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Grixti L, Lane LC, Pearce SH. The genetics of Graves' disease. Rev Endocr Metab Disord 2024; 25:203-214. [PMID: 38108994 PMCID: PMC10808215 DOI: 10.1007/s11154-023-09848-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 10/27/2023] [Indexed: 12/19/2023]
Abstract
Graves' disease (GD) is the commonest cause of hyperthyroidism and has a strong female preponderance. Everyday clinical practice suggests strong aggregation within families and twin studies demonstrate that genetic factors account for 60-80% of risk of developing GD. In this review, we collate numerous genetic studies and outline the discoveries over the years, starting with historic candidate gene studies and then exploring more recent genome-wide linkage and association studies, which have involved substantial cohorts of East Asian patients as well as those of European descent. Variants in genes including HLA, CTLA4, and PTPN22 have been shown to have substantial individual effects on disease susceptibility. In addition, we examine emerging evidence concerning the possibility that genetic variants may correlate with relevant clinical phenotypes including age of onset of GD, severity of thyrotoxicosis, goitre size and relapse of hyperthyroidism following antithyroid drug therapy, as well as thyroid eye disease. This review supports the inheritance of GD as a complex genetic trait, with a growing number of more than 80 susceptibility loci identified so far. Future implementation of more targeted clinical therapies requires larger studies investigating the influence of these genetic variants on the various phenotypes and different outcomes of conventional treatments.
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Affiliation(s)
- Lydia Grixti
- Translational and Clinical Research Institute, Newcastle University, BioMedicine West, Central Parkway, Newcastle-upon-Tyne, NE1 3BZ, UK
- Endocrine Unit, Royal Victoria Infirmary, Queen Victoria Road, Newcastle-upon-Tyne, NE1 4LP, UK
| | - Laura C Lane
- Translational and Clinical Research Institute, Newcastle University, BioMedicine West, Central Parkway, Newcastle-upon-Tyne, NE1 3BZ, UK
- Department of Paediatric Endocrinology, The Great North Children's Hospital, Queen Victoria Road, Newcastle-upon-Tyne, NE1 4LP, UK
| | - Simon H Pearce
- Translational and Clinical Research Institute, Newcastle University, BioMedicine West, Central Parkway, Newcastle-upon-Tyne, NE1 3BZ, UK.
- Endocrine Unit, Royal Victoria Infirmary, Queen Victoria Road, Newcastle-upon-Tyne, NE1 4LP, UK.
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Stasiak M, Stasiak B, Zawadzka-Starczewska K, Lewiński A. Significance of HLA in Graves' disease and Graves' orbitopathy in Asian and Caucasian populations - a systematic review. Front Immunol 2023; 14:1256922. [PMID: 37841270 PMCID: PMC10568027 DOI: 10.3389/fimmu.2023.1256922] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/11/2023] [Accepted: 09/04/2023] [Indexed: 10/17/2023] Open
Abstract
Introduction Graves' disease (GD) and Graves' orbitopathy (GO) development were suspected to be HLA-related in both Asian and Caucasian populations. However, most studies were performed with application of serological methods or low resolution genetic typing, which led to inconsistent results even among the same population. The present review is intended to summarize the state-of-art knowledge on the HLA significance in GD and GO in Asians and Caucasians, as well as to find the most significant alleles for each of the populations. Methods PubMed was searched for relevant articles using the following search terms: HLA plus thyroid-associated ophthalmopathy or Graves' disease or Graves' orbitopathy or thyroid eye disease or thyroid-associated orbitopathy. Results In Asian population GD was found to be associated mostly with B*46:01, DPB1*05:01, DRB1*08:02/03, DRB1*16:02, DRB1*14:03, DRB1*04:05, DQB1*05:02 and DQB1*03:03, while DRB1*07:01, DRB1*01:01, DRB1*13:02, DRB1*12:02 are potentially protective. HLA-B*38:02, DRB1*16:02, DQA1*01:02, DQB1*05:02 can be considered associated with increased risk of GO in Asians, while HLA-B*54:01 may play protective role. In Caucasians, C*07:01, DQA1*05:01, DRB1*03, DQB1*02:01 are associated with GD risk while DRB1*07:01, DQA1*02:01 may be protective. Significance of HLA in the course of GD and novel aspects of HLA amino acid variants and potential HLA-based treatment modalities were also discussed.
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Affiliation(s)
- Magdalena Stasiak
- Department of Endocrinology and Metabolic Diseases, Polish Mother’s Memorial Hospital—Research Institute, Lodz, Poland
| | - Bartłomiej Stasiak
- Institute of Information Technology, Lodz University of Technology, Lodz, Poland
| | | | - Andrzej Lewiński
- Department of Endocrinology and Metabolic Diseases, Polish Mother’s Memorial Hospital—Research Institute, Lodz, Poland
- Department of Endocrinology and Metabolic Diseases, Medical University of Lodz, Lodz, Poland
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Radziszewski M, Kuś A, Bednarczuk T. Genotype-phenotype correlations in Graves' disease. Best Pract Res Clin Endocrinol Metab 2023; 37:101745. [PMID: 36828713 DOI: 10.1016/j.beem.2023.101745] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/13/2023]
Abstract
Graves' disease (GD) is a heterogeneous autoimmune disease affecting with varying degrees of severity the thyroid gland, orbital tissues and skin. The pathogenesis of GD involves a complex interplay between multiple genetic, environmental and endogenous factors. Although the genetic predisposition to GD is well established, the significance of genotype-phenotype correlations and the role of epigenetic modifications in the disease pathogenesis remains largely unknown. In this review, we provide an up-to-date overview of genotype-phenotype correlations and summarize possible clinical implications of genetic and epigenetic markers in GD patients. We will specifically discuss the association of genetic markers and epigenetic modifications with age of GD onset, severity of Graves' hyperthyroidism and the development of clinically evident Graves' orbitopathy.
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Affiliation(s)
- Mikołaj Radziszewski
- Department of Internal Medicine and Endocrinology, Medical University of Warsaw, Warsaw, Poland.
| | - Aleksander Kuś
- Department of Internal Medicine and Endocrinology, Medical University of Warsaw, Warsaw, Poland.
| | - Tomasz Bednarczuk
- Department of Internal Medicine and Endocrinology, Medical University of Warsaw, Warsaw, Poland.
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Lee HJ, Stefan-Lifshitz M, Li CW, Tomer Y. Genetics and epigenetics of autoimmune thyroid diseases: Translational implications. Best Pract Res Clin Endocrinol Metab 2023; 37:101661. [PMID: 35459628 PMCID: PMC9550878 DOI: 10.1016/j.beem.2022.101661] [Citation(s) in RCA: 22] [Impact Index Per Article: 22.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
Abstract
Hashimoto's thyroiditis (HT) and Graves' disease (GD) are prevalent autoimmune disorders, representing opposite ends of the clinical spectrum of autoimmune thyroid diseases (AITD). The pathogenesis involves a complex interplay between environment and genes. Specific susceptibility genes have been discovered that predispose to AITD, including thyroid-specific and immune-regulatory genes. Growing evidence has revealed that genetic and epigenetic variants can alter autoantigen presentation during the development of immune tolerance, can enhance self-peptide binding to MHC (major histocompatibility complex), and can amplify stimulation of T- and B-cells. These gene-driven mechanistic discoveries lay the groundwork for novel treatment targets. This review summarizes recent advances in our understanding of key AITD susceptibility genes (Tg1, TSHR, HLA-DR3, and CD40) and their translational therapeutic potential.
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Affiliation(s)
- Hanna J Lee
- Department of Medicine, The Fleischer Institute for Diabetes and Metabolism, Albert Einstein College of Medicine, New York, NY, USA.
| | - Mihaela Stefan-Lifshitz
- Department of Medicine, The Fleischer Institute for Diabetes and Metabolism, Albert Einstein College of Medicine, New York, NY, USA.
| | - Cheuk Wun Li
- Department of Medicine, The Fleischer Institute for Diabetes and Metabolism, Albert Einstein College of Medicine, New York, NY, USA.
| | - Yaron Tomer
- Department of Medicine, The Fleischer Institute for Diabetes and Metabolism, Albert Einstein College of Medicine, New York, NY, USA.
