if they are elevated,again at 18-22 weeks of gestation [5,9th decades of life.A typical presentation with weight 21-23,43,44,149,150].Finally,fetal/neonatal hyperthy loss,tremor,agitation,and heat intolerance can occur; roidism requires an acute management,including MMI, however,older individuals sometimes present with subtle beta-blockade,and cardiovascular support therapy [43]. symptoms such as fatigue,mood disturband ce,or breath Dramati D 36 All pa with ahist congestive cardi d h oid dis- esa re,or i t in older hary syn sured at the first presentation of pregnar ere throtoxicosis should be along similar lines to that in younger people with an initial course of atd to render assay and,if they are elevated,again at 18-22 weeks of the patient euthyroid,along with beta-blockers if appro- estation.1,☑☑☑0 priate.If there is atrial fibrillation or other tachyarrhyth 37ifthe mate e cut-o r thy o ea herapy,norr to preven roid roughout pregnancy is recom on 4a1 ssible dose of ATD d witho should the block-and-replace ATD reg ow-dose MMI(CBZ)2.5-5 is n effecti men is discouraged 1 0000 vell-tolerated treatment especially when there is no ac 39 Maternal FT4(TT4)and TSH should be measured ev- s to RAI and/or contraindication to thyroidectomy ery 2 weeks after the initiation of therapy,and every 4 Older patients are more likely to suffer vere conse weeks after achieving the target valu quences from ATD-induce d agranulocytosis 155,and i 0A to MMI should be consi ered if s in warning people abou 16 n.I, sue,anc on 4 ding written ATD dayoi or cognitive In a .he gestation prior to weeks 6-10.2. Go 11561 so should be d for this:whe elevant smoking cessation advice should be given and Postpartum Phase treatment-related hypothyroidism should be assiduously The risk of GD recurrence was highest 7-9 months avoided partum (RR 3.8)in studies conducted in Denmarl Only small amounts of ATD ente Recommendations W20 <250 mg)anc for the ohave had atrial fibrillation,cardia erapy child and in divided doses [153.1541. a11DAT1 45 Long-term MMI(CBZ)should be considered as a sat. Recommendations isfactory treatment for older individuals with mild 42 Lactating women with GD should be offered the same GD.2.0000 treatments as non-lactating women.1. 43 MMI is recommended during lactation,given the con cerns about PTU-mediated hepatotoxicity.1,C dren and teenagers freque ntly prese with nd in retrospec The Elderly,Children and Adolescents,and Immune nge in behav suc s impaired educ for 41 Reco gnized.Imp ty.the isis easily overlooked in teenage girls with weight loss who are as Elderly sumed to have an eating disorder.The outcome of ATD Although the incidence of GD decreases with advanc- treatment of younger people with GD is disappointing ing age,cases may still occur in patients in their 8th and as compared to the results in adults.Remission rates fol Kahaly/Bartalena/Hegeduis/Leenhardt/ Poppe/Pearce 医通 http://guide.medlive.cn/ Kahaly/Bartalena/Hegedüs/Leenhardt/ Poppe/Pearce 178 Eur Thyroid J 2018;7:167–186 DOI: 10.1159/000490384 if they are elevated, again at 18–22 weeks of gestation [5, 21–23, 43, 44, 149, 150]. Finally, fetal/neonatal hyperthy￾roidism requires an acute management, including MMI, beta-blockade, and cardiovascular support therapy [43]. Recommendations 36 All patients with a history of autoimmune thyroid dis￾ease should have their TSH-R-Ab serum levels mea￾sured at the first presentation of pregnancy using ei￾ther a sensitive binding or a functional cell-based bio￾assay and, if they are elevated, again at 18–22 weeks of gestation. 1, ∅∅∅∅ 37 If the maternal TSH-R-Ab concentration remains high (>3 times the cut-off), monitoring of the fetus for thy￾roid dysfunction throughout pregnancy is recom￾mended. 1, ∅∅∅∅ 38 During pregnancy the lowest possible dose of ATD should be given and the block-and-replace ATD regi￾men is discouraged. 1, ∅∅∅∅ 39 Maternal FT4 (TT4) and TSH should be measured ev￾ery 2 weeks after the initiation of therapy, and every 4 weeks after achieving the target value. 1, ∅∅○○ 40 A change from PTU to MMI should be considered if ATD are required after 16 weeks gestation. 1, ∅○○○ 41 In women on a low dose of MMI (<5–10 mg/day) or PTU (<50–100 mg/day), ATD may be stopped during gestation prior to weeks 6–10. 2, ∅○○○ Postpartum Phase The risk of GD recurrence was highest 7–9 months postpartum (RR 3.8) in studies conducted in Denmark and Japan [135, 152]. Only small amounts of ATD enter into breast milk, and low doses of PTU (<250 mg) and MMI (<20 mg) are considered safe for the mother and child. ATD should be taken after having breastfed the child and in divided doses [153, 154]. Recommendations 42 Lactating women with GD should be offered the same treatments as non-lactating women. 1, ∅∅○○ 43 MMI is recommended during lactation, given the con￾cerns about PTU-mediated hepatotoxicity. 1, ∅∅○○ The Elderly, Children and Adolescents, and Immune Reconstitution Elderly Although the incidence of GD decreases with advanc￾ing age, cases may still occur in patients in their 8th and 9th decades of life. A typical presentation with weight loss, tremor, agitation, and heat intolerance can occur; however, older individuals sometimes present with subtle symptoms such as fatigue, mood disturbance, or breath￾lessness (termed “apathetic thyrotoxicosis”). Dramatic presentations with atrial fibrillation, congestive cardiac failure, or ischemic acute coronary syndrome are also more frequent in older people. Treatment for those with severe thyrotoxicosis should be along similar lines to that in younger people, with an initial course of ATD to render the patient euthyroid, along with beta-blockers if appro￾priate. If there is atrial fibrillation or other tachyarrhyth￾mia or cardiac compromise, it is good practice to proceed to early definitive therapy, normally with RAI, to prevent any further heart complication from recurrent hyperthy￾roidism. In older or frail patients with milder hyperthy￾roidism and without cardiac compromise, long-term low-dose MMI (CBZ) 2.5–5 mg daily is an effective and well-tolerated treatment, especially when there is no ac￾cess to RAI and/or contraindication to thyroidectomy. Older patients are more likely to suffer severe conse￾quences from ATD-induced agranulocytosis [155], and it is important to be meticulous in warning people about this issue, and providing written information to family or caregivers in the case of cognitive impairment. In addi￾tion, older patients have a higher chance of developing GO [156], so should be carefully assessed for this: where relevant, smoking cessation advice should be given and treatment-related hypothyroidism should be assiduously avoided. Recommendations 44 Older patients who have had atrial fibrillation, cardiac failure, or cardiac ischemic symptoms precipitated by hyperthyroidism should undergo definitive therapy, usually RAI. 1, ∅∅∅○ 45 Long-term MMI (CBZ) should be considered as a sat￾isfactory treatment for older individuals with mild GD. 2, ∅○○○ Childhood and Adolescence Children and teenagers frequently present late with GD and in retrospect features such as impaired educa￾tional performance, change in behavior, anxiety, or sleep disturbance may have been present for years before the cause is recognized. Importantly, the diagnosis is easily overlooked in teenage girls with weight loss who are as￾sumed to have an eating disorder. The outcome of ATD treatment of younger people with GD is disappointing, as compared to the results in adults. Remission rates fol￾http://guide.medlive.cn/