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Rajabi MT, Rafizadeh SM, Mohammadi A, Eshraghi B, Mohammadi N, Hosseini SS, Rajabi MB, Keshmirshekan MM, Shahriari M, Poursayed Lazarjani SZ, Parandin MM. Mycophenolate Mofetil (CellCept®) in Combination With Low Dose Prednisolone in Moderate to Severe Graves' Orbitopathy. Front Med (Lausanne) 2022; 9:788228. [PMID: 35223896 PMCID: PMC8873183 DOI: 10.3389/fmed.2022.788228] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/01/2021] [Accepted: 01/17/2022] [Indexed: 11/17/2022] Open
Abstract
Although corticosteroids are currently the first-choice drug for thyroid eye disease (TED), in 20–30% of cases, patients show poor or non-existent responses, and when the drug is withdrawn, 10–20% of patients relapse. Thus, in this study, we aimed to investigate the efficacy of the combined use of mycophenolate mofetil (CellCept®) and low dose oral prednisolone in patients with moderate to severe Graves' orbitopathy (GO). For the first time, we investigated the relationship between TED-related parameters and proptosis reduction. In a prospective, non-randomized, interventional case series, 242 patients with moderate-to-severe GO were, assigned to receive oral prednisolone (5 mg/ d) and mycophenolate mofetil (CellCept®) (one 500 mg tablet twice per day according to the therapeutic response). The patients were monitored regularly during the 3rd, 6th, 12th, and 18th month of treatment. The main outcome measures were the clinical activity score (CAS), intraocular pressure (IOP), diplopia, proptosis and visual acuity. We also assessed the relationship between the main outcomes with proptosis changes and time to improvement (months). Adverse effects were recorded during each visit. The clinical response rate increased from 67.7% on the third month to 89.2% on the sixth month, and 94.2% on the 12th month. This therapeutic response continued until the 18th month of follow-up. The CAS responses [disease inactivation (CAS <3)] improved during our study: 70.6% on the third month, 90.0% on the sixth month, and 92.5% at 12th month. These conditions continued until the 18th month of follow-up. Proptosis improvement was 52% on the third month, 71% on the sixth month, 83% on the 12th month, and 87.1% on the 18th month. Changes in IOP and visual acuity were not significant (P = 0.568 and 0.668, respectively). The patient showed significant improvement in the Gorman score. A Shorter duration of treatment was seen in patients with earlier onset of intervention, younger age, and lack of all extraocular muscle (EOM) enlargement on computed tomography (CT) scan (p < 0.05). In addition, a better response (more reduction) in proptosis was related to: younger age at disease, earlier treatment intervention (less interval from the time the diagnosis of moderate-to-severe GO was made until medication initiation), shorter treatment time (less time to improvement), less IOP, lack of EOM enlargement on CT scan, and lack of diplopia (P < 0.05). Adverse events occurred in six patients. Findings show that mycophenolate mofetil (CellCept®) plus low-dose prednisolone can be introduced as a new optimal dosing regimen in GO due to its better effect on chronic complications such as proptosis and diplopia.
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Affiliation(s)
- Mohammad Taher Rajabi
- Eye Research Center, Farabi Eye Hospital, Tehran University of Medical Sciences, Tehran, Iran
| | - Seyed Mohsen Rafizadeh
- Eye Research Center, Farabi Eye Hospital, Tehran University of Medical Sciences, Tehran, Iran
| | - Abbas Mohammadi
- Eye Research Center, Farabi Eye Hospital, Tehran University of Medical Sciences, Tehran, Iran
- *Correspondence: Abbas Mohammadi ; orcid.org/0000-0001-7295-8494
| | - Bahram Eshraghi
- Eye Research Center, Farabi Eye Hospital, Tehran University of Medical Sciences, Tehran, Iran
| | - Nader Mohammadi
- Eye Research Center, Farabi Eye Hospital, Tehran University of Medical Sciences, Tehran, Iran
| | | | - Mohammad Bagher Rajabi
- Eye Research Center, Farabi Eye Hospital, Tehran University of Medical Sciences, Tehran, Iran
| | | | - Mansoor Shahriari
- Eye Research Center, Farabi Eye Hospital, Tehran University of Medical Sciences, Tehran, Iran
| | - Seyedeh Zahra Poursayed Lazarjani
- Eye Research Center, Farabi Eye Hospital, Tehran University of Medical Sciences, Tehran, Iran
- Department of Eye, Eye Research Center, Amiralmomenin Hospital, School of Medicin, Guilan University of Medical Science, Rasht, Iran
| | - Mohammad Mehdi Parandin
- Eye Research Center, Farabi Eye Hospital, Tehran University of Medical Sciences, Tehran, Iran
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Sviridenko NY, Sheremeta MS, Belovalova IM, Melnichenko GA. [Treatment of Graves' disease in patients with thyroid eye disease]. Vestn Oftalmol 2021; 137:128-135. [PMID: 34965078 DOI: 10.17116/oftalma2021137061128] [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: 11/18/2022]
Abstract
Graves' disease (GD) is an autoimmune disease that is often complicated by thyroid eye disease (TED). Clinical presentations of TED can develop simultaneously with the manifestation of GD, after the manifestation of GD amid treatment, and before the development of thyrotoxicosis. Treatment of such patients is a difficult task, because on the one hand, it is necessary to take into account the clinical picture of thyrotoxicosis, and on the other - the symptoms of eye damage. The combination of the two pathologies determines the need for simultaneous treatment of GD and TED, and the choice of a treatment method for GD will depend on the manifestations of TED. This article presents current views on the treatment of GD with concomitant TED. The choice of GD treatment method will be largely determined by the clinical manifestations of TED and will be conducted jointly by endocrinologists and ophthalmologists.
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Affiliation(s)
- N Yu Sviridenko
- Scientific Medical Research Center of Endocrinology, Moscow, Russia
| | - M S Sheremeta
- Scientific Medical Research Center of Endocrinology, Moscow, Russia
| | - I M Belovalova
- Scientific Medical Research Center of Endocrinology, Moscow, Russia
| | - G A Melnichenko
- Scientific Medical Research Center of Endocrinology, Moscow, Russia
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Allen RC, Bradley EA, Fante RG, Lucarelli MJ. A Perspective on the Current Role of Teprotumumab in Treatment of Thyroid Eye Disease. Ophthalmology 2021; 128:1125-1128. [PMID: 33823982 DOI: 10.1016/j.ophtha.2021.03.006] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/03/2021] [Accepted: 03/05/2021] [Indexed: 12/27/2022] Open
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Diana T, Ponto KA, Kahaly GJ. Thyrotropin receptor antibodies and Graves' orbitopathy. J Endocrinol Invest 2021; 44:703-712. [PMID: 32749654 PMCID: PMC8310479 DOI: 10.1007/s40618-020-01380-9] [Citation(s) in RCA: 28] [Impact Index Per Article: 9.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/17/2020] [Accepted: 07/30/2020] [Indexed: 12/18/2022]
Abstract
CONTEXT AND PURPOSE The thyrotropin receptor (TSHR) is the key autoantigen in Graves' disease (GD) and associated orbitopathy (GO). Antibodies targeting the TSHR (TSHR-Ab) impact the pathogenesis and the course of GO. This review discusses the role and clinical relevance of TSHR-Ab in GO. METHODS Review of the current and pertinent literature. RESULTS GO is the most common extrathyroidal manifestation of GD and is caused by persistent, unregulated stimulation of TSHR-expressing orbital target cells (e.g. fibroblasts and pre-adipocytes). Serum TSHR-Ab and more specifically, the stimulatory Ab (TSAb) are observed in the vast majority of patients with GD and GO. TSHR-Ab are a sensitive serological parameter for the differential diagnosis of GO. TSHR-Ab can be detected either with conventional binding immunoassays that measure binding of Ab to the TSHR or with cell-based bioassays that provide information on their functional activity and potency. Knowledge of the biological activity and not simply the presence or absence of TSHR-Ab has relevant clinical implications e.g. predicting de-novo development or exacerbation of pre-existing GO. TSAb are specific biomarkers of GD/GO and responsible for many of its clinical manifestations. TSAb strongly correlate with the clinical activity and clinical severity of GO. Further, the magnitude of TSAb indicates the onset and acuity of sight-threatening GO (optic neuropathy). Baseline serum values of TSAb and especially dilution analysis of TSAb significantly differentiate between thyroidal GD only versus GD + GO. CONCLUSION Measurement of functional TSHR-Ab, especially TSAb, is clinically relevant for the differential diagnosis and management of GO.
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Affiliation(s)
- T. Diana
- Molecular Thyroid Research Laboratory, Department of Medicine I (TD, GJK), Johannes Gutenberg University (JGU) Medical Center, 55101 Mainz, Germany
| | - K. A. Ponto
- Department of Ophthalmology and Center for Thrombosis and Hemostasis (KAP), Johannes Gutenberg University (JGU) Medical Center, Mainz, Germany
| | - G. J. Kahaly
- Molecular Thyroid Research Laboratory, Department of Medicine I (TD, GJK), Johannes Gutenberg University (JGU) Medical Center, 55101 Mainz, Germany
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Limone PP, Mellano M, Ruo Redda MG, Macera A, Ferrero V, Sellari Franceschini S, Deandrea M. Graves' orbitopathy: a multidisciplinary approach. THE QUARTERLY JOURNAL OF NUCLEAR MEDICINE AND MOLECULAR IMAGING : OFFICIAL PUBLICATION OF THE ITALIAN ASSOCIATION OF NUCLEAR MEDICINE (AIMN) [AND] THE INTERNATIONAL ASSOCIATION OF RADIOPHARMACOLOGY (IAR), [AND] SECTION OF THE SOCIETY OF RADIOPHARMACEUTICAL CHEMISTRY AND BIOLOGY 2021; 65:157-171. [PMID: 33634673 DOI: 10.23736/s1824-4785.21.03350-1] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/04/2023]
Abstract
Orbitopathy is the main extra thyroidal manifestation of Graves' disease. It is a very challenging condition, which requires a cooperation between many specialists (endocrinologists, ophthalmologists, radiologists, radiotherapeutic, orbital surgeons) for an optimal clinical management. An accurate diagnostic assessment is required, in order to plan an adequate treatment of Graves' orbitopathy. Medical therapy, radiotherapy or surgery may be necessary to control the disease. In this review, the authors analyze the various therapeutic strategies, as well the more recent therapies based on pharmacologic immunomodulation.