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Stasiak M, Zawadzka-Starczewska K, Tymoniuk B, Stasiak B, Lewiński A. Significance of HLA in the development of Graves' orbitopathy. Genes Immun 2023; 24:32-38. [PMID: 36639701 PMCID: PMC9935388 DOI: 10.1038/s41435-023-00193-z] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/09/2022] [Revised: 12/21/2022] [Accepted: 01/05/2023] [Indexed: 01/15/2023]
Abstract
Graves' disease (GD), similarly to most autoimmune disease, is triggered by environmental factors in genetically predisposed individuals. Particular HLA alleles increase or decrease GD risk. No such correlation was demonstrated for Graves' orbitopathy (GO) in Caucasian population. HLA-A, -B, -C, -DQB1 and -DRB1 genotyping was performed using a high-resolution method in a total number of 2378 persons including 70 patients with GO, 91 patients with non-GO GD and 2217 healthy controls to compare allele frequencies between GO, non-GO and controls. Significant associations between GO and HLA profile were demonstrated, with HLA-A*01:01, -A*32:01, -B*37:01, -B*39:01, -B*42:01, -C*08:02, C*03:02, DRB1*03:01, DRB1*14:01 and DQB1*02:01 being genetic markers of increased risk of GO, and HLA-C*04:01, -C*03:04, -C*07:02 and -DRB1*15:02 being protective alleles. Moreover, correlations between HLA alleles and increased or decreased risk of non-GO GD, but with no impact on risk of GO development, were revealed. Identification of these groups of GO-related and GO-protective alleles, as well as the alleles strongly related to non-GO GD, constitutes an important step in a development of personalized medicine, with individual risk assessment and patient-tailored treatment.
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Affiliation(s)
- Magdalena Stasiak
- Polish Mother's Memorial Hospital - Research Institute, Department of Endocrinology and Metabolic Diseases, Lodz, Poland.
| | - Katarzyna Zawadzka-Starczewska
- grid.415071.60000 0004 0575 4012Polish Mother’s Memorial Hospital - Research Institute, Department of Endocrinology and Metabolic Diseases, Lodz, Poland
| | - Bogusław Tymoniuk
- grid.8267.b0000 0001 2165 3025Medical University of Lodz, Department of Immunology, Rheumatology and Allergy, Lodz, Poland
| | - Bartłomiej Stasiak
- grid.412284.90000 0004 0620 0652Lodz University of Technology, Institute of Information Technology, Lodz, Poland
| | - Andrzej Lewiński
- grid.415071.60000 0004 0575 4012Polish Mother’s Memorial Hospital - Research Institute, Department of Endocrinology and Metabolic Diseases, Lodz, Poland ,grid.8267.b0000 0001 2165 3025Medical University of Lodz, Department of Endocrinology and Metabolic Diseases, Lodz, Poland
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Zhu X, Zhang Y, Zhao X, Zhang X, Ru Z, Wu Y, Yang X, Hou B, Qiao H. The relationship between atherosclerotic disease and relapse during ATD treatment. Front Cardiovasc Med 2022; 9:1039829. [DOI: 10.3389/fcvm.2022.1039829] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/08/2022] [Accepted: 09/29/2022] [Indexed: 11/13/2022] Open
Abstract
BackgroundClinical relapse is a potential risk for traditional antithyroid drug (ATD) treatment in hyperthyroid patients. Evidence suggests that atherosclerotic disease is closely associated with hyperthyroidism, while the relationship between atherosclerosis and relapse remains unclear.MethodsTwo hundred and twenty-five patients with GD who underwent ATD as their first treatment were studied; 88 and 137 patients were categorized as drug reduction relapse and drug reduction remission, respectively. Logistic regression was used to analyze risk factors of drug reduction relapse in patients with GD.ResultsDuring a median of 48 months followed up 88 patients who relapsed. According to multivariate analyses, atherosclerosis related diseases, FT4, goiter, and anxiety rating scores are independent risk factors for drug reduction. According to K-M survival analysis, patients with atherosclerosis related diseases, FT4 > 18.82 pmol/L, anxiety rating scores > 23, and gradation of goiter ≥ Grade II had a higher risk of relapse than those with lower levels. ROC analysis shown atherosclerosis related diseases significantly improved the predictive accuracy of relapse.ConclusionsAtherosclerotic disease is closely related to the relapse of hyperthyroidism, ATD treatment in hyperthyroid patients with atherosclerosis should be given more attention.
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Jiang X, Hu H, Fu Z, Su Y, Long J. ASSOCIATION BETWEEN THE CTLA-4 EXON 1+49A/G POLYMORPHISM AND THE RELAPSE OF GRAVE'S DISEASE AFTER ATD WITHDRAWAL: A META-ANALYSIS. ACTA ENDOCRINOLOGICA (BUCHAREST, ROMANIA : 2005) 2022; 18:324-332. [PMID: 36699166 PMCID: PMC9867805 DOI: 10.4183/aeb.2022.324] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/21/2023]
Abstract
Background The cytotoxic T lymphocyte-associated molecules-4 (CTLA-4) is related to the relapse of Graves' disease (GD) after anti-thyroid drugs (ATDs) withdrawal. We performed a meta-analysis to generate large-scale evidence on whether the CTLA-4 exon 1+49A/G polymorphism can predict the relapse of GD after ATDs withdrawal. Methods and Results The PubMed, EMBASE,the Cochrane Library and reference lists of relevant studies were searched to identify eligible studies from inception to Jan, 2021. Ten eligible studies consisting of 1450 GD patients with a total of 848 relapsed patients were included in the meta-analysis.In Caucasians patients, the CTLA-4 exon 1+49A/G polymorphism significantly elevated the relapse risk of GD in additive (OR = 2.07, 95% CI: 1.18-3.62, P=0.011), dominant (OR = 2.52, 95% CI: 1.17-5.41, P=0.02), homozygote model(OR = 3.264, 95% CI: 1.25-8.52, P=0.016), except recessive (OR = 2.18, 95% CI = 0.98-4.86, P = 0.062) and heterozygote model (OR = 2.141, 95% CI = 0.958-4.786, P = 0.064). In Asian subgroup, none of these genotypes show any associations with the relapse of GD after ATDs withdrawal. Conclusion This meta-analysis suggests that the CTLA-4 exon1 +49A/G polymorphism is associated with the relapse risk of GD after ATDs withdrawal in Caucasians, not Asians. Compared with the AA genotype, Caucasian patients with GG genotype have 3.264 times risk of relapse. A more aggressive treatment such as radioactive iodine or thyroidectomy, or longer periods treatment of ATDs should be recommended in Caucasian patients with the GG genotype.
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Affiliation(s)
- X. Jiang
- The Second Affiliated Hospital, Army Medical University, Chongqing, China
| | - H. Hu
- The Second Affiliated Hospital, Army Medical University, Chongqing, China
| | - Z. Fu
- The Second Affiliated Hospital, Army Medical University, Chongqing, China
| | - Y. Su
- The Second Affiliated Hospital, Army Medical University, Chongqing, China
| | - J. Long
- The Second Affiliated Hospital, Army Medical University, Chongqing, China
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Actual Associations between HLA Haplotype and Graves' Disease Development. J Clin Med 2022; 11:jcm11092492. [PMID: 35566618 PMCID: PMC9099647 DOI: 10.3390/jcm11092492] [Citation(s) in RCA: 16] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/05/2022] [Revised: 04/19/2022] [Accepted: 04/26/2022] [Indexed: 11/21/2022] Open
Abstract
The association between HLA and the risk of Graves’ disease (GD) has been analyzed for many years. However, the results were often inconsistent and mostly regarded Asian populations. The purpose of our study was to perform HLA genotyping using a next-generation sequencing (NGS) method in Caucasians, to find out which alleles are eventually correlated with GD morbidity as well as which of them can be considered protective. HLA-A, -B, -C, -DQB1, -DRB1 were genotyped using a next-generation sequencing method in 2376 persons, including 159 GD patients and 2217 healthy controls. We have demonstrated a significant association between the risk of GD and the following alleles: HLA-B*08:01, -B*39:06, -B*37:01, -C*07:01, -C*14:02, -C*03:02, -C*17:01, -DRB1*03:01, -DRB1*11:01, -DRB1*13:03, -DRB1*01:03, -DRB1*14:01, -DQB1*03:01, DQB1*02:01. The alleles HLA-B*39:06, -B*37:01, -C*14:02, -C*03:02, -C*17:01, -DRB1*14:01 are novel GD-associated, previously not-reported independent ones with no linkage disequilibrium with other high-risk alleles. On the other hand, the frequencies of HLA-B*07:02, -C*07:02, -C*03:04, DRB1*07:01, -DQB1*02:02, -DQB1*03:03 were significantly lower in GD compared to controls. This study demonstrated the actual relationships between HLA and GD based on the NGS method and provided a novel set of alleles as a reliable tool for an individual personalized risk assessment.
