摘要：INTRODUCTION:AutoimmunityagainsttheTSHreceptorisakeypathogenicelementinGraves'disease.Theautoimmuneaberrationmaybemodifiedbytherapyofthehyperthyroidism.OBJECTIVE:TocomparetheeffectsofthecommontypesoftherapyforGraves'hyperthyroidismonTSH-receptorautoimmunity.METHODS:PatientswithnewlydiagnosedGraves'hyperthyroidismaged20-55yearswererandomizedtomedicaltherapy,thyroidsurgery,orradioiodinetherapy（radioiodinewasonlygiventopatients>or=35yearsofage）.L-thyroxine（L-T4）wasaddedtotherapyasappropriatetokeeppatientseuthyroid.Anti-thyroiddrugswerewithdrawnafter18monthsoftherapy.TSH-receptorantibodies（TRAb）inserumweremeasuredbeforeandfor5yearsaftertheinitiationoftherapy.RESULTS:Medicaltherapy（n=48）andsurgery（n=47）werefollowedbyagradualdecreaseinTRAbinserum,withthedisappearanceofTRAbin70-80%ofthepatientsafter18months.Radioiodinetherapy（n=36）ledtoa1-yearlongworseningofautoimmunityagainsttheTSHreceptor,andthenumberofpatientsenteringremissionofTSH-receptorautoimmunitywiththedisappearanceofTRAbfromserumduringthefollowingyearswasconsiderablylowerthanwiththeothertypesoftherapy.CONCLUSION:ThemajorityofpatientswithGraves'diseasegraduallyenterremissionofTSH-receptorautoimmunityduringmedicaloraftersurgicaltherapy,withnodifferencebetweenthetypesoftherapy.RemissionofTSH-receptorautoimmunityafterradioiodinetherapyislesscommon.专家评价：PatriceRodienwithDrFrédéricIllouzUniversityofAngers,FranceDIABETES&ENDOCRINOLOGYThisprospectiveSwedishstudyisinterestingsinceitclarifiesthemanagementoftheTSH-receptorautoimmunityinGraves'disease.Iftheobjectiveoftreatmentistoobtainnegativeautoimmunity,surgeryorantithyroiddrugsappeartobethemostefficient.ThesetherapiescouldbeproposedinsubjectswithGraves'orbitopathyorinwomenwithautoimmunethyroiddisorderswhoaretryingtobecomepregnant.TheauthorsstudythekineticofTSH-receptorantibodies（TRAb）inthethreedifferenttreatmentsofGraves'diseaseforthefirsttime.Onehundredandthirty-onesubjectswererandomlyassignedtoantithyroiddrugs（methimazoleinfirstchoice）plusL-thyroxine,subtotalthyroidectomyplusL-thyroxineorradioiodine（RAI）with120grayfor18months.ThepresenceandlevelsofTRAbwereanalysedbeforeandduringthefive-yearfollow-up.TheserumthyroidhormoneandbaselineTRAbvalueswerenotsignificantlydifferentbetweenthethreegroups.Amongtheantithyroiddrugandsurgerygroups,TRAbdecreasedrapidlyinthefirstyear,whereas,onthecontrary,thisdecreasewasslowerandprecededbyantransitionalincreaseintheRAIgroup.Afterfiveyears,thesubjectsbecameTRAb-negativetoalesserdegreeinRAIthaninthesurgeryandmethimazolegroups.Inotesomelimitationsandcommentsinthiswork,however.Afewsubjectswithantithyroiddrugswereexcludedbecauseofaninefficienttreatmentorarecurrenthyperthyroidism.Intheantithyroiddruggroups,theTRAbdisappearanaverageninemonthsafterofstartingmedications;however,thisstudydoesnotallowcorrelatingTRAbautoimmunitywiththedurationofmethimazole.Thus,theoptimaldurationofmethimazolecannotberecommended.Finally,thisstudydoesnotseparatetheeffectsofthetherapyitselffromthecorrectionofhyperthyroidism.Indeed,theauthorsdonotspecifytheperiodofhyperthyroidismineachgroup,whichmaymodulatetheTRAbautoimmunity.Nonetheless,excludingtheproblemofradioactiveradiationsinwomenwithautoimmunethyroiddisorderswhoaretryingtobecomepregnant,IthinktheoptimaltreatmentforGraves'diseaseisnowsurgeryratherthanRAI.
