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Malboosbaf R, Maghsoomi Z, Emami Z, Khamseh ME, Azizi F. Statins and thyroid eye disease (TED): a systematic review. Endocrine 2024; 85:11-17. [PMID: 38194219 DOI: 10.1007/s12020-023-03680-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/18/2023] [Accepted: 12/26/2023] [Indexed: 01/10/2024]
Abstract
PURPOSE Thyroid eye disease (TED) is the foremost extrathyroidal manifestation of Graves' disease (GD). Currently, available treatments do not entirely prevent the long-term consequences of TED and have distinct disadvantages. Therefore, this systematic review explored available evidence regarding the efficacy of statins in preventing and treating TED. METHODS Relevant studies investigating statin usage in patients with GD or TED were identified by searching Medline (Pubmed and Ovid), Scopus, Web of Science, ProQuest, and Cochrane Library databases (from the database inception to September 2023). The review was done according to the PRISMA statement. Web searching was done independently by two investigators. Two researchers independently extracted the data, and any disagreement was adjudicated by consensus. Based on the study design, the studies' quality appraisal was done using the Newcastle-Ottawa Scale (NOS) and Version 2 of the Cochrane risk-of-bias tool (RoB2). RESULTS The literature search identified 145 publications, of which four met the inclusion criteria (Three retrospective cohort studies and one randomized clinical trial) and were reviewed in full text. The two retrospective cohort studies demonstrated the beneficial effects of statins on TED in newly diagnosed GD Stein et al. showed that statins, regardless of the type, prevent or delay TED (HR: 0.74 (0.65-0.84)), especially in men or treatment duration of more than one year. Nilsson et al. fascinatingly revealed that at least 60 days of statin usage in the preceding year could decrease the risk of TED development by around 40%. One RCT showed a higher treatment response for active moderate-to-severe TED in patients with hypercholesterolemia who took atorvastatin 20 mg in addition to ivGC for 24 weeks without any increase in serious side effects. The retrospective study revealed that the need for reconstructive surgery was reduced in patients with severe TED who received statin therapy. CONCLUSION Statin therapy could be a potential adjunctive modality for preventing and treating TED. TRIAL REGISTRATION PROSPERO registration number: CRD42022315522.
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Affiliation(s)
- Ramin Malboosbaf
- Endocrine Research Center, Institute of Endocrinology and Metabolism, Iran University of Medical Sciences, Tehran, Iran
| | - Zohreh Maghsoomi
- Endocrine Research Center, Institute of Endocrinology and Metabolism, Iran University of Medical Sciences, Tehran, Iran.
| | - Zahra Emami
- Endocrine Research Center, Institute of Endocrinology and Metabolism, Iran University of Medical Sciences, Tehran, Iran
| | - Mohammad E Khamseh
- Endocrine Research Center, Institute of Endocrinology and Metabolism, Iran University of Medical Sciences, Tehran, Iran
| | - Fereidoun Azizi
- Endocrine Research Center, Research Institute for Endocrine Sciences, Shahid Beheshti University of Medical Sciences, Tehran, Iran
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Zhang C, Ersan S, Yousef Y, Sandhur B, Desilets J, McGlone C, Kellner T, Teru S, Reynolds AL. The effect of teprotumumab infusion on ocular alignment in patients with symptomatic thyroid eye disease. J AAPOS 2024:103959. [PMID: 38944235 DOI: 10.1016/j.jaapos.2024.103959] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/11/2024] [Revised: 03/26/2024] [Accepted: 03/29/2024] [Indexed: 07/01/2024]
Abstract
BACKGROUND Thyroid eye disease (TED) can result in proptosis and ocular misalignment, leading to eye pain, diplopia, and vision loss. Teprotumumab, a humanized antibody against insulin-like growth factor 1 receptor, was approved in 2020 for the treatment of TED. The purpose of this study was to describe the effect of a full course of teprotumumab on ocular misalignment. METHODS The medical records of patients who underwent treatment with teprotumumab for active moderate-to-severe TED at a single institution from April 2020 to September 2023 were reviewed retroactively. Sensorimotor examination was performed at each visit using simultaneous prism-cover testing. Demographic information and previous history of radioactive iodine, steroids, strabismus surgery, and smoking were extracted from the record for analysis. RESULTS A total of 19 patients were treated during the study period, of whom 11 had strabismus and diplopia. The initial absolute horizontal misalignment in these 11 was 6.0Δ ± 1.5Δ, vertical misalignment was 7.7Δ ± 2.4Δ, and total misalignment was 11.5Δ ± 2.0Δ. On completion of treatment, these measurements decreased by 2.0Δ ± 1.5Δ, 2.2Δ ± 1.0Δ, and 3.2Δ ± 1.6Δ, respectively (P = 0.10, 0.02, and 0.04, resp.). Eight patients (73%) had a decrease in their strabismus, and 5 (46%) reported complete resolution of their diplopia at the final visit. No factors were predictive of which patients would have resolution of their misalignment. Of the remaining 3 patients who had no improvement in ocular alignment, 2 (66%) underwent strabismus surgery. Of the 8 patients with improvement of strabismus, only a single patient (13%) underwent strabismus surgery for persistent diplopia. CONCLUSIONS In our study cohort, a full course of teprotumumab coincided with complete resolution of diplopia in 46% of patients and a decrease in strabismus in 73% of patients.
