Pediatric hyperthyroidism and thyroid eye disease management

Thyroid eye disease arising in patients with Graves' disease is a complex condition affecting both children and adults that may lead to permanent visual loss. This review pro-vides an update on management of hyperthyroidism and thyroid eye disease in pediatric patients up to 18 years of age. Management options for Graves' disease include antithyroid drugs, radioactive iodine therapy, thyroidec-tomy, and potentially highly selective thyrotropin receptor antagonists and immunomodulator agents. Treatment for thyroid eye disease includes steroids, surgery, and immu-nomodulator agents. Many current therapies for the man-agement of Graves' disease and thyroid eye disease have been successfully demonstrated in the pediatric popula-tion. However, additional research is necessary to further evaluate the effectiveness of highly selective thyrotropin re-ceptor antagonists and immunomodulator agents in pedi-atric patients.Graves' disease is an inflammatory autoimmune condi-tion affecting primarily the thyroid, orbit, and subcutane-ous tissues of the extremities; the hormonal effects of the associated hyperthyroidism are systemic. Although Graves' disease occurs more frequently in adults than children, it remains the most common underlying cause of hyperthy-roidism in both children and adolescents.1,2 In these popu-lations, the incidence of Graves' disease has been reported to be 0.1 per 100,000 children per year and 3.0 per 100,000 adolescents per year.1,2The reported incidence of thyroid eye disease (TED) developing in patients with juvenile Graves' disease is esti-mated to be 33%-67%.3,4 As in Graves' disease, TED is more common in females than in males and is more prev-alent in adolescents (11-18 years of age [68.2%]) than in younger children (\11 years of age [31.8%]).3 Smoking is a known risk factor for the development and exacerbation of TED, with reports of higher incidences of ocular symp-toms in children living in countries with higher tobacco consumption.3,5Although there is limited data on ethnic factors in the development of Graves' disease specifically in the pediatric population, one study of patients 12-49 years of age demonstrated increased odds ratio of overt thyrotoxicosis in African American (8.7) and Mexican American (4.6) compared with non-Hispanic White individuals.6 Several autoimmune thyroid disease susceptibility genes have been identified, and human leukocyte antigen (HLA) genes appear to play a major role.7 Pediatric and adult-onset Graves' disease share multiple genetic risk factors, with certain polymorphisms associated with earlier onset.8