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Bartalena L, Baldeschi L, Boboridis K, Eckstein A, Kahaly GJ, Marcocci C, Perros P, Salvi M, Wiersinga WM. The 2016 European Thyroid Association/European Group on Graves' Orbitopathy Guidelines for the Management of Graves' Orbitopathy. Eur Thyroid J 2016; 5:9-26. [PMID: 27099835 PMCID: PMC4836120 DOI: 10.1159/000443828] [Citation(s) in RCA: 597] [Impact Index Per Article: 74.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/05/2015] [Accepted: 01/05/2016] [Indexed: 11/19/2022] Open
Abstract
Graves' orbitopathy (GO) is the main extrathyroidal manifestation of Graves' disease, though severe forms are rare. Management of GO is often suboptimal, largely because available treatments do not target pathogenic mechanisms of the disease. Treatment should rely on a thorough assessment of the activity and severity of GO and its impact on the patient's quality of life. Local measures (artificial tears, ointments and dark glasses) and control of risk factors for progression (smoking and thyroid dysfunction) are recommended for all patients. In mild GO, a watchful strategy is usually sufficient, but a 6-month course of selenium supplementation is effective in improving mild manifestations and preventing progression to more severe forms. High-dose glucocorticoids (GCs), preferably via the intravenous route, are the first line of treatment for moderate-to-severe and active GO. The optimal cumulative dose appears to be 4.5-5 g of methylprednisolone, but higher doses (up to 8 g) can be used for more severe forms. Shared decision-making is recommended for selecting second-line treatments, including a second course of intravenous GCs, oral GCs combined with orbital radiotherapy or cyclosporine, rituximab or watchful waiting. Rehabilitative treatment (orbital decompression surgery, squint surgery or eyelid surgery) is needed in the majority of patients when GO has been conservatively managed and inactivated by immunosuppressive treatment.
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Affiliation(s)
- Luigi Bartalena
- Department of Clinical and Experimental Medicine, University of Insubria, Endocrine Unit, Ospedale di Circolo, Varese, Italy
- *Prof. Luigi Bartalena, Department of Clinical and Experimental Medicine, University of Insubria, Endocrine Unit, Ospedale di Circolo, Viale Borri 57, IT-21100 Varese (Italy), E-Mail
| | - Lelio Baldeschi
- Department of Ophthalmology, Hospital Saint Luc, Catholic University of Louvain, Brussels, Belgium
| | - Kostas Boboridis
- Ophthalmology Department, Aristotle University of Thessaloniki, Thessaloniki, Greece
| | - Anja Eckstein
- Zentrum für Augenheilkunde, Universitätsklinikum Essen, Essen, Germany
| | - George J. Kahaly
- Department of Medicine I, Johannes Gutenberg University (JGU) Medical Center, Mainz, Germany
| | - Claudio Marcocci
- Department of Clinical and Experimental Medicine, University of Pisa, Pisa, Italy
| | - Petros Perros
- Department of Endocrinology, Newcastle upon Tyne Hospitals NHS Foundation Trust, Newcastle upon Tyne, UK
| | - Mario Salvi
- Graves' Orbitopathy Center, Endocrinology, Fondazione Ca' Granda IRCCS, University of Milan, Milan, Italy
| | - Wilmar M. Wiersinga
- Department of Endocrinology and Metabolism, Academic Medical Center, University of Amsterdam, Amsterdam, The Netherlands
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Radioactive Iodine Therapy and Thyroid Eye Disease From an Ophthalmologist’s Perspective. Clin Ophthalmol 2015; 55:63-72. [DOI: 10.1097/iio.0000000000000079] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
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Erdei A, Gazdag A, Bodor M, Berta E, Katkó M, Ujhelyi B, Steiber Z, Győry F, Urbancsek H, Barna S, Galuska L, Nagy VE. [Novel treatment opportunities in Graves' orbitopathy]. Orv Hetil 2014; 155:1295-300. [PMID: 25109914 DOI: 10.1556/oh.2014.29963] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
Graves' orbitopathy is the most common extrathyroidal manifestation of Graves' disease. Up to now, curative treatment modalities for the most severe sight-threatening cases have not been developed. Here the authors summarize the treatment protocol of Graves' orbitopathy and review novel therapeutic options. They review the literature on this topic and present their own clinical experience. The authors point out that anti-CD20 antibody could positively influence the clinical course of Graves' orbitopathy. Selenium is efficient in mild cases. Further prospective investigations are warranted.
