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“Block-and-replace” treatment in Graves’ disease: experience in a cohort of pediatric patients

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Abstract

Purpose

The “block-and-replace” (BR) method involves the use of a high dose of antithyroid drugs (ATD) with levothyroxine (L-T4). Its use in the management of Graves’ disease (GD) is still debated mainly because the frequency of side effects of ATD is dose dependent. We retrospectively studied the effect of medium dose of ATD with L-T4 versus monotherapy with ATD in pediatric patients with unstable GD.

Methods

28 pediatric patients with GD with unstable response to ATD were treated with L-T4 and medium dose of ATD. We compared the rate of euthyroidism, hypothyroidism and hyperthyroidism episodes observed during treatment with methimazole alone with those observed during the BR approach. We evaluated the occurrence of side effects and the rate of remission in patients treated with ATD + L-T4 therapy and the efficacy of combination therapy to postpone a definitive treatment (radioiodine and thyroidectomy).

Results

Patients showed a better control of thyroid function during the BR therapy, presenting fewer episodes of hyperthyroidism and hypothyroidism. No serious side effects during the BR approach were observed. Only one patient went into remission with the ATD + L-T4 therapy. Fifteen patients required a definitive therapy (4 radioiodine, 11 thyroidectomy). The use of BR method has delayed radioiodine treatment for 4.9 years and surgery for 2.9 years.

Conclusions

The BR method does not increase the remission rates. It may be useful to combine L-T4 with a medium dose of methimazole when GD is difficult to manage with methimazole alone. It may represent a therapeutic option to postpone definitive treatments to a suitable age.

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Funding

This study is an academic investigation with no external funding.

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Author notes

  1. M. C. Vigone and E. Peroni made an equal contribution.

Authors and Affiliations

  1. Department of Pediatrics, IRCCS San Raffaele Scientific Institute, via Olgettina 60, 20132, Milan, Italy

    M. C. Vigone, E. Peroni & M. Di Frenna

  2. Laboratory of Pediatric Endocrinology, IRCCS San Raffaele Scientific Institute, via Olgettina 60, 20132, Milan, Italy

    S. Mora

  3. Pediatrics and Neonatal Disease Units, IRCCS San Raffaele Scientific Institute, via Olgettina 60, 20132, Milan, Italy

    G. Barera

  4. Department of Pediatrics, IRCCS San Raffaele Scientific Institute, Vita-Salute San Raffaele University, via Olgettina 60, 20132, Milan, Italy

    G. Weber

Authors
  1. M. C. Vigone
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  2. E. Peroni
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  3. M. Di Frenna
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  4. S. Mora
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Correspondence to S. Mora.

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All procedures performed were in accordance with the ethical standards of the institutional regulations and with the 1964 Helsinki declaration and its later amendments.

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Vigone, M.C., Peroni, E., Di Frenna, M. et al. “Block-and-replace” treatment in Graves’ disease: experience in a cohort of pediatric patients. J Endocrinol Invest 43, 595–600 (2020). https://doi.org/10.1007/s40618-019-01144-0

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  • DOI: https://doi.org/10.1007/s40618-019-01144-0

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