Introduction: The management of active thyroid eye disease (TED) remains controversial. High dose intravenous methylprednisolone (IVMP) is the current recommended first-line treatment based on EUGOGO guidance. Such therapy has the potential for serious adverse effects. We present the outcomes of an alternative approach in the management of moderate-to-severely active TED, using steroid-sparing agents (SSAs) in conjunction with IVMP. Methotrexate is used as the first-line SSA alongside ciclosporin and rituximab depending on activity score.
Methods: Presented is a retrospective, 4-year, single-centre, consecutive case series of patients with moderate-to-severe TED treated using the Oxford protocol. Treatment modality, disease activity (derived from the VISA classification) and adverse effects are reported at initial presentation, 6- and 12-month follow-up.
Results: 104 consecutive case notes were reviewed of TED patients treated by the TED MDT. 24 patients with moderate-to-severely active disease were identified (mean age 46.8 years; 12 female) with a mean pre-treatment VISA activity score of 5.5/10 (S.D.=1.98; range 19). IVMP and an SSA was commenced in all patients. Mean total steroid dose was 2.72 g (S.D.=1.4; 1.06.9). 38% of patients (n=9) received 1.5 g of IVMP or less. Only two patients required >4.5 g of IVMP equating to the EUGOGO treatment protocol dose for this patient group. There was significant improvement in VISA activity score both at the intermediate review (mean score 2.7; S.D.=2.8; P<0.001; mean follow up 25.2 weeks) and at one year or last follow up (mean score 1.4; S.D.=1.5; P<0.001; mean follow up 48.0 weeks). Three patients stopped methotrexate due to a non-specific chronic cough, deranged liver function or nausea. No serious or long-term adverse effects were reported.
Conclusion: Based on our experience and outcomes, the initiation of an SSA with limited adjuvant IVMP is as an effective and safe therapy for moderate-to-severely active TED. This approach results in a significant reduction in disease activity with reduced total steroid load.
20 - 23 May 2017
European Society of Endocrinology