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Affiliation(s)
- Charles Zhang
- Department of Ophthalmology, Ross Eye Institute, University at Buffalo, Buffalo, New York.
| | - Sinan Ersan
- Jacobs School of Medicine and Biomedical Sciences, State University of New York at Buffalo, Buffalo, New York
| | - Yousef Yousef
- Jacobs School of Medicine and Biomedical Sciences, State University of New York at Buffalo, Buffalo, New York
| | - Baltaj Sandhur
- Jacobs School of Medicine and Biomedical Sciences, State University of New York at Buffalo, Buffalo, New York
| | - Jeffrey Desilets
- Department of Ophthalmology, Massachusetts Eye and Ear, Harvard Medical School, Boston, Massachusetts
| | - Cameron McGlone
- Department of Ophthalmology, Ross Eye Institute, University at Buffalo, Buffalo, New York
| | - Thomas Kellner
- Department of Ophthalmology, Ross Eye Institute, University at Buffalo, Buffalo, New York
| | - Smaran Teru
- Lake Erie College of Osteopathic Medicine, Erie, Pennsylvania
| | - Andrew L Reynolds
- Department of Ophthalmology, Ross Eye Institute, University at Buffalo, Buffalo, New York
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Gunes IB, Yilmaz H, Onal ED. The evaluation of retrobulbar fat tissue in Graves' orbitopathy with shear-wave ultrasound elastography. Int Ophthalmol 2024; 44:13. [PMID: 38321200 DOI: 10.1007/s10792-024-02962-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/20/2023] [Accepted: 12/04/2023] [Indexed: 02/08/2024]
Abstract
PURPOSE To evaluate retrobulbar adipose tissue of patients with active and inactive Graves' orbitopathy (GO) by shear-wave ultrasound elastography (SWE). METHODS Followed-up in our ophthalmology clinic due to GO, 72 eyes of 36 patients and 38 eyes of 19 healthy controls were included in this cross-sectional case-control study. Graves' patients were divided into two subgroups under clinical activity score (CAS): active Graves' orbitopathy (AGO) (CAS ≥ 3) and inactive Graves' orbitopathy (IGO) (CAS < 3). SWE measurement values of retrobulbar adipose tissue of all participants were recorded in meters/second, and the intergroup comparisons were performed. RESULTS Thirty-four eyes of 17 patients in AGO, 38 eyes of 19 patients in IGO, and 38 eyes of 19 participants in the control group were included in the study. Mean values measured from retrobulbar adipose tissue through SWE were 1.00 ± 0.01 m/sec in AGO, 1.16 ± 0.01 m/sec in IGO, and 0.94 ± 0.01 m/sec in the control groups. Even so, the mean SWE value was significantly higher in the IGO group than in the other groups (p < 0.001). Mean SWE values were significantly higher in the AGO group than in the controls (p = 0.008). In the correlation analysis performed, a significant positive correlation was found between SWE and Hertel exophthalmometer measurement values (p = 0.026, r = 0.212), and thyroid-stimulating hormone receptor antibody (TSHR-Ab) levels (p = 0.018, r = 0.224). CONCLUSION We detected SWE values of retrobulbar adipose tissue high in GO, especially in the IGO group. Such a situation, which we associated with the development of fibrosis, may be an indicator of unresponsiveness to immunomodulatory treatments.
