Overview of the management of Graves disease in children and adolescents

This algorithm presents the most common treatment approaches for management of Graves disease in children and adolescents. Surgery and RAI generally are used as second-line options in patients who develop major side effects with antithyroid drug treatment or who fail to enter a remission off drug treatment, though some clinicians recommend RAI or surgery as first-line treatment in selected cases, as shown by the dashed lines.

MMI: methimazole; fT4: free thyroxine; T3: triidothyronine; TSH: thyroid-stimulating hormone; RAI: radioactive iodine; 131-I: iodine 131; WBC: white blood cell count.
* When treating with MMI, initially monitor fT4 and T3 every 4 to 6 weeks and adjust dose of MMI to normalize these values. Once these values are in the normal range, continue to monitor fT4, T3, and TSH every 3 to 4 months. During any febrile illness, stop MMI and check WBC to monitor for the development of granulocytopenia.
¶ Major side effects of MMI include agranulocytosis, vasculitis (lupus-like syndrome), or hepatitis. Minor side effects include rash, hives, arthralgias, transient granulocytopenia, or gastrointestinal symptoms.
Δ Practice varies regarding the length of time that a provider will continue to treat with MMI after treatment has resulted in control of the hyperthyroidism. We do not recommend a trial off of MMI after an arbitrary period of treatment. Instead, we prescribe MMI indefinitely, providing that the antithyroid drug is the preferred treatment choice of the patient and parents and that no major side effects occur. Refer to UpToDate topic text for details.
◊ Patient should be off of MMI for at least 7 days before RAI treatment. We suggest using a RAI dose calculated to achieve hypothyroidism.

Courtesy of Stephen LaFranchi, MD.

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Overview of the management of Graves disease in children and adolescents