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Faustino LC, Kahaly GJ, Frommer L, Concepcion E, Stefan-Lifshitz M, Tomer Y. Precision Medicine in Graves' Disease: CD40 Gene Variants Predict Clinical Response to an Anti-CD40 Monoclonal Antibody. Front Endocrinol (Lausanne) 2021; 12:691781. [PMID: 34149627 PMCID: PMC8212124 DOI: 10.3389/fendo.2021.691781] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/07/2021] [Accepted: 05/13/2021] [Indexed: 12/15/2022] Open
Abstract
BACKGROUND CD40, a key co-stimulatory molecule expressed on antigen-presenting cells, is genetically associated with a number of autoimmune diseases including Graves' disease (GD). Therefore, recent therapies targeting CD40 have been developed, including the anti-CD40 monoclonal antibody Iscalimab. In a recent pilot study, Iscalimab was shown to induce clinical remission in ~ 50% of GD patients, but the reason why only 50% of GD patients responded is not known. The aim of our study was to test the hypothesis that specific CD40 single nucleotide polymorphism (SNP) genotypes and haplotypes are associated with clinical response of GD patients to Iscalimab. METHODS We extracted genomic DNA from the whole blood of 13 GD patients treated with Iscalimab, and genotyped seven CD40 single nucleotide polymorphisms (SNPs) associated with autoimmunity. Additionally, we analyzed CD40 mRNA expression levels in whole blood. The patients' CD40 SNP genotypes and mRNA levels were tested for association with clinical response to Iscalimab. RESULTS Three common haplotypes, designated haplotypes A, B, and C, were identified. Haplotypes B and C were associated with higher CD40 mRNA levels and clinical response to Iscalimab (i.e., patients achieving euthyroidism without need for additional medications), while haplotype A was associated with decreased CD40 mRNA levels and no response to Iscalimab. CONCLUSION Our data suggest that genetic polymorphisms in the CD40 gene drive its expression levels and response to Iscalimab. Polymorphisms associated with higher CD40 levels are also associated with clinical response to CD40-targeted therapies. These results set the stage to implementing precision medicine in the therapeutic approach to GD.
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Affiliation(s)
- Larissa C. Faustino
- Department of Medicine, Albert Einstein College of Medicine, New York, NY, United States
| | - George J. Kahaly
- Department of Medicine I, Johannes Gutenberg University (JGU) Medical Center, Mainz, Germany
| | - Lara Frommer
- Department of Medicine I, Johannes Gutenberg University (JGU) Medical Center, Mainz, Germany
| | - Erlinda Concepcion
- Department of Medicine, Albert Einstein College of Medicine, New York, NY, United States
| | | | - Yaron Tomer
- Department of Medicine, Albert Einstein College of Medicine, New York, NY, United States
- *Correspondence: Yaron Tomer,
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Lane LC, Cheetham TD, Perros P, Pearce SHS. New Therapeutic Horizons for Graves' Hyperthyroidism. Endocr Rev 2020; 41:5897403. [PMID: 32845332 PMCID: PMC7567404 DOI: 10.1210/endrev/bnaa022] [Citation(s) in RCA: 38] [Impact Index Per Article: 9.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/17/2020] [Accepted: 08/20/2020] [Indexed: 11/19/2022]
Abstract
Graves' hyperthyroidism is characterized by the presence of autoantibodies that stimulate the thyroid-stimulating hormone receptor (TSHR), resulting in uncontrolled secretion of excessive thyroid hormone. Conventional treatments, including antithyroid medication, radioiodine, or surgery have remained largely unchanged for the past 70 years and either lack efficacy for many patients, or result in lifelong thyroid hormone replacement therapy, in the case of the latter 2 options. The demand for new therapeutic options, combined with greater insight into basic immunobiology, has led to the emergence of novel approaches to treat Graves' hyperthyroidism. The current therapies under investigation include biologics, small molecules, and peptide immunomodulation. There is a growing focus on TSHR-specific treatment modalities, which carry the advantage of eliciting a specific, targeted approach, with the aim of avoiding disruption of the functioning immune system. These therapies present a new opportunity to supersede the inadequate treatments currently available for some Graves' patients, offering hope of successful restoration of euthyroidism without the need for ongoing therapy. Several of these therapeutic options have the potential to translate into clinical practice in the near future. This review provides a comprehensive summary of the recent advances and various stages of development of the novel therapeutic approaches to treat Graves' hyperthyroidism.
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Affiliation(s)
- Laura C Lane
- Translational and Clinical Research Institute, Newcastle University, Newcastle-upon-Tyne, UK.,Endocrine unit, Royal Victoria Infirmary, Newcastle-upon-Tyne Hospitals NHS Foundation Trust, Newcastle-upon-Tyne, UK.,Department of Paediatric Endocrinology, The Great North Children's Hospital, Newcastle-upon-Tyne, UK
| | - Tim D Cheetham
- Translational and Clinical Research Institute, Newcastle University, Newcastle-upon-Tyne, UK.,Department of Paediatric Endocrinology, The Great North Children's Hospital, Newcastle-upon-Tyne, UK
| | - Petros Perros
- Endocrine unit, Royal Victoria Infirmary, Newcastle-upon-Tyne Hospitals NHS Foundation Trust, Newcastle-upon-Tyne, UK
| | - Simon H S Pearce
- Translational and Clinical Research Institute, Newcastle University, Newcastle-upon-Tyne, UK.,Endocrine unit, Royal Victoria Infirmary, Newcastle-upon-Tyne Hospitals NHS Foundation Trust, Newcastle-upon-Tyne, UK
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Abstract
Context: Antithyroid drugs (ATD) are the first-line treatment for Graves’ disease (GD); however, relapse following treatment is approximately 30% - 40% in the first year, and 50% - 60% in the long term. Identification of risk factors that predict relapse, after discontinuing ATD, plays an important role in guiding therapeutic options. Evidence Acquisition: PubMed was used to search for studies published in English between 1995 and 2019. The following search terms were used: Graves’ disease, antithyroid drugs, relapse, recurrence, and outcome. The reference lists from review articles were also included in the search in order to find older journals. Results: Factors associated with a high recurrence rate, as reported in most studies, were divided into phenotype and genotype predictors. Phenotype factors included large goiter size, persistence of high TSH receptor antibody (TRAb), severe hyperthyroidism, smoking, younger age, male sex, and prior history of recurrence. Genotype factors included human leukocyte antigen (HLA), CD40, CTLA-4, PTPN22, Tg, and TSHR genes. In a subgroup analysis by age, genetic factors were better predictors in the younger group, while clinical signs were more useful in the older group. The reliability of using individual baseline risk factors to predict subsequent relapse is poor; however, predictive scores calculated by grouping single risk factors might help to predict future outcomes. Conclusions: Longer normalization time of TRAb, the persistence of a palpable goiter, and harboring genetic risk factors in younger patients are associated with high recurrence rate of GD. Multi-marker prediction models have been proposed and validated to improve the predictive value of relapse after ATD withdrawal.
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Yan CY, Ma YR, Sun F, Zhang RJ, Fang Y, Zhang QY, Wu FY, Zhao SX, Song HD. Candidate gene associations reveal sex-specific Graves' disease risk alleles among Chinese Han populations. Mol Genet Genomic Med 2020; 8:e1249. [PMID: 32342657 PMCID: PMC7336758 DOI: 10.1002/mgg3.1249] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/17/2019] [Revised: 03/18/2020] [Accepted: 03/24/2020] [Indexed: 12/15/2022] Open
Abstract
BACKGROUND With several susceptibility single nucleotide polymorphisms identified by case-control association studies, Graves' disease is one of the most common forms of autoimmune thyroid disease. In this study, we aimed to determine whether any observed differences in genetic associations are influenced by sex in Chinese Han populations. METHODS A total of 8,835 patients with Graves' disease and 9,936 sex-matched healthy controls were enrolled in the study. Confirmed by a two-staged association analysis, sex-specific analyses among 20 Graves' disease susceptibility loci were conducted. RESULTS A significant sex-gene interaction was detected primarily at rs5912838 on Xq21.1 between the GPR174 and ITM2A genes, whereby male Graves' disease patients possessed a significantly higher frequency of risk alleles than their female counterparts. Interestingly, compared to women, male patients with Graves' disease had a higher cumulative genetic risk and higher persistent thyroid stimulating hormone receptor antibody-positive rate after receiving antithyroid drug therapy for at least 1 year. CONCLUSION The findings of this study suggest the existence of one potential sex-specific Graves' disease variant on Xq21.1. This could increase our understanding of the pivotal mechanism behind Graves' disease and ultimately aid in identifying possible therapeutic targets.