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Affiliation(s)
- Irfan Botan Gunes
- Department of Ophthalmology, Medicalpark Kocaeli Hospital, Kocaeli Health and Technology University, Başiskele, Kocaeli, Turkey.
| | - Hakan Yilmaz
- Department of Radiology, Medicalpark Kocaeli Hospital, Başiskele, Kocaeli, Turkey
| | - Eda Demir Onal
- Department of Endocrinology, Medicalpark Kocaeli Hospital, Başiskele, Kocaeli, Turkey
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Gürkan E, Çakmak Aİ, Burakgazi G, Keleş FÖ. Optical coherence tomography and shear wave elastography findings in Graves ophthalmopathy. Int Ophthalmol 2024; 44:9. [PMID: 38319450 DOI: 10.1007/s10792-024-02931-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/05/2023] [Accepted: 12/17/2023] [Indexed: 02/07/2024]
Abstract
PURPOSE The main feature of Graves ophthalmopathy (GO) is revealed by determining the activity and severity of the disease. We aimed to evaluate the use of imaging methods can also provide additional information about the severity of this disease. METHODS Optical coherence tomography (OCT) and shear wave elastography (SWE) findings were compared in 32 patients with mild GO group and in the healthy control group. Measuring for TSH receptor antibody (TRAb) serum level is used third-generation assay. RESULTS In Graves group, optic nerve sheath diameter (ONSD) values were increased in both eyes (p < 0.001, p < 0.001). SWE measurements showed a significant increase both eye optic nerve (ON) and right eye soft tissue elasticity values in GO group (p < 0.001, p < 0.001, p < 0.001, respectively). There was a significant thinning in left temporal retinal nerve fiber layer (RNFL) thickness and left RNFL peripapillary thickness in GO group (p < 0.001, p < 0.025, respectively). There was a correlation between left eye OCT and SWE findings. Also, there was a significant difference between the median left eye ON and soft tissue elasticity results in the TRAb-positive GO group (p = 0.049, p = 0.048, respectively). CONCLUSION SWE measurements showed a significant increase both eyes ONSD, ON and right eye soft tissue elasticity values in GO group. GO group was significant thinning in some left eye regions in OCT measurements. There was a correlation between left eye OCT and SWE findings. In addition to clinical activity score and TRAb, SWE and OCT can be used to monitor in patients with GO.
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Affiliation(s)
- Eren Gürkan
- Department of Endocrinology and Metabolism, Medical Faculty of Tayfur Ata Sökmen, University of Hatay Mustafa Kemal, Alahan Mah, 31001, Hatay, Turkey.
| | - Ayşe İdil Çakmak
- Department of Ophthalmopathy, University of Hatay Mustafa Kemal, Antakya, Hatay, Turkey
| | - Gülen Burakgazi
- Department of Radiology, University of Recep Tayyip Erdoğan, Rize, Turkey
| | - Fatma Öztürk Keleş
- Department of Radiology, University of Hatay Mustafa Kemal, Antakya, Hatay, Turkey
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Schuh A, Ayvaz G, Baldeschi L, Baretić M, Bechtold D, Boschi A, Brix TH, Burlacu MC, Ciric J, Covelli D, Currò N, Donati S, Eckstein AK, Fichter N, Führer D, Horn M, Jabłońska-Pawlak A, Juri Mandić J, Kahaly GJ, Konuk O, Langbein A, Lanzolla G, Marcocci C, Marinò M, Miśkiewicz P, Beleslin BN, Pérez-Lázaro A, Pérez-López M, Ponto KA, Quinn A, Rudofsky G, Salvi M, Schittkowski MP, Tanda ML, Toruner F, Vaidya B, Hintschich CR. Presentation of Graves' orbitopathy within European Group On Graves' Orbitopathy (EUGOGO) centres from 2012 to 2019 (PREGO III). Br J Ophthalmol 2024; 108:294-300. [PMID: 36627174 PMCID: PMC10850632 DOI: 10.1136/bjo-2022-322442] [Citation(s) in RCA: 8] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/20/2022] [Accepted: 12/22/2022] [Indexed: 01/12/2023]
Abstract
BACKGROUND Graves' orbitopathy (GO) is subject to epidemiological and care-related changes. Aim of the survey was to identify trends in presentation of GO to the European Group On Graves' Orbitopathy (EUGOGO) tertiary referral centres and initial management over time. METHODS Prospective observational multicentre study. All new referrals with diagnosis of GO within September-December 2019 were included. Clinical and demographic characteristics, referral timelines and initial therapeutic decisions were recorded. Data were compared with a similar EUGOGO survey performed in 2012. RESULTS Besides age (mean age: 50.5±13 years vs 47.7±14 years; p 0.007), demographic characteristics of 432 patients studied in 2019 were similar to those in 2012. In 2019, there was a decrease of severe cases (9.8% vs 14.9; p<0.001), but no significant change in proportion of active cases (41.3% vs 36.6%; p 0.217). After first diagnosis of GO, median referral time to an EUGOGO tertiary centre was shorter (2 (0-350) vs 6 (0-552) months; p<0.001) in 2019. At the time of first visit, more patients were already on antithyroid medications (80.2% vs 45.0%; p<0.001) or selenium (22.3% vs 3.0%; p<0.001). In 2019, the initial management plans for GO were similar to 2012, except for lid surgery (2.4% vs 13.9%; p<0.001) and prescription of selenium (28.5% vs 21.0%; p 0.027). CONCLUSION GO patients are referred to tertiary EUGOGO centres in a less severe stage of the disease than before. We speculate that this might be linked to a broader awareness of the disease and faster and adequate delivered treatment.
