Endocrine Abstracts (2017) 49 S12.2 | DOI: 10.1530/endoabs.49.S12.2

Management of Graves orbitopathy

Luigi Bartalena


Management of Graves’ orbitopathy (GO) depends on the severity and activity of the disease. Guidelines for the management of GO have recently been published by EUGOGO (European Group on Graves’ Orbitopathy) (European Thyroid Journal 2016 5 9–26). Assessment of GO by standardized criteria is fundamental to determine the type of intervention. General measures for all patients with GO, irrespective of the degree of severity and activity, include restoration and stable maintenance of euthyroidism, refrain from smoking, use of local measures (e.g. artificial tears, ocular gels). All GO patients, except for the mildest cases, should be referred to specialists. Mild GO is not treated actively, except for a 6-month course of selenium supplementation, shown in a randomized clinical trial (RCT) to be more effective than placebo also in terms of prevention of progression to more severe forms of GO. Sight-threatening GO, due to dysthyroid optic neuropathy and/or corneal breakdown, is an endocrine emergency and should be treated immediately with very high doses of intravenous glucocorticoids (ivGCs) and measures to protect the corneal surface. If, however, response is absent or poor within 2 weeks, the patient should be promptly submitted to orbital decompression. Treatment of moderate-to-severe GO depends on disease activity. If GO is stably inactive, there is no place for medical treatment, and rehabilitative surgery (orbital decompression, squint surgery, eyelid surgery) can be performed, as needed. For moderate-to-severe AND active GO, ivGCs represent, for the time being, the first-line treatment. ivGCs are given as 12 weekly, slow infusions of methylprednisolone (MP). Most commonly, the cumulative dose of MP is 4.5 g, but the dose should be tailored to the patient conditions, avoiding a cumulative dose >8 g and a single dose >0.75 g, to minimize the risk of toxicity. If response is not satisfactory in terms of regression and inactivation of GO, second-line therapies include a second course of ivGCs, a course of oral glucocorticoids combined with either orbital radiotherapy or cyclosporine, treatment with rituximab. The choice of second-line treatments should be part of a shared decision-making process with the informed patient. In addition to rituximab, the effectivess and safety of which should be confirmed in larger RCTs, ongoing studies are investigating the effectiveness and safety of other biologics, including teprotumumab and tolicizumab. Results of these studies are not available yet.

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