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Affiliation(s)
- Paolo P Limone
- Center for Thyroid Diseases, A.O. Ordine Mauriziano, Turin, Italy -
| | - Marco Mellano
- Center for Thyroid Diseases, A.O. Ordine Mauriziano, Turin, Italy
| | | | - Annalisa Macera
- Center for Thyroid Diseases, A.O. Ordine Mauriziano, Turin, Italy
| | - Vittorio Ferrero
- Center for Thyroid Diseases, A.O. Ordine Mauriziano, Turin, Italy
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Abdi H, Zakavi SR, Azizi F. A Clinical Debate: What Is the Therapeutic Choice for Recurrent Graves' Hyperthyroidism? Int J Endocrinol Metab 2020; 18:e108876. [PMID: 33613682 PMCID: PMC7887460 DOI: 10.5812/ijem.108876] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/31/2020] [Revised: 09/26/2020] [Accepted: 09/29/2020] [Indexed: 11/21/2022] Open
Affiliation(s)
- Hengameh Abdi
- Endocrine Research Center, Research Institute for Endocrine Sciences, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Seyed Rasoul Zakavi
- Nuclear Medicine Research Center, Mashhad University of Medical Sciences, Mashhad, Iran
| | - Fereidoun Azizi
- Endocrine Research Center, Research Institute for Endocrine Sciences, Shahid Beheshti University of Medical Sciences, Tehran, Iran
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Lee ACH, Riedl M, Frommer L, Diana T, Kahaly GJ. Systemic safety analysis of mycophenolate in Graves' orbitopathy. J Endocrinol Invest 2020; 43:767-777. [PMID: 31834613 DOI: 10.1007/s40618-019-01161-z] [Citation(s) in RCA: 17] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/07/2019] [Accepted: 12/09/2019] [Indexed: 12/11/2022]
Abstract
PURPOSE The dual antiproliferative mechanism of mycophenolate appears to be beneficial in Graves' orbitopathy (GO). METHODS Safety data from the two published mycophenolate trials and the original database of the European Group on Graves' Orbitopathy (EUGOGO) trial were systematically analyzed. Treatment efficacy stratified by individual visual parameters of activity and severity were compared. RESULTS A total of 129 adverse events (AE) involving 50 patients (29.4%) were noted among all mycophenolate-treated patients. Mycophenolate sodium plus intravenous glucocorticoid (MPS + GC) group of the EUGOGO trial recorded significantly more AE (55.4% versus 4.6% of patients affected) and serious adverse events (SAE) (12.5% versus 0%) than mycophenolate mofetil (MMF) group of the Chinese trial. None of those SAE was side effect (SE). Most SE in MPS + GC group were mild. Gastrointestinal disorders, infection and liver dysfunction affected 8.8%, 7.1% and 1.2% of all mycophenolate-treated patients (versus 5.4%, 5.4% and 1.2% of all patients on GC monotherapy, respectively). MPS + GC did not significantly increase the risk of infection or liver dysfunction when compared to GC monotherapy. No cytopenia, serious infection or treatment-related mortality was reported. The much higher AE rates of mycophenolate trials in other autoimmune diseases or transplantations suggested that major mycophenolate toxicities were mostly dose- and duration dependent. Mycophenolate, either as monotherapy or as combination, achieved better overall response than GC monotherapy. CONCLUSION The risk-benefit ratio of low-dose mycophenolate treatment in active moderate-to-severe GO is highly favorable given its reassuring safety profile with low rate of mild-to-moderate SE and promising efficacy.
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Affiliation(s)
- A C H Lee
- Department of Medicine I, Johannes-Gutenberg University Medical Center, Langenbeckstreet 1, 55131, Mainz, Germany
| | - M Riedl
- Department of Medicine I, Johannes-Gutenberg University Medical Center, Langenbeckstreet 1, 55131, Mainz, Germany
| | - L Frommer
- Department of Medicine I, Johannes-Gutenberg University Medical Center, Langenbeckstreet 1, 55131, Mainz, Germany
| | - T Diana
- Department of Medicine I, Johannes-Gutenberg University Medical Center, Langenbeckstreet 1, 55131, Mainz, Germany
| | - G J Kahaly
- Department of Medicine I, Johannes-Gutenberg University Medical Center, Langenbeckstreet 1, 55131, Mainz, Germany.
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Hai YP, Lee ACH, Frommer L, Diana T, Kahaly GJ. Immunohistochemical analysis of human orbital tissue in Graves' orbitopathy. J Endocrinol Invest 2020; 43:123-137. [PMID: 31538314 DOI: 10.1007/s40618-019-01116-4] [Citation(s) in RCA: 33] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/02/2019] [Accepted: 09/11/2019] [Indexed: 12/11/2022]
Abstract
PURPOSE Immunohistochemistry of orbital tissues offers a correlation between the microscopic changes and macroscopic clinical manifestation of Graves' orbitopathy (GO). Summarizing the participation of different molecules will help us to understand the pathogenesis of GO. METHODS The pertinent and current literature on immunohistochemistry of human orbital tissue in GO was reviewed using the NCBI PubMed database. RESULTS 33 articles comprising over 700 orbital tissue samples were included in this review. The earliest findings included the demonstration of HLA-DR and T cell (to a lesser extent B cell) markers in GO orbital tissues. Subsequent investigators further contributed by characterizing cellular infiltration, confirming the presence of HLA-DR and TSHR, as well as revealing the participation of cytokines, growth factors, adhesion molecules and miscellaneous substances. HLA-DR and TSHR are over-expressed in orbital tissues of GO patients. The inflammatory infiltration mainly comprises CD4 + T cells and macrophages. Cytokine profile suggests the importance of Th1 (especially in early active phase) and Th17 immunity in the pathogenesis of GO. Upregulation of proinflammatory/profibrotic cytokines, adhesion molecules and growth factors finally culminate in activation of orbital fibroblasts and perpetuation of orbital inflammation. The molecular status of selected parameters correlates with the clinical presentation of GO. CONCLUSION Further investigation is warranted to define precisely the role of different molecules and ongoing search for new players yet to be discovered is also important. Unfolding the molecular mechanisms behind GO will hopefully provide insights into the development of novel therapeutic strategies and optimize our clinical management of the disease.
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Affiliation(s)
- Y P Hai
- Molecular Thyroid Research Laboratory, Department of Medicine I, Johannes Gutenberg University Medical Center, Langenbeckstreet 1, 55131, Mainz, Germany
| | - A C H Lee
- Molecular Thyroid Research Laboratory, Department of Medicine I, Johannes Gutenberg University Medical Center, Langenbeckstreet 1, 55131, Mainz, Germany
| | - L Frommer
- Molecular Thyroid Research Laboratory, Department of Medicine I, Johannes Gutenberg University Medical Center, Langenbeckstreet 1, 55131, Mainz, Germany
| | - T Diana
- Molecular Thyroid Research Laboratory, Department of Medicine I, Johannes Gutenberg University Medical Center, Langenbeckstreet 1, 55131, Mainz, Germany
| | - G J Kahaly
- Molecular Thyroid Research Laboratory, Department of Medicine I, Johannes Gutenberg University Medical Center, Langenbeckstreet 1, 55131, Mainz, Germany.
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Premoli P, Tanda ML, Piantanida E, Veronesi G, Gallo D, Masiello E, Rosetti S, Cusini C, Boi F, Bulla J, Rodia R, Mariotti S, Capelli V, Rotondi M, Magri F, Chiovato L, Rocchi R, Campopiano MC, Elisei R, Vitti P, Barbato F, Pilli T, Castagna MG, Pacini F, Bartalena L. Features and outcome of differentiated thyroid carcinoma associated with Graves' disease: results of a large, retrospective, multicenter study. J Endocrinol Invest 2020; 43:109-116. [PMID: 31327128 DOI: 10.1007/s40618-019-01088-5] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/11/2019] [Accepted: 07/17/2019] [Indexed: 02/05/2023]
Abstract
BACKGROUND Whether differentiated thyroid cancer (DTC) occurring concomitantly with Graves' disease (GD) is more aggressive and bound to a less favorable outcome is controversial. OBJECTIVE Aim of this multicenter retrospective study was to compare baseline features and outcome of DTC patients with GD (DTC/GD+) or without GD (DTC/GD-). PATIENTS Enrolled in this study were 579 patients referred to five endocrine units (Cagliari, Pavia, Pisa, Siena, and Varese) between 2005 and 2014: 193 patients had DTC/GD+ , 386 DTC/GD-. Patients were matched for age, gender and tumor size. They underwent surgery because of malignancy, large goiter size, or relapse of hyperthyroidism in GD. RESULTS Baseline DTC features (histology, lymph node metastases, extrathyroidal extension) did not differ in the two groups, except for multifocality which was significantly more frequent in DTC/GD+ (27.5% vs. 7.5%, p < 0.0001). At the end of follow-up (median 7.5 years), 86% of DTC/GD+ and 89.6% DTC/GD- patients were free of disease. Patients with persistent or recurrent disease (PRD) had "biochemical disease" in the majority of cases. Microcarcinomas were more frequent in the DTC/GD+ group (60% vs. 37%, p < 0.0001) and had an excellent outcome, with no difference in PRD between groups. However, in carcinomas ≥ 1 cm, PRD was significantly more common in DTC/GD+ (24.4% vs. 11.5%; p = 0.005). In the whole group, univariate and multivariate analyses showed that GD+ , lymph node involvement, extrathyroidal invasion, multifocality and tall cell histotype were associated with a worse outcome. Female gender and microcarcinomas were favorable features. No association was found between baseline TSH-receptor antibody levels and outcome. Graves' orbitopathy (GO) seemed to be associated with a better outcome of DTC, possibly because patients with GO may early undergo surgery for hyperthyroidism. CONCLUSIONS GD may be associated with a worse outcome of coexisting DTC only if cancer is ≥ 1 cm, whereas clinical outcome of microcarcinomas is not related to the presence/absence of GD.
