Disease Presentation and Remission Rate in Graves Disease Treated With Antithyroid Drugs

Is Gender Really a Factor?

Talia Diker-Cohen, MD, PhD; Hadar Duskin-Bitan, MD; Ilan Shimon, MD; Dania Hirsch, MD; Amit Akirov, MD; Gloria Tsvetov, MD; Eyal Robenshtok, MD

Disclosures

Endocr Pract. 2019;25(1):43-50. 

In This Article

Abstract and Introduction

Abstract

Objective: Male gender is considered an adverse prognostic factor for remission of Graves disease treatment with antithyroid drugs (ATDs), although published data are conflicting. This often results in early consideration of radioiodine treatment and surgery for men. Our objective was to compare disease presentation and outcome in men versus women treated with ATDs.

Methods: Retrospective study of 235 patients (64 men, 171 women) with Graves disease who were evaluated for features at presentation and outcome at the end of follow-up between 2010 and 2015.

Results: Disease presentation was similar in men and women for age at diagnosis (41.4 ± 14 years vs. 40 ± 15 years), duration of follow-up (6.6 ± 7 years vs. 7.7 ± 6 years), rates of comorbid autoimmune diseases, and rate of Graves ophthalmopathy. Smoking was more prevalent in males (31% vs. 15%; P = .009). Free thyroxine and triiodothyronine levels were comparable. ATDs were first-line treatment in all males and in 168 of 171 females, for a median duration of 24 and 20 months, respectively (P = .55). Remission rates were 47% in men and 58% in women (P = .14). Males had fewer adverse events (9% vs. 18%) and treatment discontinuation (5% vs. 16%). Disease recurrence was comparable (14% vs. 20%; P = .32), as was requirement for second-line treatment, either radioiodine therapy or thyroidectomy.

Conclusion: Graves disease presentation is similar in men and women. Men treated with ATDs have high remission rates and similar recurrence rates compared to women, with fewer adverse events and less discontinuation of treatment. ATDs are an attractive first-line treatment for both genders.

Introduction

Graves disease is an autoimmune thyroid disease with an interplay between environmental factors and genetic predisposition.[1–4] Gender is considered a predisposing factor, as women are affected 4 to 10 times more than men,[1,2,5–8] but only a few studies have evaluated the possible effects of gender on the clinical course of Graves disease. While gender has a known effect on Graves ophthalmopathy (GO), which is more prevalent in women yet men are more likely to have severe disease,[9,10] the impact of gender on hyperthyroidism and remission rate is less clear, with conflicting data in the literature.[11–28]

Therapeutic options in Graves patients include antithyroid drugs (ATDs), radioiodine therapy, and thyroidectomy. Since there is no consensus for an algorithmic approach to treatment of Graves disease, either can be used as first-line therapy.[11] When ATDs are used as first-line therapy, remission is induced in up to 68% of subjects, varying considerably between geographic areas.[11] Male gender is often associated with lower rates and shorter duration of remission after a course of ATD,[6] a notion that has been translated to early consideration of alternative therapies in men, namely radioiodine ablation and surgery.[6,11]

In line with the above, recent guidelines state that there is a higher likelihood of remission after ATD treatment in women,[11] though data are conflicting. Moreover, autoimmune thyroid disease is much more common in women,[5,12] so men are less likely to be represented in studies on Graves disease, leading to uncertainty regarding the optimal therapeutic approach in men. We therefore aimed to compare disease presentation and treatment outcomes in male and female patients with Graves disease.

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