Graves’ Disease in the Young: Could We Change the Weather?

Graves' disease is a distressing disease for patients.They are told that doctors understand the mechanisms but not the origin of the disease, that it is usually not a life-threatening disease but a long-lasting unpredictable one, that they will have to be on medication for months with no guarantee they will be cured, that the medication may cause some side effects, and that in the rare event of side effects or, more frequently, in case of relapse, they will be offered a definitive treatment leading to hypothyroidism, another disease requiring lifelong treatment (1-3).Graves' disease is a vexing disease for doctors.They have only poorly grounded guidelines and consensus (2, 3) to address simple questions that deserve simple and clear answers: How come?How long?Are you sure it will work?Is there a risk of complications?What about my eyes?Can I become pregnant?The poor performance of our therapeutic approach to Graves' disease is even worse in the case of children and adolescents.Several years ago, French pediatric endocrinologists conducted a large prospective observational study of medically treated Graves' disease in children and teenagers (4).This provided important and practical information.The risk of relapse of hyperthyroidism after 24 months of carbimazole was higher in younger, non-Caucasian patients presenting with severe disease (high free thyroxine and high thyrotropin receptor antibodies), whereas a longer duration of antithyroid drug (ATD) treatment was associated with a higher probability of remission.Quite deceptive was the near 60% and 70% relapse rate, 1 and 2 years, respectively, after carbimazole withdrawal.The study was prolonged with 2 to 3 rounds of treatment if a relapse had occurred (5).Repeating long periods of treatment improved the estimated remission rate from 20% at 4 years to a near 50% plateau after 10 years, solid but disappointing results.Who can be satisfied and expect a teenager to be compliant and happy with treatment for 4 years to get an 80% relapse risk, and up to 10 years for a 50% risk?Young patients would rather have a definitive treatment recommended (6).