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Affiliation(s)
- P Premoli
- Department of Medicine and Surgery, University of Insubria, Endocrine Unit, Ospedale di Circolo, ASST dei Sette Laghi, Viale Borri, 57, 21100, Varese, Italy
| | - M L Tanda
- Department of Medicine and Surgery, University of Insubria, Endocrine Unit, Ospedale di Circolo, ASST dei Sette Laghi, Viale Borri, 57, 21100, Varese, Italy
| | - E Piantanida
- Department of Medicine and Surgery, University of Insubria, Endocrine Unit, Ospedale di Circolo, ASST dei Sette Laghi, Viale Borri, 57, 21100, Varese, Italy
| | - G Veronesi
- Research Centre in Epidemiology and Preventive Medicine, University of Insubria, Varese, Italy
| | - D Gallo
- Department of Medicine and Surgery, University of Insubria, Endocrine Unit, Ospedale di Circolo, ASST dei Sette Laghi, Viale Borri, 57, 21100, Varese, Italy
| | - E Masiello
- Department of Medicine and Surgery, University of Insubria, Endocrine Unit, Ospedale di Circolo, ASST dei Sette Laghi, Viale Borri, 57, 21100, Varese, Italy
| | - S Rosetti
- Department of Medicine and Surgery, University of Insubria, Endocrine Unit, Ospedale di Circolo, ASST dei Sette Laghi, Viale Borri, 57, 21100, Varese, Italy
| | - C Cusini
- Department of Medicine and Surgery, University of Insubria, Endocrine Unit, Ospedale di Circolo, ASST dei Sette Laghi, Viale Borri, 57, 21100, Varese, Italy
| | - F Boi
- Department of Medical Sciences and Public Health, University of Cagliari, Cagliari, Italy
| | - J Bulla
- Department of Medical Sciences and Public Health, University of Cagliari, Cagliari, Italy
| | - R Rodia
- Department of Medical Sciences and Public Health, University of Cagliari, Cagliari, Italy
| | - S Mariotti
- Department of Medical Sciences and Public Health, University of Cagliari, Cagliari, Italy
| | - V Capelli
- Unit of Internal Medicine and Endocrinology, Istituti Clinici Scientifici Maugeri, Department of Internal Medicine and Therapeutics, University of Pavia, Pavia, Italy
| | - M Rotondi
- Unit of Internal Medicine and Endocrinology, Istituti Clinici Scientifici Maugeri, Department of Internal Medicine and Therapeutics, University of Pavia, Pavia, Italy
| | - F Magri
- Unit of Internal Medicine and Endocrinology, Istituti Clinici Scientifici Maugeri, Department of Internal Medicine and Therapeutics, University of Pavia, Pavia, Italy
| | - L Chiovato
- Unit of Internal Medicine and Endocrinology, Istituti Clinici Scientifici Maugeri, Department of Internal Medicine and Therapeutics, University of Pavia, Pavia, Italy
| | - R Rocchi
- Endocrinology Unit, Department of Clinical and Experimental Medicine, University of Pisa, Pisa, Italy
| | - M C Campopiano
- Endocrinology Unit, Department of Clinical and Experimental Medicine, University of Pisa, Pisa, Italy
| | - R Elisei
- Endocrinology Unit, Department of Clinical and Experimental Medicine, University of Pisa, Pisa, Italy
| | - P Vitti
- Endocrinology Unit, Department of Clinical and Experimental Medicine, University of Pisa, Pisa, Italy
| | - F Barbato
- Endocrinology Unit, University of Siena, Siena, Italy
| | - T Pilli
- Endocrinology Unit, University of Siena, Siena, Italy
| | - M G Castagna
- Endocrinology Unit, University of Siena, Siena, Italy
| | - F Pacini
- Endocrinology Unit, University of Siena, Siena, Italy
| | - L Bartalena
- Department of Medicine and Surgery, University of Insubria, Endocrine Unit, Ospedale di Circolo, ASST dei Sette Laghi, Viale Borri, 57, 21100, Varese, Italy.
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Vannucchi G, Covelli D, Campi I, Currò N, Dazzi D, Rodari M, Pepe G, Chiti A, Guastella C, Lazzaroni E, Salvi M. Prevention of Orbitopathy by Oral or Intravenous Steroid Prophylaxis in Short Duration Graves' Disease Patients Undergoing Radioiodine Ablation: A Prospective Randomized Control Trial Study. Thyroid 2019; 29:1828-1833. [PMID: 31860407 DOI: 10.1089/thy.2019.0150] [Citation(s) in RCA: 17] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
Background: Radioiodine (RAI) is a known risk factor for activation or de novo occurrence of Graves' orbitopathy (GO). Several studies demonstrated that GO can be prevented by glucocorticoids (GCs) in patients with pre-existing GO. We have previously shown that Graves' disease duration (GDd) <5 years is a risk factor for RAI-induced GO. We studied the effect of prophylaxis with either oral GCs (OGCs) or intravenous GCs (IVGCs) on GO activation in patients with GDd. Methods: In total, 99 hyperthyroid patients without GO or with pre-existing inactive GO with GDd <5 years were randomized to receive IVGCs (N = 49) or OGCs (N = 50) before RAI; 22 patients with GDd >5 did not receive steroids and were studied as controls. All patients underwent ophthalmological assessment before and 45, 90, 180 days and for a 5-year follow-up after RAI. Serum thyrotropin (TSH) receptor antibodies (TRAbs), thyroid hormones, and thyroid volume (TV) were also measured in response to RAI therapy and steroid prophylaxis. Results: No patient on prophylaxis developed GO after RAI. One woman of the control group, without steroid prophylaxis, and who had a marked elevation of her TSH, showed transient reactivation of GO, which spontaneously improved after restoring euthyroidism. On follow-up at 12 and 20 months after RAI, two patients developed overt optic neuropathy. A smaller TV was associated with a higher prevalence of RAI-induced hypothyroidism. Serum TRAbs increased significantly after RAI (p < 0.0001) but less in patients receiving steroids than in those without prophylaxis at 45 days (p < 0.01). Conclusions: The risk of RAI-induced GO can be prevented in all patients with GDd <5 years by steroids. Such treatment may not be necessary in patients with GDd >5 years. The blunting of TRAb elevation after RAI may be related to the prophylactic effect of steroids.
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Affiliation(s)
- Guia Vannucchi
- Department of Endocrine and Metabolic Diseases, Istituto Auxologico Italiano IRCCS, Milan, Italy
| | - Danila Covelli
- Graves' Orbitopathy Center, Endocrinology, Fondazione IRCCS Cà Granda, Ospedale Maggiore Policlinico, Milan, Italy
| | - Irene Campi
- Department of Endocrine and Metabolic Diseases, Istituto Auxologico Italiano IRCCS, Milan, Italy
| | - Nicola Currò
- Ophthalmology, Fondazione IRCCS Cà Granda, Ospedale Maggiore Policlinico, Milan, Italy
| | - Davide Dazzi
- Division of Internal Medicine, Ospedale Vaio, Fidenza, Italy
| | - Marcello Rodari
- Department of Nuclear Medicine, Istituto Clinico Humanitas, Milan, Italy
| | - Giovanna Pepe
- Department of Nuclear Medicine, Istituto Clinico Humanitas, Milan, Italy
| | - Arturo Chiti
- Department of Nuclear Medicine, Istituto Clinico Humanitas, Milan, Italy
| | - Claudio Guastella
- Department of Otolaryngology, University of Milan and Fondazione IRCCS Cà Granda, Milan, Italy
| | - Elisa Lazzaroni
- Graves' Orbitopathy Center, Endocrinology, Fondazione IRCCS Cà Granda, Ospedale Maggiore Policlinico, Milan, Italy
| | - Mario Salvi
- Graves' Orbitopathy Center, Endocrinology, Fondazione IRCCS Cà Granda, Ospedale Maggiore Policlinico, Milan, Italy
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Furmaniak J, Sanders J, Clark J, Wilmot J, Sanders P, Li Y, Rees Smith B. Preclinical studies on the toxicology, pharmacokinetics and safety of K1-70 TM a human monoclonal autoantibody to the TSH receptor with TSH antagonist activity. AUTOIMMUNITY HIGHLIGHTS 2019; 10:11. [PMID: 32257067 PMCID: PMC7065368 DOI: 10.1186/s13317-019-0121-9] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 08/15/2019] [Accepted: 10/09/2019] [Indexed: 12/27/2022]
Abstract
Background The human monoclonal autoantibody K1-70™ binds to the TSH receptor (TSHR) with high affinity and blocks TSHR cyclic AMP stimulation by TSH and thyroid stimulating autoantibodies. Methods The preclinical toxicology assessment following weekly intravenous (IV) or intramuscular (IM) administration of K1-70™ in rats and cynomolgus monkeys for 29 days was carried out. An assessment of delayed onset toxicity and/or reversibility of toxicity was made during a further 4 week treatment free period. The pharmacokinetic parameters of K1-70™ and the effects of different doses of K1-70™ on serum thyroid hormone levels in the study animals were determined in rats and primates after IV and IM administration. Results Low serum levels of T3 and T4 associated with markedly elevated levels of TSH were observed in the study animals following IV and IM administration of K1-70™. The toxicological findings were attributed to the pharmacology of K1-70™ and were consistent with the hypothyroid state. The no observable adverse effect level (NOAEL) could not be established in the rat study while in the primate study it was 100 mg/kg/dose for both males and females. Conclusions The toxicology, pharmacodynamic and pharmacokinetic data in this preclinical study were helpful in designing the first in human study with K1-70™ administered to subjects with Graves’ disease.