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Affiliation(s)
- Annamária Erdei
- Debreceni Egyetem, Általános Orvostudományi Kar Belgyógyászati Intézet, Endokrinológia Tanszék Debrecen Nagyerdei krt. 98. 4012
| | - Annamária Gazdag
- Debreceni Egyetem, Általános Orvostudományi Kar Belgyógyászati Intézet, Endokrinológia Tanszék Debrecen Nagyerdei krt. 98. 4012
| | - Miklós Bodor
- Debreceni Egyetem, Általános Orvostudományi Kar Belgyógyászati Intézet, Endokrinológia Tanszék Debrecen Nagyerdei krt. 98. 4012 Debreceni Egyetem, Gyógyszerésztudományi Kar Klinikai Farmakológiai Tanszék Debrecen
| | - Eszter Berta
- Debreceni Egyetem, Általános Orvostudományi Kar Belgyógyászati Intézet, Endokrinológia Tanszék Debrecen Nagyerdei krt. 98. 4012 Debreceni Egyetem, Gyógyszerésztudományi Kar Klinikai Farmakológiai Tanszék Debrecen
| | - Mónika Katkó
- Debreceni Egyetem, Általános Orvostudományi Kar Belgyógyászati Intézet, Endokrinológia Tanszék Debrecen Nagyerdei krt. 98. 4012
| | - Bernadett Ujhelyi
- Debreceni Egyetem, Általános Orvostudományi Kar Szemészeti Klinika Debrecen
| | - Zita Steiber
- Debreceni Egyetem, Általános Orvostudományi Kar Szemészeti Klinika Debrecen
| | - Ferenc Győry
- Debreceni Egyetem, Általános Orvostudományi Kar Sebészeti Intézet, Pajzsmirigy Centrum Debrecen
| | - Hilda Urbancsek
- Debreceni Egyetem, Általános Orvostudományi Kar Sugárterápiás Tanszék Debrecen
| | - Sándor Barna
- Debreceni Egyetem, Általános Orvostudományi Kar Nukleáris Medicina Tanszék Debrecen
| | - László Galuska
- Debreceni Egyetem, Általános Orvostudományi Kar Nukleáris Medicina Tanszék Debrecen
| | - V Endre Nagy
- Debreceni Egyetem, Általános Orvostudományi Kar Belgyógyászati Intézet, Endokrinológia Tanszék Debrecen Nagyerdei krt. 98. 4012
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Abstract
Management of Graves' ophthalmopathy (GO) is based on three pillars: to stop smoking, to restore and maintain euthyroidism, and to treat the eye changes according to severity and activity of GO. Difficulties are frequently encountered in each of these three management issues. The advice to discontinue smoking is straightforward, but just a small minority of smokers is able to quit smoking. Detailed information on how smoking adversely affects the outcome of Graves' disease may convince patients they have to stop smoking right away. Controversy exists on the most appropriate treatment of Graves' hyperthyroidism in the presence of GO. 131I therapy is associated with a risk of about 15% for worsening of GO; a preventive course of steroids is indicated in the presence of risk factors (smoking, biochemically severe hyperthyroidism, high level of TSH receptor antibodies, active GO). Alternatives are thyroidectomy or long-term treatment with antithyroid drugs, which apparently are rather neutral with respect to the course of GO. Mild GO is not always perceived as being mild by the patients themselves. Selenium improves mild GO. Moderate-to-severe GO is preferably treated with intravenous methylprednisolone pulses, but serious side effects and relapsing GO do occur. After steroid failure combination therapy with low-dose oral prednisone with either cyclosporine or retrobulbar irradiation can be effective. Dysthyroid optic neuropathy is best treated with IV pulses, followed by orbital decompression if visual functions do not improve. In resistant cases, rituximab might be considered, although failures of this drug are also described.
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Affiliation(s)
- Wilmar M. Wiersinga
- Department of Endocrinology and Metabolism, Academic Medical Center, University of Amsterdam, Netherlands
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Bonnema SJ, Hegedüs L. Radioiodine therapy in benign thyroid diseases: effects, side effects, and factors affecting therapeutic outcome. Endocr Rev 2012; 33:920-80. [PMID: 22961916 DOI: 10.1210/er.2012-1030] [Citation(s) in RCA: 160] [Impact Index Per Article: 13.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/18/2023]
Abstract
Radioiodine ((131)I) therapy of benign thyroid diseases was introduced 70 yr ago, and the patients treated since then are probably numbered in the millions. Fifty to 90% of hyperthyroid patients are cured within 1 yr after (131)I therapy. With longer follow-up, permanent hypothyroidism seems inevitable in Graves' disease, whereas this risk is much lower when treating toxic nodular goiter. The side effect causing most concern is the potential induction of ophthalmopathy in predisposed individuals. The response to (131)I therapy is to some extent related to the radiation dose. However, calculation of an exact thyroid dose is error-prone due to imprecise measurement of the (131)I biokinetics, and the importance of internal dosimetric factors, such as the thyroid follicle size, is probably underestimated. Besides these obstacles, several potential confounders interfere with the efficacy of (131)I therapy, and they may even interact mutually and counteract each other. Numerous studies have evaluated the effect of (131)I therapy, but results have been conflicting due to differences in design, sample size, patient selection, and dose calculation. It seems clear that no single factor reliably predicts the outcome from (131)I therapy. The individual radiosensitivity, still poorly defined and impossible to quantify, may be a major determinant of the outcome from (131)I therapy. Above all, the impact of (131)I therapy relies on the iodine-concentrating ability of the thyroid gland. The thyroid (131)I uptake (or retention) can be stimulated in several ways, including dietary iodine restriction and use of lithium. In particular, recombinant human thyrotropin has gained interest because this compound significantly amplifies the effect of (131)I therapy in patients with nontoxic nodular goiter.
