How to restore euthyroidism in the presence of Graves orbitopathy? Is there a best way?
Around 50% of patients with Graves disease (GD) have Graves orbitopathy (GO). However, only 510% have overt active disease which merits more than symptomatic treatment. Clearly, the best treatment is prophylaxis related to avoiding tobacco smoking and to obtain and maintain euthyroidism.
Whether antithyroid drugs (ATDs), radioiodine (RAI), or thyroidectomy should be chosen for therapy of GD, whether or not there is presence of active GO, is a matter of debate and randomized controlled trials (RCTs) are scarce. Thus, much is based on expert opinion. ATDs, independent of whether the titration or the block-repacement regimen is used, and thyroidectomy (as long as euthyroidism is maintained) do not influence the natural history of GO. RAI can cause progression or de novo GO in around 15% of GD patients, smokers being particularly at risk. This can at large be prevented by prophylactic glucocorticoid therapy.
In patients with mild or inactive GO, the choice of therapy for GD is independent of GO. In patients with active GO the choice of therapy is mainly based on expert opinion modified by the wishes of the patient and not based on RCTs. Questionnaire surveys indicate that RAI, in this situation, is only used by a small minority of experts. Preliminary data suggest that biological therapy with rituximab (monoclonal anti-CD20 antibodies), aiming at B cell depletion may be advantageous for both GD and GO and thereby offer a shift in paradigm.The recently investigated low-cost administration of the trace-element selenium, also holds promise. Importantly, a too strong focus on the risk of GO may unintentionally overrule taking availability of therapy options, co-morbidity, perceived risk of overall side-effects, cost-benefit, and the wish of the patient into consideration.
Declaration of interest: The authors declare that there is no conflict of interest that could be perceived as prejudicing the impartiality of the research project.
Funding: This research did not receive any specific grant from any funding agency in the public, commercial or not-for-profit sector.