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Affiliation(s)
- Jadwiga Furmaniak
- AV7 Limited, FIRS Laboratories, Parc Ty Glas, Llanishen, Cardiff, CF14 5DU UK
| | - Jane Sanders
- AV7 Limited, FIRS Laboratories, Parc Ty Glas, Llanishen, Cardiff, CF14 5DU UK
| | - Jill Clark
- AV7 Limited, FIRS Laboratories, Parc Ty Glas, Llanishen, Cardiff, CF14 5DU UK
| | - Jane Wilmot
- AV7 Limited, FIRS Laboratories, Parc Ty Glas, Llanishen, Cardiff, CF14 5DU UK
| | - Paul Sanders
- AV7 Limited, FIRS Laboratories, Parc Ty Glas, Llanishen, Cardiff, CF14 5DU UK
| | - Yang Li
- AV7 Limited, FIRS Laboratories, Parc Ty Glas, Llanishen, Cardiff, CF14 5DU UK
| | - Bernard Rees Smith
- AV7 Limited, FIRS Laboratories, Parc Ty Glas, Llanishen, Cardiff, CF14 5DU UK
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Zhao WJ, Lv QG, Fei Y, Zhao Z, Zhang YW. Prognostic factors analysis for a calculated dose of 131I therapy in Graves' disease in China. GAZZETTA MEDICA ITALIANA ARCHIVIO PER LE SCIENZE MEDICHE 2019. [DOI: 10.23736/s0393-3660.17.03708-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
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Kahaly GJ, Bartalena L, Hegedüs L, Leenhardt L, Poppe K, Pearce SH. 2018 European Thyroid Association Guideline for the Management of Graves' Hyperthyroidism. Eur Thyroid J 2018; 7:167-186. [PMID: 30283735 PMCID: PMC6140607 DOI: 10.1159/000490384] [Citation(s) in RCA: 422] [Impact Index Per Article: 70.3] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/26/2018] [Revised: 05/24/2018] [Indexed: 12/12/2022] Open
Abstract
Graves' disease (GD) is a systemic autoimmune disorder characterized by the infiltration of thyroid antigen-specific T cells into thyroid-stimulating hormone receptor (TSH-R)-expressing tissues. Stimulatory autoantibodies (Ab) in GD activate the TSH-R leading to thyroid hyperplasia and unregulated thyroid hormone production and secretion. Diagnosis of GD is straightforward in a patient with biochemically confirmed thyrotoxicosis, positive TSH-R-Ab, a hypervascular and hypoechoic thyroid gland (ultrasound), and associated orbitopathy. In GD, measurement of TSH-R-Ab is recommended for an accurate diagnosis/differential diagnosis, prior to stopping antithyroid drug (ATD) treatment and during pregnancy. Graves' hyperthyroidism is treated by decreasing thyroid hormone synthesis with the use of ATD, or by reducing the amount of thyroid tissue with radioactive iodine (RAI) treatment or total thyroidectomy. Patients with newly diagnosed Graves' hyperthyroidism are usually medically treated for 12-18 months with methimazole (MMI) as the preferred drug. In children with GD, a 24- to 36-month course of MMI is recommended. Patients with persistently high TSH-R-Ab at 12-18 months can continue MMI treatment, repeating the TSH-R-Ab measurement after an additional 12 months, or opt for therapy with RAI or thyroidectomy. Women treated with MMI should be switched to propylthiouracil when planning pregnancy and during the first trimester of pregnancy. If a patient relapses after completing a course of ATD, definitive treatment is recommended; however, continued long-term low-dose MMI can be considered. Thyroidectomy should be performed by an experienced high-volume thyroid surgeon. RAI is contraindicated in Graves' patients with active/severe orbitopathy, and steroid prophylaxis is warranted in Graves' patients with mild/active orbitopathy receiving RAI.
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Affiliation(s)
- George J. Kahaly
- Department of Medicine I, Johannes Gutenberg University (JGU) Medical Center, Mainz, Germany
- *Prof. George J. Kahaly, JGU Medical Center, DE-55101 Mainz (Germany), E-Mail
| | - Luigi Bartalena
- Department of Medicine and Surgery, University of Insubria, Varese, Italy
| | - Lazlo Hegedüs
- Department of Endocrinology and Metabolism, Odense University Hospital, Odense, Denmark
| | - Laurence Leenhardt
- Thyroid and Endocrine Tumors Unit, Pitié Salpêtrière Hospital, Sorbonne University, Paris, France
| | - Kris Poppe
- Endocrine Unit, CHU Saint-Pierre, Université Libre de Bruxelles (ULB), Brussels, Belgium
| | - Simon H. Pearce
- Department of Endocrinology, Institute of Genetic Medicine, Newcastle University, Newcastle upon Tyne, United Kingdom
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Sabini E, Ionni I, Rocchi R, Vitti P, Marcocci C, Marinò M. Occurrence of Graves' Orbitopathy and Graves' Hyperthyroidism after a Trauma to the Eye. Eur Thyroid J 2018; 7:51-54. [PMID: 29594055 PMCID: PMC5836176 DOI: 10.1159/000479629] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/10/2017] [Revised: 07/17/2017] [Indexed: 12/11/2022] Open
Abstract
BACKGROUND Graves' orbitopathy (GO) is believed to be the consequence of autoimmunity against antigens that are present both in the thyroid and orbital tissues. Massive release of thyroid antigens causes the appearance or deterioration of GO in patients with Graves' hyperthyroidism (GH), as it occurs following radioiodine treatment. In theory, a similar release of autoantigens may occur at the eye level, for example due to an orbital trauma or surgical manipulation. To our knowledge, this is the first report of a case of de novo appearance of GO and then GH after an eye trauma, possibly reflecting spreading of autoantigens and activation of the immune system against shared orbital and thyroid antigens. CASE REPORT An otherwise healthy, 57-year-old man presented 6 months after the appearance of a monolateral right orbitopathy, which occurred 40 days after a trauma in the ipsilateral eye. His thyroid function was normal, with positive serum anti-TSH receptor autoantibodies. The thyroid was normal on ultrasound. A month later he developed hyperthyroidism and orbitopathy in the left eye. DISCUSSION The development of GO after an eye trauma may reflect tissue damage with release of autoantigens and consequent autoimmunity in a predisposed individual (our patient had a familial history of autoimmune thyroid disease). The subsequent development of hyperthyroidism is in keeping with the hypothesis that GH and GO are due to autoimmunity against antigens present both in the thyroid and in orbital tissues.
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Affiliation(s)
| | | | | | | | | | - Michele Marinò
- *Michele Marinò, Department of Clinical and Experimental Medicine, Endocrinology Unit I, University of Pisa and University Hospital of Pisa, Via Paradisa 2, IT-56124 Pisa (Italy), E-Mail
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15
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Wang Y, Zhou H, Fan X. The effect of orbital radiation therapy on thyroid-associated orbitopathy complicated with dysthyroid optic neuropathy. Front Med 2017; 11:359-364. [PMID: 28500433 DOI: 10.1007/s11684-017-0528-5] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/01/2016] [Accepted: 02/08/2017] [Indexed: 01/11/2023]
Abstract
Thyroid-associated orbitopathy (TAO) is an inflammatory autoimmune disorder. The most serious complication of TAO is dysthyroid optic neuropathy (DON), which can lead to permanent vision loss because of volume expansion in the orbital apex. Orbital radiation therapy (ORT) is an anti-inflammatory treatment used in the treatment of active TAO. Clinical studies support radiotherapy as having a modest effect on DON, and early radiotherapy may protect against disease progression to DON. Current studies suggest that radiotherapy is generally safe. However, risks still exist in some cases. The possible effects of radiotherapy on TAO, especially complicated with DON, are reviewed. The effects of radiotherapy on DON are not completely known, and evidence from standardized, prospective, and multicenter clinical trials is still lacking.
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Affiliation(s)
- Yang Wang
- Department of Ophthalmology, Ninth People's Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, 200011, China
| | - Huifang Zhou
- Department of Ophthalmology, Ninth People's Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, 200011, China.
| | - Xianqun Fan
- Department of Ophthalmology, Ninth People's Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, 200011, China.
