Doxycycline vs Placebo at 12 Weeks in Patients With Mild Thyroid-Associated Ophthalmopathy: A Randomized Clinical Trial

Selenium supplementation in thyroid eye disease: an updated review from a clinical ophthalmic perspective

Thyroid eye disease (TED) consists of a spectrum of autoimmune orbital pathology that threatens patients' quality of life and vision. Research suggests that oxidative stress plays a role in both the thyroid gland and orbit. Selenium has been proposed as a potential therapeutic adjunct given its role in thyroid physiology and antioxidant metabolism. Furthermore, selenium status has been linked to multiple pathological thyroid states. Despite the preponderance of evidence demonstrating a role for selenium in thyroid disease, limited research exists highlighting its role in TED specifically. This review summarizes the pathophysiology and role of selenium in thyroid eye disease (TED) and the current body of evidence including in vitro and in vivo studies highlighting the role for supplementation in clinical ophthalmic practice. Notably, relatively lower selenium levels have been shown to have a modest correlation with severity of thyroid eye disease. Selenium supplementation has shown some benefit in patients with mild Graves' Orbitopathy in European populations presumed deficient. Despite the preponderance of evidence demonstrating a role for selenium in thyroid disease, limited data is available to conclusively expand its role in TED outside of a 6-month course of supplementation in selenium deficient or relatively deficient populations. Data subject to geographic and population differences in selenium levels limits the generalizability of supplementation in TED. Despite mechanistic evidence of its antioxidant effects in TED beyond the advantages of thyroid disease in general, the benefits of selenium supplementation should be interrogated further and contextually tailored in both clinical and research formats for ophthalmic practice.

One Incremental Stride for Doxycycline, One Substantial Advancement for Thyroid Eye Disease

The aim of this study is to assess the effectiveness of a 12-week doxycycline treatment for thyroid eye disease (TED), an autoimmune condition associated with thyroid dysfunction. In this randomized controlled clinical trial, 82 patients were randomly assigned at a 1:1 ratio to receive doxycycline (50 mg) or to undergo no treatment. Various metrics, including margin reflex distance (MRD1 and MRD2), eyelid aperture, levator muscle function, lagophthalmos, proptosis, ocular motility, diplopia, and Graves' ophthalmopathy-specific quality-of-life (GO-QOL) scale scoring were assessed. Exclusion criteria were uncontrolled systemic diseases, tetracycline allergies, pregnancy, lactation, or age below 18. The mean age was 51.6 years (SD), 87.8% of participants were female, and all were Caucasians. By week 12, the doxycycline group exhibited a significant improvement rate based on MRD2 (from 4 to 15 participants with physiological findings), clinical activity score (from 7 to 35 participants with non-active disease), and GO-QOL (from 51.22% to 70.73% of participants with a good life quality). Doxycycline showcased anti-inflammatory and immunomodulatory effects in treating TED, suggesting its potential efficacy for TED and other orbit inflammatory conditions. However, these results warrant further validation through future research involving extended follow-up periods and larger cohorts.

Current and promising therapies based on the pathogenesis of Graves' ophthalmopathy

Graves' ophthalmopathy (GO) is a hyperthyroidism-related and immune-mediated disease that poses a significant threat to human health. The pathogenesis of GO primarily involves T cells, B cells, and fibroblasts, suggesting a pivotal role for the thyrotropin-antibody-immunocyte-fibroblast axis. Traditional treatment approaches for Graves' disease (GD) or GO encompass antithyroid drugs (ATDs), radioactive iodine, and beta-blockers. However, despite decades of treatment, there has been limited improvement in the global incidence of GO. In recent years, promising therapies, including immunotherapy, have emerged as leading contenders, demonstrating substantial benefits in clinical trials by inhibiting the activation of immune cells like Th1 and B cells. Furthermore, the impact of diet, gut microbiota, and metabolites on GO regulation has been recognized, suggesting the potential of non-pharmaceutical interventions. Moreover, as traditional Chinese medicine (TCM) components have been extensively explored and have shown effective results in treating autoimmune diseases, remarkable progress has been achieved in managing GO with TCM. In this review, we elucidate the pathogenesis of GO, summarize current and prospective therapies for GO, and delve into the mechanisms and prospects of TCM in its treatment.

Safety of Longer-Term Doxycycline Use: A Systematic Review and Meta-Analysis With Implications for Bacterial Sexually Transmitted Infection Chemoprophylaxis

BACKGROUND

Sexually transmitted infections (STIs) such as syphilis, gonorrhea, and chlamydia have significantly increased over the past decade in the United States. Doxycycline as chemoprophylaxis (i.e., postexposure prophylaxis) offers promise for addressing bacterial STIs. The goal of the current study was to evaluate the safety of longer-term doxycycline use (defined as 8 or more weeks) in the context of potential use as STI chemoprophylaxis through a systematic literature review and meta-analysis.

