Table 5 Summary of best practice recommendations for the role of TRAbs in the diagnosis, prognostication, prediction and monitoring of Graves’ disease
Recommendation | Quality of evidence | Strength of Recommendation |
|---|---|---|
R1. The measurement of TRAbs is a sensitive and specific tool for differential diagnosis of thyrotoxicosis | High/ Moderate | Strong |
R2. The measurement of TRAbs is a sensitive and specific tool for accurate and rapid diagnosis of Graves’ disease | High/ Moderate | Strong |
R3. Baseline levels of TRAbs, along with other clinical indicators, can help in predicting treatment response to therapy in Graves’ Disease | Moderate | Strong |
R4. Baseline levels of TRAbs can help in predicting prognosis and recurrence of Graves’ Disease, especially in young individuals | Moderate | Strong |
R5. Measurement of serum TRAb levels after 12–18 months of ATD therapy should inform decision regarding further management of Graves’ disease | High/ Moderate | Strong |
R6. Antithyroid therapy with either ATDs or RAI or thyroidectomy should be offered to patients in whom serum TRAbs levels are persistently high after 12–18 months of therapy with ATDs | High/ Moderate | Strong |
R7. Evidence is insufficient to recommend regular TRAb level estimation in addition to fT4 and TSH levels for monitoring antithyroid drug (ATD) treatment response in Graves’ disease | Moderate/ Low | Conditional |
R8. TRAbs levels among female GD patients who are planning conception guide treatment selection | High/ Moderate | Strong |
R9. Definitive therapy (radioactive iodine therapy or thyroid surgery) may be recommended over ATD if TRAbs levels are very high | High/ Moderate | Strong |
R10. Low maternal TRAbs levels, in addition to other indicators such as disease history, goitre size, duration of therapy, and clinical indicators, can be considered while deciding to withhold ATD therapy among pregnant GD women who achieve clinical and biochemical euthyroid state | Low | Conditional |
R11. All pregnant women with current GD irrespective of treatment status, euthyroid pregnant women with past GD, and women with history of delivering an infant with neonatal hypothyroidism, must undergo TRAbs estimation to evaluate the risk of foetal and neonatal thyroid dysfunction, first contact with antenatal care team | High | Strong |
R12. TRABs helps in the differential diagnosis of GD from gestational thyrotoxicosis | High | Strong |
R13. If TRAbs levels are elevated in early pregnancy, the levels must be reassessed at weeks 18–22, and again at weeks 30–34, to evaluate the need for monitoring the neonate for thyroid dysfunction | High | Strong |
R14. High maternal serum TRAbs level in women with GD during 2nd trimester is prognostic for development of neonatal hyperthyroidism | High | Strong |
R15. Maternal TRAbs level estimation should guide ATD dose modification when there is evidence of foetal goitre in women with GD on ATD therapy | High | Strong |
R16. Elevated TRAbs levels in newborn serum or cord blood, along with elevated thyroid hormone levels, should inform the initiation of ATD therapy in the neonate | High | Strong |
R17. Postpartum TRAbs measurement may help distinguish postpartum thyroiditis presenting as clinical hyperthyroidism from GD | Low/ Moderate | Conditional |
R18. Low TRAbs level, along with small thyroid gland size, are associated with higher possibility of remission in paediatric GD | Moderate | Strong |
R19. Stopping of ATD therapy in paediatric GD patients should be based on TRAbs level after at least 3 years of ATD therapy, and treatment should be continued for 5 years or potentially longer for patients with high TRAbs levels | Moderate | Strong |
R20. Baseline TRAbs value can provide prognosis about the risk of patients developing severe TAO, but evidence is insufficient to recommend using TRAbs level for treatment decisions in TAO | Low/ Moderate | Conditional |
R21. Evidence is not sufficient to recommend TRAbs estimation for diagnosis, prognosis, or management of Graves’ dermopathy | Low/ Moderate | Conditional |