What are the management guidelines for active Graves' orbitopathy (Thyroid Eye Disease)?

From the Guidelines

Management of active thyroid eye disease requires a multidisciplinary approach involving ophthalmologists and endocrinologists, with the primary goal of achieving euthyroidism and reducing inflammation, and teprotumumab, a human monoclonal antibody inhibitor of IGF-IR, is now a key treatment option at a dose of 10 mg/kg for the first infusion, then 20 mg/kg every 3 weeks for 7 additional infusions, as shown in the most recent study 1. The treatment approach should prioritize the reduction of morbidity, mortality, and improvement of quality of life. Key considerations in the management of active thyroid eye disease include:

• Achieving euthyroidism through appropriate thyroid management, as uncontrolled thyroid dysfunction can worsen eye disease 1
• Using conservative measures such as artificial tears, lubricating ointments, and elevation of the head while sleeping to reduce periorbital edema 1
• Considering selenium supplementation (200 mcg daily) to reduce disease progression in mild cases, although it does not impact control of hyperthyroidism in populations that are not selenium deficient 1
• Using oral glucocorticoids as first-line therapy for moderate to severe active disease, typically prednisone 40-80 mg daily for 4-6 weeks followed by a gradual taper over 2-3 months [@Example@]
• Considering intravenous methylprednisolone pulse therapy for patients with severe, vision-threatening disease, and orbital radiation for patients with active disease, particularly those with diplopia or extraocular muscle involvement [@Example@]
• Deferring surgical interventions until the disease has been inactive for at least 6 months, except in cases of optic neuropathy unresponsive to medical therapy, where urgent orbital decompression may be necessary 1
• Ensuring smoking cessation throughout treatment, as smoking worsens disease outcomes and reduces treatment efficacy 1

From the Research

Management Guidelines for Active Thyroid Eye Disease

The management of active thyroid eye disease (TED) involves a combination of medical and surgical approaches. The primary goal is to reduce disease activity, alleviate symptoms, and prevent long-term sequelae.

Medical Management

• The first-line treatment for moderate-to-severe TED is high-dose intravenous corticosteroids, which can have serious adverse effects 2, 3.
• Steroid-sparing agents, such as methotrexate, can be used as an alternative or adjunct to corticosteroids to reduce disease activity and total steroid load 2.
• Other immunosuppressive and immunomodulating agents, such as teprotumumab, tocilizumab, rituximab, and mycophenolate, are being investigated for the treatment of active TED 4.
• Smoking cessation and attainment of euthyroid status are essential for managing TED 5.

Surgical Management

• Elective surgery may be required for patients with moderate TED to address proptosis, diplopia, lid retraction, or to debulk the eyelid 6.
• Surgical intervention during the active phase of moderate disease is rarely indicated, but early orbital decompression can limit progression to more severe disease 6.
• In cases of acute severe TED, prompt retractor recession with or without a suture tarsorrhaphy can protect the ocular surface from severe exposure, and decompression of the deep medial orbital wall and floor can rapidly relieve compressive optic neuropathy 6.

Treatment Protocols

• The EUGOGO protocol involves high-dose intravenous methylprednisolone (500 mg weekly for six weeks, followed by 250 mg weekly for the next 6 weeks) 3.
• A modified protocol involving six repeated cycles of high-dose pulsed intravenous methylprednisolone (1g/day for 3 days, monthly for 6 months) has been shown to be effective in reducing disease activity and morbidity 3.