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Affiliation(s)
- Steen Joop Bonnema
- Department of Endocrinology, Odense University Hospital, DK-5000 Odense C, Denmark.
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Hegedüs L, Bonnema SJ, Smith TJ, Brix TH. Treating the thyroid in the presence of Graves' ophthalmopathy. Best Pract Res Clin Endocrinol Metab 2012; 26:313-24. [PMID: 22632368 DOI: 10.1016/j.beem.2011.09.005] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Abstract
The etiology of Graves' orbitopathy (GO) remains enigmatic. Optimal therapeutic choices for the hyperthyroidism associated with Graves' disease (GD) in the presence of GO remain controversial. Whether antithyroid drugs (ATDs), radioiodine (RAI), or thyroidectomy should be favored in such patients remains debated. Pre-therapy variables such as ethnicity, sex, age, thyroid function, level of TSH-receptor antibodies and smoking behavior influence response to therapy. Among the most important management goals are restoring euthyroidism and abstaining from smoking. On average, ATDs and thyroidectomy - independent of extent - do not influence the natural course of GO. RAI can cause de novo development or progression of GO, which is largely preventable with oral steroid prophylaxis. In patients with mild GO, the thyroid treatment is largely independent of GO. Moderate to severe GO should be treated promptly. Deciding whether, in the latter, GD is better treated with ATDs, RAI, or surgery, is based more on expert opinion than on evidence. It is clear that in the individual patient a number of factors, not addressed in any trial, influence the final choice of therapy for GD, including concern of developing or negatively affecting pre-existing GO. Evidently, there is room for improving therapy of GO. Progress using novel drugs such as rituximab, which might potentially influence positively both GD and GO, are impatiently awaited.
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Abstract
Thyroid eye disease (TED) is a chronic debilitating condition causing physical discomfort, facial disfigurement and impaired visual function. The physical consequences of TED could have a negative and lasting impact on patients' employment, hobbies and psychosocial function. In this review, we assess the evidence of the impact of TED on patients' quality of life (QOL) and also explore the effects of suboptimal quality of care on QOL of patients with this disease. It is hoped that recent initiatives, including the Amsterdam declaration, to raise the quality of care for patients with TED will help to improve their QOL.
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Affiliation(s)
- Stephanie Estcourt
- Department of Endocrinology Ophthalmology, Royal Devon and Exeter Hospital, Exeter EX2 5DW, UK
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Bartalena L. The dilemma of how to manage Graves' hyperthyroidism in patients with associated orbitopathy. J Clin Endocrinol Metab 2011; 96:592-9. [PMID: 21190983 DOI: 10.1210/jc.2010-2329] [Citation(s) in RCA: 67] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
CONTEXT Graves' orbitopathy (GO) is present in about 50% of patients with Graves' hyperthyroidism. It may range from mild to moderately severe and (rarely) to sight-threatening. Whether antithyroid drugs (ATDs), radioactive iodine (RAI), or thyroidectomy should be the treatment of choice in the presence of overt and active GO is a matter of debate. EVIDENCE ACQUISITION The major source of data acquisition included PubMed search strategies. Articles published in the last 30 yr were screened. Furthermore, the bibliographies of relevant citations and chapters of major textbooks were evaluated for any additional appropriate citation. EVIDENCE SYNTHESIS Prompt restoration and stable maintenance of euthyroidism is important for the course of GO. ATDs and thyroidectomy per se do not influence the natural history of GO. RAI can cause progression or de novo development of GO, particularly in smokers. This effect can be prevented by oral steroid prophylaxis. In patients with mild orbitopathy, the choice of thyroid treatment is largely independent of GO. Moderate-to-severe and active GO should be treated without delay. Whether in these patients, concomitant treatment of hyperthyroidism should be conservative (ATDs) or ablative (RAI, thyroidectomy, or both) is presently based on expert opinion rather than evidence. Emerging and potentially interesting biological agents, such as rituximab, counteracting pathogenic mechanisms of both hyperthyroidism and GO, need to be evaluated in randomized clinical trials. CONCLUSIONS The choice of the optimal treatment for hyperthyroidism in patients with moderate-to-severe and active GO remains unsettled and is mainly based on personal experience. Randomized clinical trials in this field are eagerly needed.
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Affiliation(s)
- Luigi Bartalena
- Department of Clinical Medicine, University of Insubria, Endocrinology Unit, Ospedale di Circolo, Viale Borri, 57, 21100 Varese, Italy.
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