tertiary referral center.
Methods: Retrospective review was performed of all patients diagnosed with GD at age ≤18 years from 2000-2015 at a tertiary care center. Neonatal GD patients and patients whose primary follow up was not performed at our center were excluded. The effect of race/ethnicity (non-Hispanic white, non-Hispanic black, Hispanic, other), insurance status (public, private, none), intolerance to ATD, presence of ophthalmopathy, age at diagnosis, and age at definitive treatment on election of definitive treatment and likelihood of remission was determined using ANOVA and logistic regression.
Results: Overall, 103 patients (81% female) were diagnosed with GD from 2000-2015 at median age 13 (range 2-18) years. Age at diagnosis did not differ between racial/ethnic groups or by insurance status. After primary ATD treatment, 11 (10.7%) patients entered remission at median 22 (range 3-126) months; 16 (15.5%) underwent RAI at median age 11 years; 34 (33.0%) underwent total thyroidectomy at median age 12 years; 45 (43.7%) continued ATD treatment only, with 23 (51.1%) of these continuing beyond 2 years. Type of treatment elected was independent of age at diagnosis, ophthalmopathy, insurance status and race/ethnicity. The likelihood of pursuing definitive treatment increased with age (OR: 2.6, p=0.01) and intolerance to ATD (OR: 174, p=0.01); patients with an earlier age at diagnosis trended toward greater likelihood of pursuing definitive treatment (OR: 1.8, p=0.06). Likelihood of remission was independent of all tested variables.
Conclusion:The management of pediatric GD is heterogeneous. Age at diagnosis and type of treatment elected were not impacted by socioeconomic status. Less than 50% of patients undergo definitive therapy (RAI or surgery) in spite of the low incidence of remission with ATD therapy alone. Increasing age and intolerance to ATD therapy increase the likelihood of pursuing definitive treatment. As pediatric GD is relatively rare, a prospective multicenter trial would be ideal to determine the optimal treatment algorithm for this patient population.