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Anagnostis P, Boboridis K, Adamidou F, Kita M. Natural course of mild Graves' orbitopathy: is it a chronic remitting or a transient disease? J Endocrinol Invest 2017; 40:257-261. [PMID: 27664101 DOI: 10.1007/s40618-016-0555-0] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/30/2016] [Accepted: 09/16/2016] [Indexed: 12/27/2022]
Abstract
BACKGROUND/AIMS The natural course of Graves' orbitopathy (GO) has been poorly documented. The aim of this review is to provide current knowledge regarding the natural course of mild GO, trying to address the issue of whether and to what extent it constitutes a chronic remitting or transient disease. METHODS We systematically searched PubMed for English language publications until August 2016 under the following terms: "Graves' orbitopathy" OR "Graves' ophthalmopathy" OR "thyroid eye disease" AND "natural course" OR "natural history". RESULTS Few studies have investigated the course of mild orbital disease in patients with GO. Large controlled trials are lacking and data can be extracted mainly from small retrospective and some prospective studies, after excluding patients who had received radioiodine for thyrotoxicosis or surgical treatment for GO. In general, more than half of GO patients may show spontaneous improvement in their clinical features, whereas no safe conclusions can be drawn with regard to complete resolution, with percentages ranging from 6 to 58 %. CONCLUSIONS The question whether mild GO is a remitting, albeit chronic disease, or even a transient event in the course of Graves' disease, remains currently unanswered.
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Affiliation(s)
- P Anagnostis
- Department of Endocrinology and Diabetes, Hippokration Hospital of Thessaloniki, Sarantaporou 10, 54640, Thessaloníki, Greece.
| | - K Boboridis
- 1st University Department of Ophthalmology, Aristotle University of Thessaloniki, Thessaloníki, Greece
| | - F Adamidou
- Department of Endocrinology and Diabetes, Hippokration Hospital of Thessaloniki, Sarantaporou 10, 54640, Thessaloníki, Greece
| | - M Kita
- Department of Endocrinology and Diabetes, Hippokration Hospital of Thessaloniki, Sarantaporou 10, 54640, Thessaloníki, Greece
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17
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Blandford AD, Zhang D, Chundury RV, Perry JD. Dysthyroid optic neuropathy: update on pathogenesis, diagnosis, and management. EXPERT REVIEW OF OPHTHALMOLOGY 2017; 12:111-121. [PMID: 28775762 DOI: 10.1080/17469899.2017.1276444] [Citation(s) in RCA: 84] [Impact Index Per Article: 12.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
Abstract
INTRODUCTION Dysthyroid optic neuropathy (DON) is a severe manifestation of thyroid eye disease (TED) that can result in permanent vision loss. Management is complex, multidisciplinary, and involves medical and/or surgical therapies. This review describes current concepts in the epidemiology, pathophysiology, diagnosis, and treatment of DON. AREAS COVERED An extensive review of the literature was performed to detail current concepts on the diagnosis and management of DON. This includes utilization of various medical and surgical modalities for disease management. EXPERT COMMENTARY DON can result in permanent blindness and often requires the use of corticosteroids and surgical decompression. We favor the use of intravenous corticosteroids and a transcaruncular approach when surgical decompression is indicated. The use of orbital radiation for DON is often reserved for patients that are poor surgical candidates and/or patients with refractory disease.
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Affiliation(s)
- Alexander D Blandford
- Cole Eye Institute, Cleveland Clinic Foundation, 9500 Euclid Avenue, Cleveland, OH 44195
| | - Dalia Zhang
- Case Western Reserve University School of Medicine, 2109 Adelbert Road, Cleveland, OH 44106
| | - Rao V Chundury
- Eugene and Marilyn Glick Eye Institute, Indiana University, 1160 W Michigan St, Indianapolis, IN 46202
| | - Julian D Perry
- Cole Eye Institute, Cleveland Clinic Foundation, 9500 Euclid Avenue, Cleveland, OH 44195
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18
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Bartalena L, Masiello E, Magri F, Veronesi G, Bianconi E, Zerbini F, Gaiti M, Spreafico E, Gallo D, Premoli P, Piantanida E, Tanda ML, Ferrario M, Vitti P, Chiovato L. The phenotype of newly diagnosed Graves' disease in Italy in recent years is milder than in the past: results of a large observational longitudinal study. J Endocrinol Invest 2016; 39:1445-1451. [PMID: 27465670 DOI: 10.1007/s40618-016-0516-7] [Citation(s) in RCA: 39] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/07/2016] [Accepted: 07/17/2016] [Indexed: 02/06/2023]
Abstract
OBJECTIVE The Merseburg triad (hyperthyroidism, goiter, and orbitopathy) characterizes classical description of Graves' disease (GD). Aim of this observational, longitudinal study was to evaluate the current clinical features of newly diagnosed GD in Italy. MATERIALS AND METHODS In two Northern Italy centers (Varese and Pavia), 283 consecutive patients (211 women, 72 men; mean age 47.4 years) with newly diagnosed GD were recruited in the years 2010-2014. Diagnosis was based on established criteria, and thyroid volume was assessed by ultrasonography. A clinical severity score (CSS) to assess the overall disease severity was developed by grading each component of the Merseburg triad. RESULTS At diagnosis, 45 % of patients had no goiter, and 30 % had a small goiter. The proportion of goitrous patients was much lower than in two Italian studies performed 20-30 years ago. Hyperthyroidism was subclinical in 16 % and mild in 29 % of patients, and Graves' orbitopathy was present in 20 %, usually mild, and active in only 2.5 % of patients. Using the CSS, less than half (44 %) of the patients had severe GD, while 22 % had mild and 34 % moderate disease. CSS was associated with a significantly higher risk of poorly controlled hyperthyroidism at 6 months. CONCLUSIONS In Italy, a relevant proportion of Graves' patients at diagnosis have mild to moderate GD; about half of them have no goiter, slightly less than one-fifth have subclinical hyperthyroidism, and only 20 % have GO. Thus, the clinical phenotype of GD is milder than in the past, possibly due to both earlier diagnosis and treatment, and improved iodine nutrition.
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Affiliation(s)
- L Bartalena
- Department of Clinical and Experimental Medicine, University of Insubria, Endocrine Unit, ASST dei Sette Laghi, Viale Borri, 57, 21100, Varese, Italy.
| | - E Masiello
- Department of Clinical and Experimental Medicine, University of Insubria, Endocrine Unit, ASST dei Sette Laghi, Viale Borri, 57, 21100, Varese, Italy
| | - F Magri
- Salvatore Maugeri Foundation and Department of Internal Medicine and Medical Therapy, University of Pavia, Pavia, Italy
| | - G Veronesi
- Department of Clinical and Experimental Medicine, University of Insubria, Endocrine Unit, ASST dei Sette Laghi, Viale Borri, 57, 21100, Varese, Italy
- Research Center in Epidemiology and Preventive Medicine (EPIMED), University of Insubria, Varese, Italy
| | - E Bianconi
- Department of Clinical and Experimental Medicine, University of Insubria, Endocrine Unit, ASST dei Sette Laghi, Viale Borri, 57, 21100, Varese, Italy
| | - F Zerbini
- Salvatore Maugeri Foundation and Department of Internal Medicine and Medical Therapy, University of Pavia, Pavia, Italy
| | - M Gaiti
- Salvatore Maugeri Foundation and Department of Internal Medicine and Medical Therapy, University of Pavia, Pavia, Italy
| | - E Spreafico
- Department of Clinical and Experimental Medicine, University of Insubria, Endocrine Unit, ASST dei Sette Laghi, Viale Borri, 57, 21100, Varese, Italy
| | - D Gallo
- Department of Clinical and Experimental Medicine, University of Insubria, Endocrine Unit, ASST dei Sette Laghi, Viale Borri, 57, 21100, Varese, Italy
| | - P Premoli
- Department of Clinical and Experimental Medicine, University of Insubria, Endocrine Unit, ASST dei Sette Laghi, Viale Borri, 57, 21100, Varese, Italy
| | - E Piantanida
- Department of Clinical and Experimental Medicine, University of Insubria, Endocrine Unit, ASST dei Sette Laghi, Viale Borri, 57, 21100, Varese, Italy
| | - M L Tanda
- Department of Clinical and Experimental Medicine, University of Insubria, Endocrine Unit, ASST dei Sette Laghi, Viale Borri, 57, 21100, Varese, Italy
| | - M Ferrario
- Department of Clinical and Experimental Medicine, University of Insubria, Endocrine Unit, ASST dei Sette Laghi, Viale Borri, 57, 21100, Varese, Italy
- Research Center in Epidemiology and Preventive Medicine (EPIMED), University of Insubria, Varese, Italy
| | - P Vitti
- Department of Clinical and Experimental Medicine, University of Pisa, Pisa, Italy
| | - L Chiovato
- Salvatore Maugeri Foundation and Department of Internal Medicine and Medical Therapy, University of Pavia, Pavia, Italy
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19
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Li HX, Xiang N, Hu WK, Jiao XL. Relation between therapy options for Graves' disease and the course of Graves' ophthalmopathy: a systematic review and meta-analysis. J Endocrinol Invest 2016; 39:1225-1233. [PMID: 27220843 DOI: 10.1007/s40618-016-0484-y] [Citation(s) in RCA: 29] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/11/2016] [Accepted: 05/07/2016] [Indexed: 12/11/2022]
Abstract
BACKGROUND The relation between therapy options for Graves' disease (GD) and the course of Graves' ophthalmopathy (GO) are still controversial. Our aim was to compare the occurrence of development or worsening of GO in patients who were treated with antithyroid drugs (ATDs) or radioactive iodine (RAI) or thyroidectomy (TX). METHODS We conducted a comprehensive search of the Embase and PubMed database. Odds ratio (OR) was used as a measure of the effect of therapy options for GD on the risk of development or worsening of GO. The analysis was further stratified by factors that could affect the treatment effects. RESULTS Nine trials involving 1773 patients were included. RAI therapy showed a significant effect on the risk of development or worsening GO compared with ATD (OR 2.25; 95 % CI 1.61-3.14; P < 0.00001). Glucocorticoid prophylaxis was effective in preventing GO development or worsening (0.40; 0.23-0.68; P = 0.002); especially for patients with preexisting GO (0.41; 0.23-0.73; P = 0.002). At 3 months, showed GO to be improved in 17 TX and 21 total thyroid ablation (TTA) patients, with no significant difference between the two groups; between 6 and 12 months, TTA did show significant beneficial effect on the improvement of GO (6.02; 2.80-12.96; P < 0.00001); GO was found to be inactive in a significantly higher percentage of patients in the TTA (2.17; 1.04-4.52; P = 0.04). CONCLUSION Radioiodine therapy is a significant risk factor for development or worsening of GO in GD. But GO progression can be prevented by prophylactic glucocorticoids in patients with preexisting GO. Compared with TX alone, TTA induces an earlier and steadier GO improvement in patients with mild to moderate-severe and active GO. Whether this is sufficient to offer TTA to patients needs further investigation.
