Immunosuppressive Therapy. In: Bahn RS, editor. Thyroid Eye Disease. Boston: Springer US; 2001. pp. 201-18. [DOI: 10.1007/978-1-4615-1447-3_12]

Measuring disease activity to predict therapeutic outcome in Graves' ophthalmopathy

OBJECTIVE

The concept of disease activity in Graves' ophthalmopathy (GO) might explain why as many as one-third of patients do not respond to immunosuppressive treatment, because only patients in the active stage of disease are expected to respond. The hypothesis was adopted that a parameter used to measure disease activity should be able to predict a response to immunosuppressive treatment. The aim of this study was to develop a multivariate prediction model in which all previous tested activity parameters are integrated.

DESIGN AND PATIENTS

We included 66 consecutive patients with untreated moderately severe GO who had been euthyroid for at least 2 months. All patients were treated with radiotherapy. Measurements Treatment efficacy after 6 months follow-up was used as the primary outcome measure. Disease severity and 15 different disease activity parameters were assessed before treatment. Univariate and multivariate logistic regression models were used to predict response (model 1) or no change (model 2).

RESULTS

In multivariate analyses, we found that duration of GO, soft tissue involvement, elevation, soluble interleukin-2 receptor (sIL-2R), soluble CD30 (sCD30), eye muscle reflectivity and octreotide uptake ratio were significant predictors of a response to radiotherapy. Gender, duration of GO, soft tissue involvement, eye muscle reflectivity, IL-6 and urinary glycosaminoglycan (GAG) excretion were significant predictors of no change upon radiotherapy. Prognostic score charts were developed for use in clinical practice to calculate the probability of response (model 1) and the probability of no change (model 2) for each new patient. Finally we used a combination of both models to define a recommended treatment modality for each individual patient, based on both the predicted probabilities of response and no change. We were able to identify the correct treatment (based on a comparison with the observed response) in 89% of the patients.

CONCLUSIONS

Although we strongly recommend that our results should be confirmed in other studies, our findings are the first evidence for the idea that disease (in)activity should determine which kind of treatment should be used.

The cost of immunosuppressive therapies currently used in patients with thyroid eye disease

Thyroid eye disease (TED) is an inflammatory condition of the orbit occurring in patients with autoimmune disease. In patients with mild TED, the most important therapeutic measure is reassurance. In severe cases, immunosuppressive therapy is the mainstay of treatment and around 10 immunosuppressive regimens have been suggested and used in such patients so far. The efficacy of these regimens varies according to the number of studies that have addressed these issues. "Response" to the treatment is also variably defined. However, to the best of our knowledge, no study has reported on the cost of immunosuppressive therapy in such patients. The aim of this study was mainly to provide information concerning the cost of different immunosuppressive regimens that patients with active thyroid ophthalmopathy undergo in different European countries. We have shown that the cheapest treatment is oral glucocorticoids (GC) and the most expensive is iv immunoglobulins. Cyclosporine is the second cheapest treatment. Radiotherapy plus oral GC have a cost between 850-3200 Euro; while SS analogues (SS-a) are expensive with a cost between 5000-10000 Euro. However, it is worth noting that the patients studied so far in this group were only few and most of them selected on a basis of a positive octreoscan, the cost of which has to be considered when choosing this type of treatment. Germany is by far the most expensive country as regards the costs of the main remedies, whereas Greece is the cheapest. Denmark is the most expensive country concerning radiotherapy, while Germany is the cheapest.