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Affiliation(s)
- Chen-Yan Yan
- Department of Molecular Diagnostics, The Core Laboratory in Medical Center of Clinical Research, Department of Endocrinology, Shanghai Ninth People's Hospital, State Key Laboratory of Medical Genomics, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Yu-Ru Ma
- Department of Molecular Diagnostics, The Core Laboratory in Medical Center of Clinical Research, Department of Endocrinology, Shanghai Ninth People's Hospital, State Key Laboratory of Medical Genomics, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Feng Sun
- Department of Molecular Diagnostics, The Core Laboratory in Medical Center of Clinical Research, Department of Endocrinology, Shanghai Ninth People's Hospital, State Key Laboratory of Medical Genomics, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Rui-Jia Zhang
- Department of Molecular Diagnostics, The Core Laboratory in Medical Center of Clinical Research, Department of Endocrinology, Shanghai Ninth People's Hospital, State Key Laboratory of Medical Genomics, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Ya Fang
- Department of Molecular Diagnostics, The Core Laboratory in Medical Center of Clinical Research, Department of Endocrinology, Shanghai Ninth People's Hospital, State Key Laboratory of Medical Genomics, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Qian-Yue Zhang
- Department of Molecular Diagnostics, The Core Laboratory in Medical Center of Clinical Research, Department of Endocrinology, Shanghai Ninth People's Hospital, State Key Laboratory of Medical Genomics, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Feng-Yao Wu
- Department of Molecular Diagnostics, The Core Laboratory in Medical Center of Clinical Research, Department of Endocrinology, Shanghai Ninth People's Hospital, State Key Laboratory of Medical Genomics, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Shuang-Xia Zhao
- Department of Molecular Diagnostics, The Core Laboratory in Medical Center of Clinical Research, Department of Endocrinology, Shanghai Ninth People's Hospital, State Key Laboratory of Medical Genomics, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Huai-Dong Song
- Department of Molecular Diagnostics, The Core Laboratory in Medical Center of Clinical Research, Department of Endocrinology, Shanghai Ninth People's Hospital, State Key Laboratory of Medical Genomics, Shanghai Jiao Tong University School of Medicine, Shanghai, China
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Lane LC, Cheetham T. Graves' disease: developments in first-line antithyroid drugs in the young. Expert Rev Endocrinol Metab 2020; 15:59-69. [PMID: 32133893 DOI: 10.1080/17446651.2020.1735359] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/09/2019] [Accepted: 02/24/2020] [Indexed: 10/24/2022]
Abstract
Introduction: First-line treatment for most young people with Graves' disease (GD) will include the administration of a thionamide antithyroid medication (ATD); Carbimazole (CBZ), Methimazole (MMZ), or rarely, propylthiouracil (PTU). GD is a challenge for families and clinicians because the likelihood of remission following a course of ATD is lower in young people when compared to adults, yet the risk of adverse events is higher. An overall consensus regarding the optimal ATD treatment regimen is lacking; how ATD are prescribed, for how long and how the associated risk of adverse events is managed varies between clinicians, units and nations. This partly reflects clinician and family uncertainty regarding outcomes.Areas covered: This review will focus on some of the key articles published in the field of thionamide ATD in children. It will highlight key issues that need to be discussed with families as well as addressing the approach and controversies in the treatment of GD. This article does not reflect a formal systematic review of the literature.Expert opinion: New strategies in areas such as immunomodulation may see the development of new antithyroid drug treatments that, either in isolation or in combination with thionamide therapy, may increase the likelihood of long-term remission.
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Affiliation(s)
- Laura C Lane
- Translational and Clinical Research Institute, Newcastle University, Newcastle-Upon-Tyne, UK
- Department of Paediatric Endocrinology, The Great North Children's Hospital, Newcastle-Upon-Tyne, UK
| | - Tim Cheetham
- Translational and Clinical Research Institute, Newcastle University, Newcastle-Upon-Tyne, UK
- Department of Paediatric Endocrinology, The Great North Children's Hospital, Newcastle-Upon-Tyne, UK
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Ma YR, Zhao SX, Li L, Sun F, Ye XP, Yuan FF, Jiang D, Zhou Z, Zhang QY, Wan YY, Zhang GY, Wu J, Zhang RJ, Fang Y, Song HD. A Weighted Genetic Risk Score Using Known Susceptibility Variants to Predict Graves Disease Risk. J Clin Endocrinol Metab 2019; 104:2121-2130. [PMID: 30649410 DOI: 10.1210/jc.2018-01551] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/18/2018] [Accepted: 01/09/2019] [Indexed: 01/07/2023]
Abstract
CONTEXT Graves disease (GD) is a common thyroid-specific autoimmune disease and one of the most heritable diseases in the population. We present a risk-prediction model, including confirmed, known genetic variants associated with GD. DESIGN To construct a stable-prediction model, we used known GD susceptibility single nucleotide polymorphisms (SNPs) as markers and trained and tested our model in a cohort of 4897 patients with GD and 5098 healthy controls. We weighted the contribution of each SNP to the disease to calculate the weighted genetic risk score (wGRS) for each individual. The efficiency of this model can be estimated by the area under the curve (AUC) receiver operator characteristic curve and the specificity and sensitivity of each wGRS. RESULTS With the 20 confirmed GD risk-related SNPs, our wGRS-prediction model could predict patients with GD from the general population (AUC 0.70 [95% CI: 0.69 to 0.71]) and did especially well in predicting patients with GD with persisting thyroid-stimulating hormone receptor antibody positive [pTRAb+; AUC 0.74 (95% CI: 0.72 to 0.76)]. We also evaluated how the four pTRAb+ specific risk SNPs predicted patients with GD with pTRAb+ among all patients with GD [AUC 0.62 (95% CI: 0.61 to 0.63)]. For clinical use, we partitioned subjects in each set into different risk categories to generate the wGRS cutoff of high risk for reference. CONCLUSIONS Our study provides an approach to predict GD risk in the general population by the calculation of the wGRS of 20 known GD susceptibility variants. The wGRS-prediction model was more stable and convenient, whereas the prediction performance was still modest.
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Affiliation(s)
- Yu-Ru Ma
- Core Laboratory, Medical Center of Clinical Research, Department of Endocrinology, Shanghai 9th People's Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Shuang-Xia Zhao
- Core Laboratory, Medical Center of Clinical Research, Department of Endocrinology, Shanghai 9th People's Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Lu Li
- Core Laboratory, Medical Center of Clinical Research, Department of Endocrinology, Shanghai 9th People's Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Feng Sun
- Core Laboratory, Medical Center of Clinical Research, Department of Endocrinology, Shanghai 9th People's Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Xiao-Ping Ye
- Core Laboratory, Medical Center of Clinical Research, Department of Endocrinology, Shanghai 9th People's Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Fei-Fei Yuan
- Core Laboratory, Medical Center of Clinical Research, Department of Endocrinology, Shanghai 9th People's Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Dan Jiang
- Department of Endocrinology, Affiliated Hospital of Jiangsu University, Zhenjiang, China
| | - Zheng Zhou
- Department of Endocrinology, Affiliated Hospital of Jiangsu University, Zhenjiang, China
| | - Qian-Yue Zhang
- Core Laboratory, Medical Center of Clinical Research, Department of Endocrinology, Shanghai 9th People's Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Yue-Yue Wan
- Core Laboratory, Medical Center of Clinical Research, Department of Endocrinology, Shanghai 9th People's Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Guang-Ya Zhang
- Core Laboratory, Medical Center of Clinical Research, Department of Endocrinology, Shanghai 9th People's Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Jing Wu
- Core Laboratory, Medical Center of Clinical Research, Department of Endocrinology, Shanghai 9th People's Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Rui-Jia Zhang
- Core Laboratory, Medical Center of Clinical Research, Department of Endocrinology, Shanghai 9th People's Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Ya Fang
- Core Laboratory, Medical Center of Clinical Research, Department of Endocrinology, Shanghai 9th People's Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Huai-Dong Song
- Core Laboratory, Medical Center of Clinical Research, Department of Endocrinology, Shanghai 9th People's Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
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García-Mayor RV, Álvarez-Vázquez P, Fluiters E, Valverde D, Andrade A. Long-term remission following antithyroid drug withdrawal in patients with Graves' hyperthyroidism: parameters with prognostic value. Endocrine 2019; 63:316-322. [PMID: 30334140 DOI: 10.1007/s12020-018-1785-z] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/14/2018] [Accepted: 10/06/2018] [Indexed: 12/19/2022]
Abstract
OBJECTIVE To assess the predictive value of some clinical and biochemical parameters, and of the +49 A/G polymorphism of the CTLA-4 gene, for long-term remission following the withdrawal of antithyroid drugs before starting antithyroid drug therapy. STUDY DESIGN Observational, prospective and longitudinal study. METHODS Seventy-two patients (11 of whom were men) with newly diagnosed Graves' hyperthyroidism who had been attended consecutively at a University Clinic in a population with sufficient iodine intake were included in the study. EXCLUSION CRITERIA patients under the age of 18, pregnant women and non-Caucasian patients. All subjects were treated following a well-defined protocol. Long-term remission was calculated at 12 and 36 months following withdrawal of the antithyroid drug. RESULTS Thirty-six of the 72 study subjects experienced a remission of at least 12 months following withdrawal of methimazole, with no differences according to their age or sex. A comparison made between the remission rates seen in both groups yielded significant differences regarding the presence of Graves' orbitopathy, the duration of the treatment with methimazole and the absence of the CTLA-4 G/G genotype. In the univariate and multivariate analyses performed, only lower frequencies of Graves' orbitopathy and an absence of the CTLA-4 G/G genotype were considered independent predictors of long-term remission. CONCLUSIONS The absence of Graves' orbitopathy and of the CTLA-4 G/G genotype are independent predictors of long-term remission following a first course of antithyroid drugs.