METHODS

This review used the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines to search MEDLINE/PubMed for clinical studies published from August 2003 to January 2023 that reported on adverse events with doxycycline use with a focus on side effects and metabolic effects of long-term use.

RESULTS

A total of 67 studies were included in the systematic review. Overall, studies on longer-term doxycycline use reported 0% to greater than 50% adverse events ranging from mild to severe. Most common adverse events included gastrointestinal symptoms (i.e., nausea, vomiting, and abdominal pain), dermatologic (i.e., rash), and neurological (i.e., headache and dizziness) symptoms. Discontinuation of doxycycline due to adverse events was relatively uncommon in most studies. A meta-analysis of placebo controlled clinical trials (N = 18) revealed that gastrointestinal and dermatological adverse events were more likely to occur in the doxycycline group.

CONCLUSIONS

Longer-term (8+ weeks) doxycycline use is generally safe and may be associated with minor side effects. Further research is needed on the potential metabolic impact of longer-term doxycycline use.

Literature Commentary

In this issue of JNO, Drs. Mark L. Moster, Marc J. Dinkin, and Deborah I. Friedman discuss the following 6 articles:Piehl F, Eriksson-Dufva A, Budzianowska A, Feresiadou A, Hansson W, Hietala MA, Håkansson I, Johansson R, Jons D, Kmezic I, Lindberg C, Lindh J, Lundin F, Nygren I, Punga AR, Press R, Samuelsson K, Sundström P, Wickberg O, Brauner S, Frisell T. Efficacy and safety of rituximab for new-onset generalized myasthenia gravis: the RINOMAX randomized clinical trial. JAMA Neurol. 2022;79:1105-1112.Cortese R, Carrasco FP, Tur C, Bianchi A, Brownlee W, De Angelis F, De La Paz I, Grussu F, Haider L, Jacob A, Kanber B, Magnollay L, Nicholas RS, Trip A, Yiannakas M, Toosy AT, Hacohen Y, Barkhof F, Ciccarelli O. Differentiating multiple sclerosis from AQP4-neuromyelitis optica spectrum disorder and MOG-antibody disease with imaging. Neurology. 2022. doi: 10.1212/WNL.0000000000201465.Carelli V, Newman NJ, Yu-Wai-Man P, Biousse V, Moster ML, Subramanian PS, Vignal-Clermont C, Wang AG, Donahue SP, Leroy BP, Sergott RC, Klopstock T, Sadun AA, Rebolleda Fernández G, Chwalisz BK, Banik R, Girmens JF, La Morgia C, DeBusk AA, Jurkute N, Priglinger C, Karanjia R, Josse C, Salzmann J, Montestruc F, Roux M, Taiel M, Sahel JA; the LHON Study Group. Indirect comparison of Lenadogene Nolparvovec gene therapy versus natural history in patients with leber hereditary optic neuropathy carrying the m.11778G>A MT-ND4 mutation. Ophthalmol Ther. 2022. doi: 10.1007/s40123-022-00611-x.Noll C, Hiltensperger M, Aly L, Wicklein R, Afzali AM, Mardin C, Gasperi C, Berthele A, Hemmer B, Korn T, Knier B. Association of the retinal vasculature, intrathecal immunity, and disability in multiple sclerosis. Front Immunol. 2022;13:997043.Mitchell JL, Buckham R, Lyons H, Walker JK, Yiangou A, Sassani M, Thaller M, Grech O, Alimajstorovic Z, Julher M, Tsermoulas G, Brock K, Mollan SP, Sinclair AJ. Evaluation of diurnal and postural intracranial pressure employing telemetric monitoring in idiopathic intracranial hypertension. Fluids Barriers CNS. 2022;19:85.Pan Y, Chen YX, Zhang J, Lin ML, Liu GM, Xu XL, Fan XQ, Zhong Y, Li Q, Ai SM, Xu W, Tan J, Zhou HF, Xu DD, Zhang HY, Xu B, Wang S, Ma JJ, Zhang S, Gan LY, Cui JT, Li L, Xie YY, Guo X, Pan-Doh N, Zhu ZT, Lu Y, Shi YX, Xia YW, Li ZY, Liang D. Doxycycline vs placebo at 12 weeks in patients with mild thyroid-associated ophthalmopathy: a randomized clinical trial. JAMA Ophthalmol. 2022;140:1076-1083.