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Affiliation(s)
- H X Li
- Tianjin Eye Hospital, Clinical College of Ophthalmology, Tianjin Medical University, Tianjin, 300020, China
| | - N Xiang
- Department of Ophthalmology, Tong Ji Hospital, Tong Ji Medical College, Huazhong University of Science and Technology, No. 1095. Jiefang Rd, Hankou District, Wuhan, 430030, China.
| | - W K Hu
- Department of Ophthalmology, Tong Ji Hospital, Tong Ji Medical College, Huazhong University of Science and Technology, No. 1095. Jiefang Rd, Hankou District, Wuhan, 430030, China
| | - X L Jiao
- Tianjin Eye Hospital, Clinical College of Ophthalmology, Tianjin Medical University, Tianjin, 300020, China
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Bartalena L, Chiovato L, Vitti P. Management of hyperthyroidism due to Graves' disease: frequently asked questions and answers (if any). J Endocrinol Invest 2016; 39:1105-14. [PMID: 27319009 DOI: 10.1007/s40618-016-0505-x] [Citation(s) in RCA: 38] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/30/2016] [Accepted: 06/11/2016] [Indexed: 02/03/2023]
Abstract
Graves' disease is the most common cause of hyperthyroidism in iodine-replete areas. Although progress has been made in our understanding of the pathogenesis of the disease, no treatment targeting pathogenic mechanisms of the disease is presently available. Therapies for Graves' hyperthyroidism are largely imperfect because they are bound to either a high rate of relapsing hyperthyroidism (antithyroid drugs) or lifelong hypothyroidism (radioiodine treatment or thyroidectomy). Aim of the present article is to offer a practical guidance to the reader by providing evidence-based answers to frequently asked questions in clinical practice.
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Affiliation(s)
- L Bartalena
- Endocrine Unit, Department of Clinical and Experimental Medicine, ASST dei Sette Laghi, Ospedale di Circolo, University of Insubria, Viale Borri, 57, Varese, Italy.
| | - L Chiovato
- Fondazione Salvatore Maugeri and University of Pavia, Pavia, Italy
| | - P Vitti
- Department of Clinical and Experimental Medicine, University of Pisa, Pisa, Italy
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Szczapa-Jagustyn J, Gotz-Więckowska A, Kocięcki J. An update on thyroid-associated ophthalmopathy in children and adolescents. J Pediatr Endocrinol Metab 2016; 29:1115-1122. [PMID: 27682712 DOI: 10.1515/jpem-2016-0122] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/07/2016] [Accepted: 08/29/2016] [Indexed: 12/13/2022]
Abstract
BACKGROUND Risk of developing thyroid-associated ophthalmopathy (TAO) in children and adolescents is similar or may be even slightly higher than in adults. The aim of this article is to review and summarize current knowledge regarding diagnostic and therapeutic measures in pediatric TAO. CONTENT MEDLINE and EMBASE papers were searched using the terms 'pediatric Graves' ophthalmopathy' 'pediatric Graves' orbitopathy', 'thyroid-associated ophthalmopathy in childhood and adolescence' from the year 1970 to December 2015. SUMMARY TAO usually accompanies hyperthyreosis in Graves' disease, but may also occur in patients with hypothyreosis due to chronic lymphocytic thyroiditis (Hashimoto's disease) or in euthyroid patients. Current information regarding epidemiology, pathogenesis, symptoms and treatment of TAO in children and adolescents is presented. The course of the disease is usually mild, eye disturbances often regress after restoring euthyroidism and a 'wait and see' policy is appropriate in the majority of patients. In rare cases, sight-threatening complications [dysthyroid optic neuropathy (DON) or corneal breakdown] may develop and immediate surgical intervention might become necessary. OUTLOOK Close cooperation between pediatric endocrinologists and opthalmologists is extremely important to ensure best care and quality of life in patients with thyroid gland dysfunction. Further investigations on pathogenesis and course of TAO in children and adolescents should be performed for better management of this disease in this group of patients.
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22
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Diana T, Wüster C, Kanitz M, Kahaly GJ. Highly variable sensitivity of five binding and two bio-assays for TSH-receptor antibodies. J Endocrinol Invest 2016; 39:1159-65. [PMID: 27197966 DOI: 10.1007/s40618-016-0478-9] [Citation(s) in RCA: 53] [Impact Index Per Article: 6.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/20/2016] [Accepted: 04/23/2016] [Indexed: 12/22/2022]
Abstract
PURPOSE TSH-receptor (TSHR) antibodies (Ab) can be measured with binding or bio-assays. Sensitivity and specificity of five binding and two bio-assays were compared. METHODS TSHR-blocking (TBAb) and TSHR-stimulating (TSAb) Ab were measured with reporter bio-assays. Blocking activity was defined as percent inhibition of luciferase expression relative to induction with bTSH alone. TSAb was reported as percentage of specimen-to-reference ratio (SRR%). TSHR-binding inhibitory immunoglobulins (TBII) were measured with Kronus, Dynex, Kryptor, Cobas, and Immulite. RESULTS Sixty patients with Graves' disease (GD), 20 with Hashimoto's thyroiditis (HT), and 20 healthy controls (C) were included. C tested negative in all assays (specificity 100 %) while all 60 hyperthyroid GD patients tested positive in the TSAb bio-assay (sensitivity 100 %). Among these 60 GD patients, 20 had low TSAb positivity (SRR% 140-279), but were TBII positive in only 20 (100 %), 7 (35 %), 9 (45 %), 11 (55 %), and 18 (90 %) using the Kronus, Dynex, Kryptor, Cobas, and Immulite, respectively. In 20 moderate TSAb-positive (SRR% 280-420) patients, TBII tested positive in 20 (100 %), 14 (70 %), 13 (65 %), 16 (80 %), and 19 (95 %), respectively. The high (SRR% > 420) TSAb-positive patients were all TBII positive. All 20 hypothyroid HT patients tested TBAb positive (sensitivity 100 %) in the bio-assay while they tested TBII positive in 20 (100 %), 18 (90 %), 20, 20, and 18, respectively. Results obtained with two luminometers correlated for TSAb positive (r = 0.99, p < 0.001), TBAb positive (r = 0.88, p < 0.001), and C (r = 0.86, p < 0.001). None of the binding assays differentiated between TSAb and TBAb. CONCLUSIONS Sensitivity is highly variable between binding and bio-assays for TSHR-Abs.
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Affiliation(s)
- T Diana
- Molecular Thyroid Research Laboratory, Department of Medicine I, Johannes Gutenberg University (JGU) Medical Center, Mainz, Germany
| | - C Wüster
- Endocrine Practice, Mainz, Germany
| | - M Kanitz
- Molecular Thyroid Research Laboratory, Department of Medicine I, Johannes Gutenberg University (JGU) Medical Center, Mainz, Germany
| | - G J Kahaly
- Molecular Thyroid Research Laboratory, Department of Medicine I, Johannes Gutenberg University (JGU) Medical Center, Mainz, Germany.
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23
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Moleti M, Sturniolo G, Vermiglio F. Safety of total thyroid ablation in patients with Graves' orbitopathy. J Endocrinol Invest 2016; 39:1199-201. [PMID: 27206633 DOI: 10.1007/s40618-016-0485-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/20/2016] [Accepted: 05/09/2016] [Indexed: 10/21/2022]
Affiliation(s)
- M Moleti
- Dipartimento di Medicina Clinica e Sperimentale, University of Messina, Messina, Italy
| | - G Sturniolo
- Dipartimento di Medicina Clinica e Sperimentale, University of Messina, Messina, Italy
- Dipartimento di Patologia Umana dell'adulto e dell'età evolutiva "Gaetano Barresi", University of Messina, Via Consolare Valeria 1, 98125, Messina, Italy
| | - F Vermiglio
- Dipartimento di Medicina Clinica e Sperimentale, University of Messina, Messina, Italy.