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Affiliation(s)
- Ricardo V García-Mayor
- Endocrine Department, Biomedical Research Institute of Southern Galicia, University Hospital of Vigo, Vigo, Spain.
| | | | | | - Diana Valverde
- Department of Biochemistry, Genetics and Immunology, University of Vigo, Vigo, Spain
| | - Amalia Andrade
- Biochemisty Service, University Hospital of Vigo, Vigo, Spain
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Karmisholt J, Andersen SL, Bulow-Pedersen I, Carlé A, Krejbjerg A, Nygaard B. Predictors of Initial and Sustained Remission in Patients Treated with Antithyroid Drugs for Graves' Hyperthyroidism: The RISG Study. J Thyroid Res 2019; 2019:5945178. [PMID: 30719273 PMCID: PMC6335719 DOI: 10.1155/2019/5945178] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/05/2018] [Revised: 11/14/2018] [Accepted: 12/02/2018] [Indexed: 11/17/2022] Open
Abstract
Purpose. To study predictors of attaining (part 1) and sustaining (part 2) remission in patients with Graves' hyperthyroidism (GH) treated with antithyroid drugs (ATD). Methods. In the prospective first part, the included patients were treated with ATD until a prespecified definition of remission (thyrotropin > 0.4 mU/L and TSH-receptor antibodies (TRAb) ≤ 1. 0 IU/L in a patient receiving a methimazole dose ≤ 5 mg/day, on two occasions two months apart) was met, or for 24 months. In the second part, patients attaining remission in part 1 were randomized to treatment or observation and followed until relapse or for 24 months. Results. 173 patients completed study 1 and 53% attained remission. TRAb and age were the only significant predictors of remission. Patients with baseline TRAb below vs above 10 IU/L attained remission in 63% compared to 39%, and 5 months priorly (p<0.001). In study 2, 96.4% of the patients randomized to treatment (n=33) sustained remission compared to 66% in the observation group (n=33). Treatment arm was the only significant parameter (p<0.001) of sustained remission. Conclusion. Baseline TRAb was prognostic for attaining remission in GH. Consecutive TRAb measurements during treatment were not worthwhile, but a single measurement after 6-8 months in patients with initial TRAb < 10 IU/L could substantially shorten the treatment period in a subgroup of patients. Only 3.6% of the patients in remission experienced relapse during follow-up when treated with a combination of fixed low dose methimazole and L-T4. ClinTrial.gov registration number is NCT00796913.
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Affiliation(s)
- J. Karmisholt
- Dept. of Endocrinology, Aalborg University Hospital, 9000 Aalborg, Denmark
- Dept. of Clinical Institute, Aalborg University, 9100 Aalborg, Denmark
| | - S. L. Andersen
- Dept. of Clinical Biochemistry, Aalborg University Hospital, 9000 Aalborg, Denmark
| | - I. Bulow-Pedersen
- Dept. of Endocrinology, Aalborg University Hospital, 9000 Aalborg, Denmark
- Dept. of Clinical Institute, Aalborg University, 9100 Aalborg, Denmark
| | - A. Carlé
- Dept. of Endocrinology, Aalborg University Hospital, 9000 Aalborg, Denmark
| | - A. Krejbjerg
- Dept. of Oncology, Aalborg University Hospital, 9000 Aalborg, Denmark
| | - B. Nygaard
- Dept. of Endocrinology and Internal Medicine, Herlev Hospital, 2730 Copenhagen, Denmark
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Graves' disease: Introduction, epidemiology, endogenous and environmental pathogenic factors. ANNALES D'ENDOCRINOLOGIE 2018; 79:599-607. [PMID: 30342794 DOI: 10.1016/j.ando.2018.09.002] [Citation(s) in RCA: 46] [Impact Index Per Article: 7.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
Graves' disease is the most frequent cause of hyperthyroidism. Many questions remain about the choice of diagnostic evaluations and treatment strategy according to clinical context (age, gender, pregnancy, etc.) and about the best management of the main extrathyroidal complication that is Graves orbitopathy. The exact pathogenic mechanisms are not fully clear. They associate genetic factors, interactions between endogenous and environmental factors, and immune system dysregulation. Graves' orbitopathy is one of the consequences of this partial understanding. Iatrogenic Graves' disease induced by the new targeted therapies are described and could help to better understand the molecular pathways involved in the disease and to develop new therapeutic approaches.
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18
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Nouvelles perspectives pour le diagnostic et pronostic de la maladie de Basedow. ANNALES D'ENDOCRINOLOGIE 2018; 79 Suppl 1:S31-S39. [DOI: 10.1016/s0003-4266(18)31239-3] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
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19
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Bagir GS, Haydardedeoglu FE, Bakiner OS, Bozkirli E, Ertorer ME. Mean Platelet Volume in Graves' disease: A Sign of Hypermetabolism Rather than Autoimmunity? Pak J Med Sci 2017; 33:871-875. [PMID: 29067056 PMCID: PMC5648955 DOI: 10.12669/pjms.334.12659] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/21/2023] Open
Abstract
Objective: To evaluate the impact of mean platelet volume (MPV) on predicting disease course among patients with Graves’ disease (GD). Methods: This retrospective study was performed between 2013-2016 at the Outpatient Endocrinology Clinic of Baskent University Faculty of Medicine, Adana hospital on 65 patients with GD. Among participants, 30 cases experienced thyrotoxicosis again during the first six months after discontinuing anti-thyroid drug (ATD) sessions that had been carried out for at least 12 months prior to stopping (Relapse group). We also observed 35 patients who exhibited normal thyroid functions within six months following ATD withdrawal (Remission group). MPV levels and thyroid function tests were recorded and total duration of ATD therapy was calculated for all participants. Results: The mean MPV level that was measured at the time of drug withdrawal did not differ between groups, being 8.0±1.2 fL in the Relapse group vs. 8.0±1.0 fL in the Remission group (p=0.81). However, we found that the relapse MPV was higher than the withdrawal MPV in the Relapse group (9.2±1.3 fL) than it was in the Remission group (8.0±1.2 fL, p=0.00). Conclusions: Higher relapse MPV in Relapse group but similar MPV levels in both groups at ATD withdrawal may be attributed to hypermetabolism or hyperthyroidism rather than autoimmunity of GD. Abbreviations: BMI: Body mass index GD: Graves’ disease MPV: Mean platelet volume TSH: Thyroid-stimulating hormone TRAbs: Thyrotropin receptor antibodies ATD: Anti-thyroid drug fT4: Free thyroxine fT3: Free triiodothyronine CBC: Complete blood count PTC: Papillary thyroid carcinoma
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Affiliation(s)
- Gulay Simsek Bagir
- Gulay Simsek Bagir, MD. Baskent University Faculty of Medicine, Division of Endocrinology Adana, Turkey
| | - Filiz Eksi Haydardedeoglu
- Filiz Eksi Haydardedeoglu, MD. Baskent University Faculty of Medicine, Division of Endocrinology Adana, Turkey
| | - Okan Sefa Bakiner
- Okan Sefa Bakiner, Associate Professor of Endocrinology, Baskent University Faculty of Medicine, Division of Endocrinology Adana, Turkey
| | - Emre Bozkirli
- Emre Bozkirli, Associate Professor of Endocrinology, Baskent University Faculty of Medicine, Division of Endocrinology Adana, Turkey
| | - Melek Eda Ertorer
- Melek Eda Ertorer, Professor of Endocrinology, Baskent University Faculty of Medicine, Division of Endocrinology Adana, Turkey
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Liu J, Fu J, Xu Y, Wang G. Antithyroid Drug Therapy for Graves' Disease and Implications for Recurrence. Int J Endocrinol 2017; 2017:3813540. [PMID: 28529524 PMCID: PMC5424485 DOI: 10.1155/2017/3813540] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/18/2016] [Revised: 03/29/2017] [Accepted: 04/02/2017] [Indexed: 12/12/2022] Open
Abstract
Graves' disease (GD) is the most common cause of hyperthyroidism worldwide. Current therapeutic options for GD include antithyroid drugs (ATD), radioactive iodine, and thyroidectomy. ATD treatment is generally well accepted by patients and clinicians due to some advantages including normalizing thyroid function in a short time, hardly causing hypothyroidism, and ameliorating immune disorder while avoiding radiation exposure and invasive procedures. However, the relatively high recurrence rate is a major concern for ATD treatment, which is associated with multiple influencing factors like clinical characteristics, treatment strategies, and genetic and environmental factors. Of these influencing factors, some are modifiable but some are nonmodifiable. The recurrence risk can be reduced by adjusting the modifiable factors as much as possible. The titration regimen for 12-18 months is the optimal strategy of ATD. Levothyroxine administration after successful ATD treatment was not recommended. The addition of immunosuppressive drugs might be helpful to decrease the recurrence rate of GD patients after ATD withdrawal, whereas further studies are needed to address the safety and efficacy. This paper reviewed the current knowledge of ATD treatment and mainly focused on influencing factors for recurrence in GD patients with ATD treatment.