摘要：前言：针对TSH受体的自身免疫是Graves'病的一个关键的致病要素。通过治疗甲状腺功能亢进可能减轻自身免疫的异常。目的：比较治疗Graves'病甲状腺功能亢进通常疗法对TSH受体自身免疫的效应。方法：将年龄在20～55岁的初诊Graves'病甲状腺功能亢进患者随机分为药物治疗组，甲状腺手术组或放射性碘治疗（放射性碘治疗在>或=35岁的患者中进行）。左旋甲状腺素（L-T4）在适当的时候加入治疗，以维持患者甲状腺功能正常。抗甲状腺药物治疗18个月后停药。血清TSH受体抗体（TRAb）在治疗前及起始治疗后的5年进行检测。结果：药物治疗（n=48）和外科手术治疗（n=47）后，患者血清TRAb逐渐下降，在治疗18个月后70～80％的患者血清中TRAb消失。放射性碘治疗（n=36）导致长达1年的对TSH受体自身免疫的加重，在随后几年中TSH受体自身免疫减轻即血清中TRAb消失的患者数目明显低于另两种治疗。结论：大多数Graves'病患者在药物或手术治疗之后，逐渐进入TSH受体自身免疫减轻的阶段，这两种治疗方法之间没有差异。放射性碘治疗后TSH受体自身免疫减轻的现象不太常见。专家评价：PatriceRodienwithDrFrédéricIllouz昂热大学,法国糖尿病和内分泌学这项瑞典的前瞻性研究阐明了在Graves'病中处理TSH受体的自身免疫，是一项有趣的研究。如果治疗的目标是自身免疫的减轻或消失，手术或抗甲状腺药物是最为有效的。这些疗法可向Graves眼病或者正试图怀孕的有自身免疫性甲状腺疾病的妇女提议。作者首次研究了Graves'病经3种不同治疗后TSH受体抗体（TRAb）的动态变化。131位受试者随机分为抗甲状腺药物（首选甲巯咪唑）加左旋甲状腺素组，甲状腺次全切除术加左旋甲状腺素组或120gray放射性碘治疗（RAI）组，治疗时间为18个月。在治疗前以及5年的随访期内分析血清中TRAb的存在及其水平。3组中血清甲状腺激素和基线TRAb值没有显著差异。在抗甲状腺药物和外科手术治疗组，第一年TRAb即迅速下降。然而在RAI组，先出现了暂时性的TRAb上升，随后下降，但下降较前两组慢。5年后，TRAb阴性的受试者RAI组少于外科手术和甲巯咪唑组。但我也注意到本研究的局限性并对之进行评论。有少数接受抗甲状腺药物治疗的受试者从该研究中被排除，主要是因为治疗无效或者是甲状腺功能亢进的复发。在抗甲状腺药物治疗组，TRAb在开始服药后平均9个月消失；但是本研究并没有将TRAb自身免疫与甲巯咪唑服药持续时间联系起来。因此，甲巯咪唑的最佳服用维持时间无从推荐。最后，本研究没有将治疗本身的效应与甲状腺功能亢进得以纠正进行区分。的确，作者没有详细说明每一组患者甲状腺功能亢进所处阶段，而疾病阶段也可以调控TRAb的自身免疫。不管怎样，除了正试图怀孕的有自身免疫性甲状腺疾病的妇女接受放射性辐射存在问题之外，我认为目前Graves'病最佳的治疗是外科手术而非RAI。