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Moleti M, Giuffrida G, Sturniolo G, Squadrito G, Campennì A, Morelli S, Puxeddu E, Sisti E, Trimarchi F, Vermiglio F, Marinò M. Acute liver damage following intravenous glucocorticoid treatment for Graves' ophthalmopathy. Endocrine 2016; 54:259-268. [PMID: 27003434 DOI: 10.1007/s12020-016-0928-3] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/03/2016] [Accepted: 03/14/2016] [Indexed: 12/17/2022]
Abstract
PURPOSE Over the last years, there have been several reports on the occurrence of acute liver damage (ALD) in patients affected with Graves' ophthalmopathy (GO) receiving intravenous glucocorticoids (ivGCs). This article is aimed at reviewing the literature on this specific topic and reporting two new cases of ALD occurring in GO patients while on ivGCs. METHODS The terms "glucocorticoid therapy" and "Graves' Ophthalmopathy"/"Graves' Orbitopathy"/"Thyroid eye disease" were used both separately and in conjunction with the terms "liver disease," "liver damage," "hepatotoxicity," "liver failure," to search MEDLINE for articles published since the first report of ALD in 2000 and up to 2015. RESULTS ALD [defined as an increase in alanine aminotransferase (ALT) >300 U/L] during or after completion of ivGCs has been so far reported in 17 fully documented cases. Overall, one-half of those patients were diagnosed as having autoimmune hepatitis (AIH) and in the vast majority of the remaining cases a diagnosis of methylprednisolone(MP)-induced hepatotoxicity was suspected. The clinical course of liver injury varied from asymptomatic hypertransaminasemia in the vast majority of patients to fatal hepatic failure in four patients receiving higher (>8 g) cumulative doses of MP. CONCLUSIONS The overall risk of ALD is relatively low (~1 %), and seems higher using a single dose >0.5 g and a cumulative dose >8.5 g MP. Whenever ivGC treatment is required, serum liver enzymes, viral hepatitis markers, and autoantibodies related to AIH should be obtained prior to ivGC administration. Liver function should be monitored during ivGC and up to 6 months after the end of treatment. Prolonging observation after 6 months is likely unnecessary, since all cases of ALD so far reported always occurred well within this term.
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Affiliation(s)
- Mariacarla Moleti
- Dipartimento di Medicina Clinica e Sperimentale, University of Messina, Messina, Italy.
| | - Giuseppe Giuffrida
- Dipartimento di Medicina Clinica e Sperimentale, University of Messina, Messina, Italy
| | - Giacomo Sturniolo
- Dipartimento di Medicina Clinica e Sperimentale, University of Messina, Messina, Italy
| | - Giovanni Squadrito
- Dipartimento di Patologia Umana dell'adulto e dell'età evolutiva, University of Messina, Messina, Italy
| | - Alfredo Campennì
- Dipartimento di Scienze Radiologiche, Sezione di Medicina Nucleare University of Messina, Messina, Italy
| | - Silvia Morelli
- Dipartimento di Medicina, University of Perugia, Perugia, Italy
| | - Efisio Puxeddu
- Dipartimento di Medicina, University of Perugia, Perugia, Italy
| | - Eleonora Sisti
- Dipartimento di Medicina Clinica e Sperimentale, University of Pisa, Pisa, Italy
| | - Francesco Trimarchi
- Dipartimento di Medicina Clinica e Sperimentale, University of Messina, Messina, Italy
| | - Francesco Vermiglio
- Dipartimento di Medicina Clinica e Sperimentale, University of Messina, Messina, Italy
| | - Michele Marinò
- Dipartimento di Medicina Clinica e Sperimentale, University of Pisa, Pisa, Italy
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Campi I, Vannucchi G, Salvi M. THERAPY OF ENDOCRINE DISEASE: Endocrine dilemma: management of Graves' orbitopathy. Eur J Endocrinol 2016; 175:R117-33. [PMID: 27032693 DOI: 10.1530/eje-15-1164] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/30/2015] [Accepted: 03/31/2016] [Indexed: 12/22/2022]
Abstract
Management of Graves' orbitopathy (GO) must be based on the correct assessment of activity and severity of the disease. Activity is usually assessed with the Clinical Activity Score, whereas severity is classified according to a European Group On Graves' Orbitopathy (EUGOGO) consensus statement as mild, moderate-to-severe, and sight-threatening. Myopathic and chronic congestive forms are uncommon clinical presentations of GO. Restoration and maintenance of stable euthyroidism are recommended in the presence of GO.In moderate-to-severe disease, steroids have been widely employed and have shown to possess an anti-inflammatory activity, but about 20-30% of patients are not responsive and present recurrence. Some novel immunosuppressors have already been employed in clinical studies and have shown interesting results, although the lack of randomized and controlled trials suggests caution for their use in clinical practice. Potential targets for therapy in GO are the thyroid-stimulating hormone and the insulin-like growth factor 1 receptor on the fibroblasts, inflammatory cytokines, B and T cells, and the PIK3/mTORC1 signaling cascades for adipogenesis. A recent open study has shown that tocilizumab, an anti-sIL-6R antibody, inactivates GO. Consistent reports on the efficacy of rituximab have recently been challenged by randomized controlled trials.As the main goal of treatment is the well-being of the patient, the therapeutic strategy should be addressed to better suit the patient needs, more than improving one or more biological parameters. The increasing availability of new therapies will expand the therapeutic options for GO patients and allow the clinician to really personalize the treatment to better suit the patients' personal needs.
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Affiliation(s)
- Irene Campi
- Graves' Orbitopathy CenterEndocrinology, Fondazione IRCCS Cà Granda, Milan, Italy
| | - Guia Vannucchi
- Graves' Orbitopathy CenterEndocrinology, Fondazione IRCCS Cà Granda, Milan, Italy
| | - Mario Salvi
- Graves' Orbitopathy CenterEndocrinology, Fondazione IRCCS Cà Granda, Milan, Italy
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Erdoğan MF, Demir Ö, Ersoy RÜ, Gül K, Aydoğan Bİ, Üç ZA, Mete T, Ertek S, Ünlütürk U, Çakır B, Aral Y, Güler S, Güllü S, Çorapçıoğlu D, Dağdelen S, Erdoğan G. Comparison of Early Total Thyroidectomy with Antithyroid Treatment in Patients with Moderate-Severe Graves' Orbitopathy: A Randomized Prospective Trial. Eur Thyroid J 2016; 5:106-11. [PMID: 27493884 PMCID: PMC4949371 DOI: 10.1159/000444796] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/14/2015] [Revised: 02/16/2016] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND The optimal therapeutic choice for Graves' hyperthyroidism in the presence of moderate-severe Graves' orbitopathy (GO) remains controversial. OBJECTIVES We aimed to compare GO course in patients with moderate-severe GO treated with early total thyroidectomy (TTx) versus antithyroid drug (ATD) regimens, in a prospective, randomized manner. METHODS Forty-two patients with moderate-severe GO were enrolled. A total of 4.5 g of pulse corticosteroids were given intravenously to all patients before randomization. Patients in the first group were given TTx, whereas patients in the second group were treated with ATDs. TSH was kept between 0.4 and 1 mIU/l. The clinical course of GO was evaluated with proptosis, lid aperture, clinical activity score (CAS), and diplopia. RESULTS Eighteen and 24 patients were randomized to the TTx and ATD groups, respectively. Thyroid autoantibodies decreased significantly, and there were significant improvements in proptosis, lid aperture, and CAS in the TTx group. While in the ATD group the decrement in thyroid autoantibodies was not significant, there were significant improvements in proptosis and CAS. When the TTx group was compared with the ATD group, anti-TPO, anti-Tg, and TSH-receptor antibodies were significantly decreased in the TTx group (p < 0.01), but there was no significant difference with respect to proptosis, lid aperture, CAS, and diplopia between the two groups during a median (min.-max.) follow-up period of 60 months (36-72). CONCLUSION Although no definitive conclusions could be drawn from the study, mainly due to limited power, early TTx and the ATD treatment regimens, followed by intravenous pulse corticosteroid therapy, seemed to be equally effective on the course of GO in this relatively small group of patients with moderate-severe GO during a median (min.-max.) follow-up period of 60 months (36-72).