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Affiliation(s)
- Jia Liu
- Department of Endocrinology, Beijing Chao-Yang Hospital, Capital Medical University, Beijing 100020, China
| | - Jing Fu
- Department of Endocrinology, Beijing Chao-Yang Hospital, Capital Medical University, Beijing 100020, China
| | - Yuan Xu
- Department of Endocrinology, Beijing Chao-Yang Hospital, Capital Medical University, Beijing 100020, China
| | - Guang Wang
- Department of Endocrinology, Beijing Chao-Yang Hospital, Capital Medical University, Beijing 100020, China
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Struja T, Fehlberg H, Kutz A, Guebelin L, Degen C, Mueller B, Schuetz P. Can we predict relapse in Graves' disease? Results from a systematic review and meta-analysis. Eur J Endocrinol 2017; 176:87-97. [PMID: 27780830 DOI: 10.1530/eje-16-0725] [Citation(s) in RCA: 43] [Impact Index Per Article: 6.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/24/2016] [Revised: 09/30/2016] [Accepted: 10/20/2016] [Indexed: 11/08/2022]
Abstract
BACKGROUND Identification of pretreatment risk factors predicting relapse in patients with hyperthyroidism of Graves' disease after stopping anti-thyroid drugs (ATD) is decisive to guide therapeutic options. PURPOSE We performed a systematic search and meta-analysis to study predictors for relapse after stopping ATD in patients with Graves' disease. METHODS Based on a pre-specified protocol, we searched PubMed, EMBASE and Cochrane in July 2015 for case-control, controlled and randomized-controlled trials reporting risk factors for relapse after stopping ATD. The primary endpoint was relapse of disease until follow-up. PRISMA and SIGN statements were used for reviewing the data and assessing the quality of included trials. RESULTS We included 54 trials with a total of 7595 participants. Most trials were small with moderate-to-high risk for bias. Ten trials were assessed only qualitatively (2227 patients), genomic data were reported in 13 trials (2178 patients) and 31 trials (4346 patients) were assessed quantitatively. In total, there were 3696 relapses in 7595 patients (48.7%). By using random-effects meta-analysis, orbitopathy, smoking, thyroid volume measured by sonography, goiter size, fT4, tT3, TRAb and TBII were significantly associated with relapse, whereas male vs female sex, age and initial tT4 level did not show significant associations. CONCLUSIONS This analysis found several risk factors to predict relapse in Graves' disease, which can be combined in a risk score. Prospective studies should evaluate the prognostic accuracy of such a score to guide treatment decisions.
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Affiliation(s)
- Tristan Struja
- Medical University DepartmentClinic for Endocrinology, Diabetes & Metabolism, Kantonsspital Aarau, Aarau, Switzerland
| | - Hannah Fehlberg
- Medical University DepartmentClinic for Endocrinology, Diabetes & Metabolism, Kantonsspital Aarau, Aarau, Switzerland
| | - Alexander Kutz
- Medical University DepartmentClinic for Endocrinology, Diabetes & Metabolism, Kantonsspital Aarau, Aarau, Switzerland
| | - Larissa Guebelin
- Medical University DepartmentClinic for Endocrinology, Diabetes & Metabolism, Kantonsspital Aarau, Aarau, Switzerland
| | - Christian Degen
- Medical University DepartmentClinic for Endocrinology, Diabetes & Metabolism, Kantonsspital Aarau, Aarau, Switzerland
| | - Beat Mueller
- Medical University DepartmentClinic for Endocrinology, Diabetes & Metabolism, Kantonsspital Aarau, Aarau, Switzerland
- Medical Faculty of the University of BaselBasel, Switzerland
| | - Philipp Schuetz
- Medical University DepartmentClinic for Endocrinology, Diabetes & Metabolism, Kantonsspital Aarau, Aarau, Switzerland
- Medical Faculty of the University of BaselBasel, Switzerland
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Pawlak-Adamska E, Frydecka I, Bolanowski M, Tomkiewicz A, Jonkisz A, Karabon L, Partyka A, Nowak O, Szalinski M, Daroszewski J. CD28/CTLA-4/ICOS haplotypes confers susceptibility to Graves' disease and modulates clinical phenotype of disease. Endocrine 2017; 55:186-199. [PMID: 27638540 PMCID: PMC5225215 DOI: 10.1007/s12020-016-1096-1] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/08/2016] [Accepted: 08/17/2016] [Indexed: 11/30/2022]
Abstract
Graves' disease, an autoimmune disease with heterogeneous symptoms including Graves' orbitopathy, has a combined genetic/environmental background, where variations within CD28/CTLA-4/ICOS genes are considered as disease markers.Association of CD28c.17+3T>C(rs3116496), CTLA-4g.319C>T(rs5742909), CTLA-4c.49A>G(rs231775), CTLA-4g.*642AT(8_33), CT60(rs3087243), Jo31(rs11571302), ICOSc.1554+4GT(8_15) polymorphisms with susceptibility to Graves' disease and clinical outcome was investigated. The study group comprised of 561 Polish Caucasians, including 172 unrelated Graves' disease patients. CTLA-4c.49A>G, CTLA-4g.319C>T, and CT60 were genotyped by PCR-RFLP; Jo31 and CD28c.17+3C>T by minisequencing; CTLA-4g.*642AT(8_33) and ICOSc.1554+4GT(8_15)-PCR and fluorescence-based technique. CD28c.17+3T>C(rs3116496)T/CTLA-4g.319C>T(rs5742909)C/CTLA-4c.49A>G(rs231775)G/CTLA-4g.*642AT(8_33)(AT16-21)/CT60(rs3087243)G/Jo31(rs11571302)G/ICOSc.1554+4GT(8_15)(m) and TCA(AT<16)GT(m) haplotypes increased risk of Graves' disease, especially in males, as well as overall Graves' orbitopathy development with severe outcome. TCG(AT16-21)GG(l) haplotype increased risk of Graves' disease and reduced the chance of successful medical treatment. Although this haplotype was mainly observed in patients without signs of Graves' orbitopathy, if Graves' orbitopathy developed it favored a Graves' orbitopathy outcome. Haplotype TCA(AT>21)GT(m) increased Graves' disease risk in women and, in all patients, was linked to Graves' disease without Graves' orbitopathy. TCG(AT<16)GG(m) haplotype was predominantly observed in patients without Graves' orbitopathy, whereas TCA(AT16-21)GG(m) was absent in those patients. TCA(AT16-21)GG(m) occurred in patients with a mild Graves' orbitopathy outcome. The marker CTLA-4g.*642AT(8_33) was the only independent Graves' disease risk factor, whereas CT60 was an independent factor for disease progression. Sporadic Graves' disease was related to presence of CTLA-4c.49A>G[A] and the rare CTLA-4g.319C>T[T] allele variant. Familial background of the disease was exclusively associated with CTLA-4g.*642AT(8_33)[AT>21]/[AT>21] genotype. CD28/CTLA-4/ICOS loci may confer inherited susceptibility to Graves' disease or may be involved in susceptibility to Graves' disease and play a pathogenetic role.
