Methimazole Desensitization in a 4-Year-Old With Refractory Graves Disease

Methimazole Desensitization in a Patient Experiencing a Thionamide-induced Hypersensitivity Reaction

Patients with newly diagnosed Graves disease often elect for treatment with the drug methimazole (MMI) over alternative therapies. However, MMI can commonly result in skin allergy that in severe cases can lead to discontinuation of therapy. We present a case of Graves thyrotoxicosis with a delayed hypersensitivity reaction while on MMI. The patient was successfully treated with a novel, individualized, 27-day desensitization protocol that resulted in tolerance of MMI with subsequent improvement in thyroid indices. Previous literature has offered various rapid desensitization protocols to MMI for immediate type hypersensitivity reactions. However, in nonimmediate, delayed hypersensitivity reactions, a slower desensitization protocol can be considered. As demonstrated in this case, desensitization to MMI is a reasonable alternative in patients who wish to avoid definitive therapy who develop an initial adverse reaction to MMI, as this can occur in up to 13% of treated cases.

Methimazole-induced urticaria in hyperthyroid patients: A safe re-administration protocol

PURPOSE

The safety profile of methimazole (MMI) seems to be better than propylthiouracil in the management of hyperthyroidism. It is therefore advisable to use IMM as the first choice in Graves' patients. It is important to keep this drug in patients regardless of minor side effects. We report a case series of MMI-induced urticaria and provide a stepwise protocol for the safe re-administration of MMI.

METHODS

It was a retrospective case series including all patients having manifested urticaria following MMI intake for hyperthyroidism; notified to the Pharmacovigilance Unit of the Clinical Pharmacology Department (March 2013-January 2022).

RESULTS

We have included 11 patients (SR: 0.22). The median time interval between the start of MMI and the onset of urticaria averaged 14.5 days. The median daily dose of MMI was 40mg. MMI was interrupted in all patients. Urticaria has progressively resolved after drug interruption and antihistamine intake. Reintroduction of MMI was performed in 10/11 patients as follows: one quarter of the daily dose on the first day, half of the daily dose on the 4th day, the three quarters of the daily dose on the 7th day, to reach the scheduled total dose on the 10th day. Cetirizine was added at the time of reintroduction and withdrawn 2 weeks later. All the patients were successfully controlled.

CONCLUSION

Given the importance of this drug in the management of hyperthyroidism, MMI should not be withdrawn in cases of urticaria. After the resolution of urticaria, a gradual reintroduction of MMI should be attempted with concomitant antihistamine therapy.

The characteristics of Grave's disease in children and adolescent patients in Al-Madinah Al-Munawwarah: A retrospective chart review

OBJECTIVES

To determine the characteristics of Graves' disease in children and adolescents in Medina, the Kingdom of Saudi Arabia, and compare them to those observed in other countries.

METHODS

This is a retrospective chart review of children and adolescents diagnosed with Graves' disease between January 2010 and May 2021.

RESULTS

Fifty-eight patients aged 12.02 ± 4.85 years were identified, of which 44 (75.9%) were females. Exophthalmos (63.8%), neck swelling (60.3%), palpitations (46.6%), and tremors (29.3%) were the most common manifestations. Vitiligo (1.72%) and alopecia (1.72%) were the only autoimmune diseases observed in our patients. The median (IQR) value was 0.01 (0.36) (ulU/mL) for thyroid-stimulating hormone (TSH) and 24.89 (29.50) (pmol/L) for FT4. In terms of treatment modalities, 55 (94.8%) received antithyroid medication, 6 (10.3%) underwent thyroidectomy and one patient (1.72%) was treated with radioactive iodine.

CONCLUSION

In general, Graves' disease is more common in females. Neck swelling, palpitation, and tremors were the main manifestations. Compared with other countries, there was a higher frequency of exophthalmos and a lower frequency of associated autoimmune conditions. The primary treatment was antithyroid drugs; thyroidectomy and radioactive iodine were used less frequently.