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Affiliation(s)
- Murat Faik Erdoğan
- Department of Endocrinology and Metabolic Diseases, Ankara University Medical Faculty, Ankara, Turkey
- *Murat Faik Erdoğan, Department of Endocrinology and Metabolic Diseases, School of Medicine, Ankara University, Adnan Saygun St., TR–06100 Samanpazarı/Ankara (Turkey), E-Mail
| | - Özgür Demir
- Department of Endocrinology and Metabolic Diseases, Ankara University Medical Faculty, Ankara, Turkey
| | - Reyhan Ünlü Ersoy
- Department of Endocrinology and Metabolic Diseases, Yıldırım Beyazıt University Medical Faculty, Ankara, Turkey
| | - Kamile Gül
- Department of Endocrinology and Metabolic Diseases, Yıldırım Beyazıt University Medical Faculty, Ankara, Turkey
| | - Berna İmge Aydoğan
- Department of Endocrinology and Metabolic Diseases, Ankara University Medical Faculty, Ankara, Turkey
| | - Ziynet Alphan Üç
- Department of Endocrinology and Metabolic Diseases, Ankara Training and Research Hospital, Ankara, Turkey
| | - Türkan Mete
- Endocrinology and Metabolic Diseases, Ankara Numune Training and Research Hospital, Ankara, Turkey
| | - Sibel Ertek
- Department of Endocrinology and Metabolic Diseases, Ufuk University Medical Faculty, Ankara, Turkey
| | - Uğur Ünlütürk
- Department of Endocrinology and Metabolic Diseases, Ankara University Medical Faculty, Ankara, Turkey
| | - Bekir Çakır
- Department of Endocrinology and Metabolic Diseases, Yıldırım Beyazıt University Medical Faculty, Ankara, Turkey
| | - Yalçın Aral
- Department of Endocrinology and Metabolic Diseases, Ankara Training and Research Hospital, Ankara, Turkey
| | - Serdar Güler
- Endocrinology and Metabolic Diseases, Ankara Numune Training and Research Hospital, Ankara, Turkey
| | - Sevim Güllü
- Department of Endocrinology and Metabolic Diseases, Ankara University Medical Faculty, Ankara, Turkey
| | - Demet Çorapçıoğlu
- Department of Endocrinology and Metabolic Diseases, Ankara University Medical Faculty, Ankara, Turkey
| | - Selçuk Dağdelen
- Department of Endocrinology and Metabolic Diseases, Hacettepe University Medical Faculty, Ankara, Turkey
| | - Gürbüz Erdoğan
- Department of Endocrinology and Metabolic Diseases, Ufuk University Medical Faculty, Ankara, Turkey
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Riedl M, Kuhn A, Krämer I, Kolbe E, Kahaly GJ. Prospective, systematically recorded mycophenolate safety data in Graves' orbitopathy. J Endocrinol Invest 2016; 39:687-94. [PMID: 26886940 DOI: 10.1007/s40618-016-0441-9] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/25/2016] [Accepted: 02/02/2016] [Indexed: 12/17/2022]
Abstract
CONTEXT The antiproliferative mechanism of mycophenolate acid (MPA) suggests a beneficial effect in patients with Graves' orbitopathy (GO). OBJECTIVE To systematically analyze for the first time adverse events (AEs) during MPA treatment in GO. DESIGN Prospective longitudinal study. SETTING Academic tertiary referral center with a joint thyroid-eye clinic. PATIENTS Fifty-three consecutive, unselected patients with clinically active and moderate-to-severe GO. METHODS MPA 0.720 g was given once daily for 24-weeks in GO patients. AEs were documented and coded according to the standardized medical dictionary for regulatory activities (MedDRA). AE were followed up and seriousness as defined by ICH-guideline E6 was documented. All AEs were analyzed regarding a possible underlying cause and if not, graded as side effect (SE). RESULTS Fifty GO patients (93 %) had Graves' disease, 37 (70 %) and 29 (54.7 %) were female and smoker, respectively. Thirty-six patients (68 %) reported at least one AE. A total of 88 AEs were documented, most frequent AEs were insomnia (N = 6), fatigue (N = 5) and optic neuropathy (N = 5), while other AEs occurred in up to three patients (5.6 %), only. In 12 (23 %) patients, at least one SE occurred. All 17 reported SE, i.e. mild infections and gastrointestinal intolerance were within the known safety profile of MPA. No patient dropped MPA medication because of drug-induced SE. Most AEs showed a recovered (76 %) or recovering (16 %) outcome. Seven (13 %) patients were hospitalized, five (62 %) due to optic neuropathy, none of these events was graded as SE. CONCLUSIONS MedDRA-coded data documented the good tolerance of a moderate MPA dose in GO patients.
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Affiliation(s)
- M Riedl
- Departments of Medicine I, Johannes Gutenberg University Medical Center, Mainz, Germany
- Interdisciplinary Center for Clinical Trials, Johannes Gutenberg University Medical Center, Mainz, Germany
| | - A Kuhn
- Interdisciplinary Center for Clinical Trials, Johannes Gutenberg University Medical Center, Mainz, Germany
| | - I Krämer
- Pharmacy Department, Johannes Gutenberg University Medical Center, Mainz, Germany
| | - E Kolbe
- Departments of Medicine I, Johannes Gutenberg University Medical Center, Mainz, Germany
| | - G J Kahaly
- Departments of Medicine I, Johannes Gutenberg University Medical Center, Mainz, Germany.
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Ruchała M, Sawicka-Gutaj N. Advances in the pharmacological treatment of Graves' orbitopathy. Expert Rev Clin Pharmacol 2016; 9:981-9. [PMID: 26966785 DOI: 10.1586/17512433.2016.1165606] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
Graves' orbitopathy has a deteriorating effect on patients' appearance and vision, thus significantly decreases their quality of life. A multidisciplinary team of endocrinologists, ophthalmologists, head and neck surgeons, nuclear medicine physicians, radiologists, and psychologists should constitute a standard health care team for those patients. It is vital that the therapy is based on an individual approach, with patients being well informed and involved in the decision-making process. Generally, traditional therapies include immunosuppression with steroids, orbital irradiation and surgical decompression. Novel treatment modalities include: biological agents, somatostatin analogs, antioxidants, methotrexate. Better insight into pathogenesis of Graves' orbitopathy is the only chance for targeted therapy development.
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Affiliation(s)
- Marek Ruchała
- a Department of Endocrinology, Metabolism and Internal Medicine , Poznan University of Medical Sciences , Poznań , Poland
| | - Nadia Sawicka-Gutaj
- a Department of Endocrinology, Metabolism and Internal Medicine , Poznan University of Medical Sciences , Poznań , Poland
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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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Jarusaitiene D, Verkauskiene R, Jasinskas V, Jankauskiene J. Predictive Factors of Development of Graves' Ophthalmopathy for Patients with Juvenile Graves' Disease. Int J Endocrinol 2016; 2016:8129497. [PMID: 27413373 PMCID: PMC4928005 DOI: 10.1155/2016/8129497] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/07/2016] [Accepted: 05/12/2016] [Indexed: 12/14/2022] Open
Abstract
Background. Due to low incidence of Graves' ophthalmopathy (GO) among children, the manifestation is poorly analyzed, posing a risk to late identification of insidious disease. Purposes. To identify predictive factors that may influence the development of GO in pediatric and young patients with Graves' disease (GD). Methods. A cross-sectional study of patients newly diagnosed with pediatric or juvenile GD during 2002-2012 was conducted at the Hospital of Lithuanian University of Health Sciences. Ocular evaluation was based on European Group on Graves' Orbitopathy survey. The ocular manifestations were analyzed in relation to demographic, environmental, and clinical factors. Results. In total, 130 patients with juvenile GD were included; 29.2% had GO. Median age at GD onset was 17 yrs (IQR 4-29). Main symptoms of GO were eyelids retraction (73.7%), proptosis (65.8%), injection of conjunctiva (42.1%), and eyeball motility disturbance (21.1%). Major significant and independent risk factors for GO development were high initial concentration of FT4 (OR = 5.963), TTHAb (OR = 6.358), stress (OR = 6.030), and smoking (OR = 7.098). Conclusion. The major factors that could influence GO development were smoking, stress, and increased levels of initial TRAb, FT4. Slight proptosis, retraction of eyelids, and conjunctive injection were found as predominant ophthalmological symptoms in juvenile GO.
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Affiliation(s)
- Dalia Jarusaitiene
- Eye Clinic, Medical Academy, Lithuanian University of Health Sciences, A. Mickevičiaus 9, LT-44307 Kaunas, Lithuania
- *Dalia Jarusaitiene:
| | - Rasa Verkauskiene
- Institute of Endocrinology, Medical Academy, Lithuanian University of Health Sciences, Eiveniu 2, LT-50009 Kaunas, Lithuania
| | - Vytautas Jasinskas
- Eye Clinic, Medical Academy, Lithuanian University of Health Sciences, A. Mickevičiaus 9, LT-44307 Kaunas, Lithuania
| | - Jurate Jankauskiene
- Eye Clinic, Medical Academy, Lithuanian University of Health Sciences, A. Mickevičiaus 9, LT-44307 Kaunas, Lithuania
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Leporati P, Groppelli G, Zerbini F, Rotondi M, Chiovato L. Etiopathogenesis of Basedow's disease. Trends and current aspects. Nuklearmedizin 2015; 54:204-10. [PMID: 26293122 DOI: 10.3413/nukmed-0739-15-04] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/30/2015] [Accepted: 08/12/2015] [Indexed: 12/13/2022]
Abstract
Basedow's disease (BD) owes its name to the German physician Karl Adolph von Basedow, who described in 1840 the clinical picture of exophthalmic toxic goitre. More than one century after the seminal paper of Karl von Basedow, the ultimate cause of BD remains to be fully elucidated. In the last years, evidence was accumulated indicating that BD is a polygenic and multifactorial disease that develops as a result of a complex interplay between genetic susceptibility and environmental and endogenous factors, which leads to the loss of immune tolerance to thyroid antigens and in particular to the TSH receptor. Our aim is to review the current knowledge on the pathogenesis of BD. To this purpose, we will firstly focus our attention on the role of genetic factors (the HLA complex, the genes encoding for thyroglobulin, the TSH receptor, CD40, CTLA-4 and PTPN22), and of environmental factors (iodine, infections, psychological stress, gender, smoking, thyroid damage, vitamin D, selenium, immune modulating agents) as possible causes of BD. Taking advantage of the experimental animal models of BD, we will then focus on the immunological mechanisms leading to the loss of tolerance in BD. The pathogenic role played by the chemokine system will be also reviewed.
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Affiliation(s)
| | | | | | | | - L Chiovato
- Luca Chiovato, M.D., Ph.D., Unit of Internal Medicine and Endocrinology, Fondazione Salvatore Maugeri I.R.C.C.S., Chair of Endocrinology, University of Pavia, Via S. Maugeri 10, I-27100, Pavia, Italy, Fax +39/03 82/59 26 92,
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