Secular Trends in the Management of Pediatric Graves' Disease: A 25-Year Cohort.
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CONTEXT: Over the past two decades, management of pediatric Graves' disease (GD) has shifted toward prolonged antithyroid drug therapy. Yet, longitudinal data describing how these changes have influenced long-term outcomes remain limited. OBJECTIVE: To examine secular trends in presentation, treatment strategies, and long-term outcomes of pediatric GD over a 25-year period at a tertiary center. DESIGN AND SETTING: A retrospective cohort study of children diagnosed with GD between 1999 and 2024. PARTICIPANTS: 128 children (79.7% female), median age 13.8 years (IQR 10.0-15.6), median follow-up 6.0 years (IQR 3.3-10.4). MAIN OUTCOME MEASURES: Temporal changes in initial therapy, methimazole (MMI) dosing, definitive therapy radioactive iodine (RAI) ablation or thyroidectomy, remission and relapse rates, and treatment-related adverse events. RESULTS: Initial management shifted exclusively to MMI, with discontinuation of propylthiouracil (PTU) after 2009 (P < 0.001). Median initial MMI dose declined progressively over the study period from 30 mg/day in 1999-2004 to 10 mg/day in 2015-2020 (P < 0.001 for the trend), with a parallel reduction in weight-adjusted dosing from 0.59 to 0.32 mg/kg/day (P < 0.001 for trend). Similarly, the use of RAI decreased steadily across calendar periods, from 55.6% in 1999-2004 to 9.8% in 2020-2024 (P < 0.001 for trend). Remission and remission with relapse rates did not differ significantly across calendar periods. Lower FT4 levels at diagnosis were marginally associated with remission (B=0.41, SE=0.22, P=0.06). MMI-related AEs occurred in 20.3% of patients, with severe events in 1.6%. CONCLUSIONS: Over 25 years, pediatric GD management evolved toward lower-dose, prolonged MMI therapy with a marked decline in definitive treatment. These secular changes were not associated with worsening remission or relapse rates, supporting the feasibility of a sustained conservative approach without evidence of inferior long-term outcomes.
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