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Affiliation(s)
- Edyta Pawlak-Adamska
- Department of Experimental Therapy, Hirszfeld Institute of Immunology and Experimental Therapy, Polish Academy of Sciences, R. Weigl 12, Wroclaw, 53-114, Poland.
| | - Irena Frydecka
- Department of Experimental Therapy, Hirszfeld Institute of Immunology and Experimental Therapy, Polish Academy of Sciences, R. Weigl 12, Wroclaw, 53-114, Poland
| | - Marek Bolanowski
- Department of Endocrinology, Diabetes and Isotope Therapy, Wroclaw Medical University, L. Pasteur 4, Wroclaw, 50-367, Poland
| | - Anna Tomkiewicz
- Department of Experimental Therapy, Hirszfeld Institute of Immunology and Experimental Therapy, Polish Academy of Sciences, R. Weigl 12, Wroclaw, 53-114, Poland
| | - Anna Jonkisz
- Department of Forensic Medicine, Wroclaw Medical University, M. Curie-Sklodowska 52, Wroclaw, 50-369, Poland
| | - Lidia Karabon
- Department of Experimental Therapy, Hirszfeld Institute of Immunology and Experimental Therapy, Polish Academy of Sciences, R. Weigl 12, Wroclaw, 53-114, Poland
| | - Anna Partyka
- Department of Experimental Therapy, Hirszfeld Institute of Immunology and Experimental Therapy, Polish Academy of Sciences, R. Weigl 12, Wroclaw, 53-114, Poland
| | - Oskar Nowak
- Department of Human Evolutionary Biology, Institute of Anthropology, Adam Mickiewicz University, Umultowska 89, Poznan, 61-614, Poland
| | - Marek Szalinski
- Department of Ophthalmology, Wroclaw Medical University, Borowska 213, Wroclaw, 50-556, Poland
| | - Jacek Daroszewski
- Department of Endocrinology, Diabetes and Isotope Therapy, Wroclaw Medical University, L. Pasteur 4, Wroclaw, 50-367, Poland
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Liu J, Fu J, Duan Y, Wang G. Predictive Value of Gene Polymorphisms on Recurrence after the Withdrawal of Antithyroid Drugs in Patients with Graves' Disease. Front Endocrinol (Lausanne) 2017; 8:258. [PMID: 29085334 PMCID: PMC5649185 DOI: 10.3389/fendo.2017.00258] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/02/2017] [Accepted: 09/19/2017] [Indexed: 12/20/2022] Open
Abstract
Graves' disease (GD) is one of the most common endocrine diseases. Antithyroid drugs (ATDs) treatment is frequently used as the first-choice therapy for GD patients in most countries due to the superiority in safety and tolerance. However, GD patients treated with ATD have a relatively high recurrence rate after drug withdrawal, which is a main limitation for ATD treatment. It is of great importance to identify some predictors of the higher recurrence risk for GD patients, which may facilitate an appropriate therapeutic approach for a given patient at the time of GD diagnosis. The genetic factor was widely believed to be an important pathogenesis for GD. Increasing studies were conducted to investigate the relationship between gene polymorphisms and the recurrence risk in GD patients. In this article, we updated the current literatures to highlight the predictive value of gene polymorphisms on recurrence risk in GD patients after ATD withdrawal. Some gene polymorphisms, such as CTLA4 rs231775, human leukocyte antigen polymorphisms (DRB1*03, DQA1*05, and DQB1*02) might be associated with the high recurrence risk in GD patients. Further prospective studies on patients of different ethnicities, especially studies with large sample sizes, and long-term follow-up, should be conducted to confirm the predictive roles of gene polymorphism.
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Affiliation(s)
- Jia Liu
- Department of Endocrinology; Beijing Chao-Yang Hospital, Capital Medical University, Beijing, China
| | - Jing Fu
- Department of Endocrinology; Beijing Chao-Yang Hospital, Capital Medical University, Beijing, China
| | - Yan Duan
- Department of Endocrinology; Beijing Chao-Yang Hospital, Capital Medical University, Beijing, China
| | - Guang Wang
- Department of Endocrinology; Beijing Chao-Yang Hospital, Capital Medical University, Beijing, China
- *Correspondence: Guang Wang,
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Langenstein C, Schork D, Badenhoop K, Herrmann E. Relapse prediction in Graves´ disease: Towards mathematical modeling of clinical, immune and genetic markers. Rev Endocr Metab Disord 2016; 17:571-581. [PMID: 27638651 DOI: 10.1007/s11154-016-9386-8] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/13/2023]
Abstract
PROBLEM Graves' disease (GD) is an important and prevalent thyroid autoimmune disorder. Standard therapy for GD consists of antithyroid drugs (ATD) with treatment periods of around 12 months but relapse is frequent. Since predictors for relapse are difficult to identify the individual decision making for optimal treatment is often arbitrary. METHODS After reviewing the literature on this topic we summarize important factors involved in GD and with respect to their potential for relapse prediction from markers before and after treatment. This information was used to design a mathematical model integrating thyroid hormone parameters, thyroid size, antibody titers and a complex algorithm encompassing genetic predisposition, environmental exposures and current immune activity in order to arrive at a prognostic index for relapse risk after treatment. CONCLUSION In the search for a tool to analyze and predict relapse in GD mathematical modeling is a promising approach. In analogy to mathematical modeling approaches in other diseases such as viral infections, we developed a differential equation model on the basis of published clinical trials in patients with GD. Although our model needs further evaluation to be applicable in a clinical context, it provides a perspective for an important contribution to a final statistical prediction model.
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Affiliation(s)
- Christoph Langenstein
- Institute of Biostatistics and Mathematical Modeling - Department of Medicine, Goethe University Frankfurt, Theodor-Stern-Kai 7, Frankfurt am Main, 60590, Germany.
| | - Diana Schork
- Department of Medicine 1 - Division of Endocrinology & Diabetes, Goethe University Hospital Frankfurt, Frankfurt am Main, Germany
| | - Klaus Badenhoop
- Department of Medicine 1 - Division of Endocrinology & Diabetes, Goethe University Hospital Frankfurt, Frankfurt am Main, Germany
| | - Eva Herrmann
- Institute of Biostatistics and Mathematical Modeling - Department of Medicine, Goethe University Frankfurt, Theodor-Stern-Kai 7, Frankfurt am Main, 60590, Germany
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Bartalena L, Chiovato L, Vitti P. Management of hyperthyroidism due to Graves' disease: frequently asked questions and answers (if any). J Endocrinol Invest 2016; 39:1105-14. [PMID: 27319009 DOI: 10.1007/s40618-016-0505-x] [Citation(s) in RCA: 38] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/30/2016] [Accepted: 06/11/2016] [Indexed: 02/03/2023]
Abstract
Graves' disease is the most common cause of hyperthyroidism in iodine-replete areas. Although progress has been made in our understanding of the pathogenesis of the disease, no treatment targeting pathogenic mechanisms of the disease is presently available. Therapies for Graves' hyperthyroidism are largely imperfect because they are bound to either a high rate of relapsing hyperthyroidism (antithyroid drugs) or lifelong hypothyroidism (radioiodine treatment or thyroidectomy). Aim of the present article is to offer a practical guidance to the reader by providing evidence-based answers to frequently asked questions in clinical practice.
