Commentary on “Remission in pediatric Graves’ disease treated with antithyroid drug and the risk factors associated with relapse”

Article information

Ann Pediatr Endocrinol Metab. 2022;27(4):245-246
Publication date (electronic) : 2022 December 31
doi :
Department of Pediatrics, Dongguk University Ilsan Hospital, Goyang, Korea
Address for correspondence: Ji Hyun Kim Department of Pediatrics, Dongguk University Ilsan Hospital, 27 Dongguk-ro, Ilsandong-gu, Goyang 10326, Korea Email:

Hyperthyroidism is a disease in which the thyroid produces excessive hormones and produces clinical symptoms. The most common cause of hyperthyroidism in children is Graves' disease (GD). Autoimmune hyperthyroidism can be diagnosed by measuring autoantibodies against the thyroid-stimulating hormone receptor. The goal of treatment is to control the overproduction of thyroid hormone, for which there are 3 options: antithyroid drug (ATD), radioactive iodine therapy, and surgery. Methimazole (MMZ) and propylthiouracil are used for drug treatment, although MMZ is mainly used in children because of its long serum half-life and low hepatotoxicity. The initial dose is MMZ 0.5 mg/kg/day, once or twice a day, and the dose titration method is most common [1].

Considering that the remission rate with ATD is not high, definite treatment is recommended if remission does not occur after 1 to 2 years of therapy with MMZ. However, there are few guidelines for children.

Remission was defined as a euthyroid state for at least 12 months after discontinuation of ATD treatment and no recurrence during the follow-up period. Many studies have reported that the remission rate increases with ATD use period in children. A recent systematic review noted that the remission rate was 43.7% when ATD was used for 5–6 years and reached 75% after 9 years of treatment [2]. In 2022, the European Thyroid Association for the Management of Childhood GD also recommended extending initial ATD for at least 3 years and potentially for more than 5 years if remission is unlikely [3]. Factors related to remission differ from study to study, but the remission rate is low in males [4], younger age at diagnosis, non-Caucasian ethnicity, higher TSH receptor antibody at diagnosis [5], and larger goiter size [6]. There is also a report of an association between the time to TSH binding inhibitory immunoglobulin normalization after treatment and GD remission [7].

In this study [8], the authors studied 81 Chinese children treated with ATD and reported that 17.8% experienced remission and 57.4% experienced relapse after discontinuation of ATD. In addition, although the remission rate through ATD treatment was low in Asian children with GD, the longer was the ATD treatment period, the higher was the remission probability. Since most relapses occur within the first 2 years after discontinuation of ATD, patients and their guardians should be educated about the long treatment period and the risk of recurrence when starting treatment.


Conflicts of interest

No potential conflict of interest relevant to this article was reported.


1. Lee HG, Yang EM, Kim CJ. Efficacy and adverse events related to the initial dose of methimazole in children and adolescents with Graves' disease. Ann Pediatr Endocrinol Metab 2021;26:199–204.
2. van Lieshout JM, Mooij CF, van Trotsenburg ASP, Zwaveling-Soonawala N. Methimazole-induced remission rates in pediatric Graves' disease: a systematic review. Eur J Endocrinol 2021;185:219–29.
3. Mooij CF, Cheetham TD, Verburg FA, Eckstein A, Pearce SH, Léger J, et al. 2022 European Thyroid Association Guideline for the management of pediatric Graves' disease. Eur Thyroid J 2022;11e210073.
4. Bayramoğlu E, Elmaogulları S, Sagsak E, Aycan Z. Evaluation of long-term follow-up and methimazole therapy outcomes of pediatric Graves' disease: a singlecenter experience. J Pediatr Endocrinol Metab 2019;32:341–6.
5. Kaguelidou F, Alberti C, Castanet M, Guitteny MA, Czernichow P, Léger J. Predictors of autoimmune hyperthyroidism relapse in children after discontinuation of antithyroid drug treatment. J Clin Endocrinol Metab 2008;93:3817–26.
6. Glaser NS, Styne DM. Predictors of early remission of hyperthyroidism in children. J Clin Endocrinol Metab 1997;82:1719–26.
7. Rho JG, Kum CD, Seo YJ, Shim YS, Lee HS, Hwang JS. Long-term outcomes of Graves' disease in children and adolescents receiving antithyroid drugs. Ann Pediatr Endocrinol Metab 2021;26:266–71.
8. Wong TWC, Shirley WMY. Remission in paediatric Graves’ disease treated with antithyroid drug and the risk factors associated with relapse. Ann Pediatr Endocrinol Metab 2022;27:308–14.

Article information Continued