What is the treatment for toxic goiter (hyperthyroidism) in pediatric patients?

From the Guidelines

The treatment for toxic goiter (hyperthyroidism) in pediatric patients typically involves a stepwise approach with antithyroid medications as first-line therapy. Methimazole is the preferred medication, starting at 0.2-0.5 mg/kg/day divided into 1-3 doses (maximum 30 mg/day), with dose adjustments based on thyroid function tests every 2-4 weeks initially 1. Propylthiouracil is generally avoided in children due to risk of liver failure, except in special circumstances like thyroid storm or first trimester pregnancy. Beta-blockers such as propranolol (0.5-2 mg/kg/day divided 2-4 times daily) may be added temporarily to control symptoms like tachycardia and tremors. If medical therapy fails after 1-2 years, or if there are medication side effects, definitive treatment with radioactive iodine (I-131) or thyroidectomy should be considered. Radioactive iodine is typically used in older children and adolescents, while surgery is preferred for younger children, large goiters, or when malignancy is suspected. Treatment decisions should be individualized based on the child's age, disease severity, and underlying cause of hyperthyroidism (most commonly Graves' disease in children) 1. Regular monitoring of thyroid function, growth, and development is essential throughout treatment, as both untreated hyperthyroidism and overtreatment can adversely affect a child's development.

Some key points to consider in the treatment of toxic goiter in pediatric patients include:

• The use of antithyroid medications as first-line therapy
• The preference for methimazole over propylthiouracil due to the risk of liver failure associated with the latter
• The potential need for definitive treatment with radioactive iodine or thyroidectomy if medical therapy fails or is not tolerated
• The importance of individualizing treatment decisions based on the child's age, disease severity, and underlying cause of hyperthyroidism
• The need for regular monitoring of thyroid function, growth, and development throughout treatment.

In terms of the specific treatment options, antithyroid medications are generally the preferred initial treatment, with radioactive iodine or surgery reserved for cases where medical therapy is not effective or is not tolerated 1. The choice between radioactive iodine and surgery will depend on a variety of factors, including the child's age, the size of the goiter, and the presence of any underlying medical conditions. Ultimately, the goal of treatment is to achieve a euthyroid state while minimizing the risk of adverse effects and optimizing the child's quality of life.

From the Research

Treatment Options for Toxic Goiter in Pediatric Patients

The treatment for toxic goiter (hyperthyroidism) in pediatric patients can be managed through various methods, including:

• Antithyroid drugs (ATDs) such as methimazole (MMI) and propylthiouracil (PTU) 2, 3, 4
• Radioactive iodine ablation of the thyroid gland 5
• Surgical thyroidectomy 5

Antithyroid Drugs

ATDs are widely used to treat diffuse toxic goiter (Graves' disease) in pediatric patients. Methimazole is effective in most patients but is associated with significant adverse events (AEs) 3. The choice of ATD and dosage depends on the underlying diagnosis, presence of contraindications, severity of hyperthyroidism, and patient preference.

• Methimazole can be given as a single daily dose and is cheaper than PTU, with less major toxicity at low doses 2
• PTU may not be suitable for initial use in children and adolescents with Graves' disease, even with the risk of major adverse reactions excluded 4

Comparison of Treatment Options

The efficacy and adverse reactions of MMI and PTU have been compared in pediatric patients with Graves' disease.

• No significant difference was found in the duration for normalization of serum T4 between MMI and PTU 4
• Minor adverse effects occurred in 25.0% of cases in the MMI-treated group and 31.9% in the PTU-treated group 4
• Remission rates did not differ between the MMI-treated group and PTU-treated group 4

Special Considerations

In pregnant women with hyperthyroidism, treatment with PTU or MMI may be necessary. However, prolonged therapy with these agents may be undesirable due to the potential risk of congenital defects 6.