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Affiliation(s)
- L Bartalena
- Endocrine Unit, Department of Clinical and Experimental Medicine, ASST dei Sette Laghi, Ospedale di Circolo, University of Insubria, Viale Borri, 57, Varese, Italy.
| | - L Chiovato
- Fondazione Salvatore Maugeri and University of Pavia, Pavia, Italy
| | - P Vitti
- Department of Clinical and Experimental Medicine, University of Pisa, Pisa, Italy
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Association of CD40 Gene Polymorphisms with Susceptibility to Neuromyelitis Optica Spectrum Disorders. Mol Neurobiol 2016; 54:5236-5242. [PMID: 27578014 DOI: 10.1007/s12035-016-0070-5] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/25/2016] [Accepted: 08/18/2016] [Indexed: 02/05/2023]
Abstract
The CD40 gene is associated with many autoimmune diseases; however, there are few studies in literatures that investigate the association between CD40 and neuromyelitis optica spectrum disorders (NMOSD). This study aimed to estimate the potential association of CD40 gene polymorphisms with susceptibility to NMOSD. Four SNPs (rs1883832, rs3765459, rs4810485, and rs6074022) were selected and genotyped in a Chinese cohort comprising 162 patients with NMOSD and 237 healthy controls. P values, odds ratios (ORs), and 95 % confidential intervals (CI) for four test models (allelic, additive, dominant, and recessive) were used to assess relationships between CD40 and NMOSD. Results showed that the rs3765459 variant was significantly associated with increased risk of NMOSD in allelic model (OR = 1.48, 95 % CI 1.10-1.98, P = 0.009, P corr = 0.037), and similar results were detected in the additive and recessive models (OR = 1.47, 95 % CI 1.09-1.97, P = 0.010, P corr = 0.042; OR = 2.12, 95 % CI 1.18-3.8, P = 0.012, P corr = 0.048, respectively). Other three SNPs showed protections on NMOSD in dominant models (rs6074022, OR = 0.64, 95 % CI 0.42-0.95, P = 0.031; rs1883832, OR = 0.65, 95 % CI 0.43-0.97, P = 0.036; and rs4810485, OR = 0.63, 95 % CI 0.42-0.95, P = 0.029, respectively), but not significantly after Bonferroni corrections for multiple tests. In addition, haplotype analysis of these SNPs in tight linkage did not reveal significant association with NMOSD. This study indicates that the rs3765459 variant in CD40 gene is associated with susceptibility to NMOSD. Larger sample size studies in other ethnicities are needed to verify this association.
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Piantanida E, Lai A, Sassi L, Gallo D, Spreafico E, Tanda ML, Bartalena L. Outcome Prediction of Treatment of Graves' Hyperthyroidism with Antithyroid Drugs. Horm Metab Res 2015. [PMID: 26197855 DOI: 10.1055/s-0035-1555759] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
Graves' disease is the most common cause of hyperthyroidism in iodine-replete areas and is ultimately due to antibodies interacting with the TSH receptor on thyroid follicular cells [TSH-receptor antibody (TRAb)]. Antithyroid drugs (ATDs) belonging to the family of thionamides are the first-line treatment in Europe. ATD treatment is commonly continued for 18-24 months. Its major limitation is the high rate of relapses after drug withdrawal. Factors particularly bound to subsequent relapses are the large thyroid volume, smoking habit, persistence of TRAb in the circulation at the end of treatment, and the post-partum period. Under these conditions, consideration should be given to a definitive therapy for hyperthyroidism (radioiodine treatment, thyroidectomy), particularly if the patient is at risk of cardiovascular complications that might be exacerbated by persistence or recurrence of hyperthyroidism.
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Affiliation(s)
- E Piantanida
- Department of Clinical and Experimental Medicine, University of Insubria, Varese, Italy
| | - A Lai
- Department of Clinical and Experimental Medicine, University of Insubria, Varese, Italy
| | - L Sassi
- Department of Clinical and Experimental Medicine, University of Insubria, Varese, Italy
| | - D Gallo
- Department of Clinical and Experimental Medicine, University of Insubria, Varese, Italy
| | - E Spreafico
- Department of Clinical and Experimental Medicine, University of Insubria, Varese, Italy
| | - M L Tanda
- Department of Clinical and Experimental Medicine, University of Insubria, Varese, Italy
| | - L Bartalena
- Department of Clinical and Experimental Medicine, University of Insubria, Varese, Italy
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28
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Lee HJ, Li CW, Hammerstad SS, Stefan M, Tomer Y. Immunogenetics of autoimmune thyroid diseases: A comprehensive review. J Autoimmun 2015; 64:82-90. [PMID: 26235382 DOI: 10.1016/j.jaut.2015.07.009] [Citation(s) in RCA: 197] [Impact Index Per Article: 21.9] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/13/2015] [Accepted: 07/15/2015] [Indexed: 12/13/2022]
Abstract
Both environmental and genetic triggers factor into the etiology of autoimmune thyroid disease (AITD), including Graves' disease (GD) and Hashimoto's thyroiditis (HT). Although the exact pathogenesis and causative interaction between environment and genes are unknown, GD and HT share similar immune-mediated mechanisms of disease. They both are characterized by the production of thyroid autoantibodies and by thyroidal lymphocytic infiltration, despite being clinically distinct entities with thyrotoxicosis in GD and hypothyroidism in HT. Family and population studies confirm the strong genetic influence and inheritability in the development of AITD. AITD susceptibility genes can be categorized as either thyroid specific (Tg, TSHR) or immune-modulating (FOXP3, CD25, CD40, CTLA-4, HLA), with HLA-DR3 carrying the highest risk. Of the AITD susceptibility genes, FOXP3 and CD25 play critical roles in the establishment of peripheral tolerance while CD40, CTLA-4, and the HLA genes are pivotal for T lymphocyte activation and antigen presentation. Polymorphisms in these immune-modulating genes, in particular, significantly contribute to the predisposition for GD, HT and, unsurprisingly, other autoimmune diseases. Emerging evidence suggests that single nucleotide polymorphisms (SNPs) in the immunoregulatory genes may functionally hinder the proper development of central and peripheral tolerance and alter T cell interactions with antigen presenting cells (APCs) in the immunological synapse. Thus, susceptibility genes for AITD contribute directly to the key mechanism underlying the development of organ-specific autoimmunity, namely the breakdown in self-tolerance. Here we review the major immune-modulating genes that are associated with AITD and their potential functional effects on thyroidal immune dysregulation.
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Affiliation(s)
- Hanna J Lee
- Division of Endocrinology, Department of Medicine, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Cheuk Wun Li
- Division of Endocrinology, Department of Medicine, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Sara Salehi Hammerstad
- Division of Endocrinology, Department of Medicine, Icahn School of Medicine at Mount Sinai, New York, NY, USA; Department of Pediatrics, Oslo University Hospital, Ullevål, Oslo, Norway
| | - Mihaela Stefan
- Division of Endocrinology, Department of Medicine, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Yaron Tomer
- Division of Endocrinology, Department of Medicine, Icahn School of Medicine at Mount Sinai, New York, NY, USA; Bronx VA Medical Center, Bronx, NY, USA.
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Effraimidis G, Wiersinga WM. Mechanisms in endocrinology: autoimmune thyroid disease: old and new players. Eur J Endocrinol 2014; 170:R241-52. [PMID: 24609834 DOI: 10.1530/eje-14-0047] [Citation(s) in RCA: 203] [Impact Index Per Article: 20.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
The last 10 years have seen some progress in understanding the etiology of autoimmune thyroid disease (AITD). The female preponderance can now be explained - at least in part - by fetal microchimerism and X-chromosome inactivation. The number of identified susceptibility genes for AITD is increasing (among others now including TSHR, TG, HLA, CTLA4, PTPN22, CD40, FCRL3, IL2RA, and FOXP3), but these genes together probably do not explain more than about 10% of the heritability of AITD. As twin studies indicate that genes contribute for 70% of AITD, it follows that there must be many more loci, each of them contributing a little. While the genetic studies have clarified why various autoimmune diseases so often cluster in the same patient, the molecular mechanism of action of these genetic polymorphisms (frequently located in introns) has hardly been explained. Polymorphisms in AITD susceptibility genes may become helpful in clinical practice, e.g. in assessing risk of recurrent Graves' hyperthyroidism (GH) after a course of antithyroid drugs. Moderate alcohol intake decreases the risk on overt GH and overt Hashimoto's hypothyroidism. Current smokers - as well known - are at increased risk for Graves' disease, but - surprisingly - at diminished risk for Hashimoto's thyroiditis. Low selenium and low vitamin D levels might increase the risk of developing AITD, but data are still inconclusive. Current options for preventive interventions in subjects at risk to develop AITD are very limited.
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Affiliation(s)
- Grigoris Effraimidis
- Department of Endocrinology and MetabolismAcademic Medical Center, Room F5-169, University of Amsterdam, Meibergdreef 9, Amsterdam 1105AZ, The Netherlands
| | - Wilmar M Wiersinga
- Department of Endocrinology and MetabolismAcademic Medical Center, Room F5-169, University of Amsterdam, Meibergdreef 9, Amsterdam 1105AZ, The Netherlands
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