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Affiliation(s)
- Anna Schuh
- Department of Ophthalmology, Ludwig Maximilians University Munich, Munich, Germany
| | - Goksun Ayvaz
- Department of Endocrinology and Metabolism, Koru Hospital, Ankara, Turkey
| | - Lelio Baldeschi
- Service d'Ophtalmologie, Université Catholique de Louvain, Cliniques Universitaires Saint-Luc, Brussels, Belgium
| | - Maja Baretić
- Department of Endocrinology and Diabetes, University Hospital Center Zagreb, Croatia, School of medicine University of Zagreb, Zagreb, Croatia
| | - Dorte Bechtold
- Department of Ophthalmology, Odense University Hospital, Odense C, Denmark
| | - Antonella Boschi
- Service d'Ophtalmologie, Université Catholique de Louvain, Cliniques Universitaires Saint-Luc, Brussels, Belgium
| | | | - Maria-Cristina Burlacu
- Department of Endocrinology, Université Catholique de Louvain, Cliniques Universitaires Saint-Luc, Brussels, Belgium
| | - Jasmina Ciric
- Clinic of Endocrinology, Diabetes and Diseases of Metabolism, University Clinical Center of Serbia, Belgrade, Serbia
- Faculty of Medicine, University of Belgrade, Belgrade, Serbia
| | - Danila Covelli
- Department of Endocrinology, Graves' Orbitopathy Center, La Fondazione IRCCS Ca' Granda Ospedale Maggiore di Milano Policlinico, Milano, Italy
| | - Nicola Currò
- Department of Ophthalmology, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Simone Donati
- Department of Medicine and Surgery, University of Insubria, Varese, Italy
| | - Anja K Eckstein
- Department of Ophthalmology, University of Duisburg-Essen, Essen, Germany
| | - Nicole Fichter
- Department of Ophthalmology, ADMEDICO orbital centre/University Basel, Olten, Switzerland
| | - Dagmar Führer
- Department of Endocrinology, Diabetes and Metabolism, University of Duisburg-Essen, Essen, Germany
| | - Maren Horn
- Department of Ophthalmology, University Medicine Goettingen, Goettingen, Germany
| | | | - Jelena Juri Mandić
- Department of Ophthalmology, Medical School, Kišpatićeva 12, University Clinical Hospital Center Zagreb, Zagreb, Croatia
| | - George J Kahaly
- Department of Medicine I, Johannes Gutenberg University Medical Center, Mainz, Germany
| | - Onur Konuk
- Department of Ophthalmology, Gazi University Medical School, Ankara, Turkey
| | - Amelie Langbein
- Department of Medicine I, Johannes Gutenberg University Medical Center, Mainz, Germany
| | - Giulia Lanzolla
- Department of Clinical and Experimental Medicine, Endocrinology Units, University of Pisa and University Hospital of Pisa, Pisa, Italy
| | - Claudio Marcocci
- Department of Clinical and Experimental Medicine, Endocrinology Units, University of Pisa and University Hospital of Pisa, Pisa, Italy
| | - Michele Marinò
- Department of Clinical and Experimental Medicine, Endocrinology Units, University of Pisa and University Hospital of Pisa, Pisa, Italy
| | - Piotr Miśkiewicz
- Department of Internal Medicine and Endocrinology, Medical University of Warsaw, Warsaw, Poland
| | - Biljana Nedeljkovic Beleslin
- Clinic of Endocrinology, Diabetes and Diseases of Metabolism, University Clinical Center of Serbia, Belgrade, Serbia
- Faculty of Medicine, University of Belgrade, Belgrade, Serbia
| | - Antonia Pérez-Lázaro
- Department of Endocrinology, Hospital Universitario y Politécnico La Fe, Valencia, Spain
| | - Marta Pérez-López
- Department of Ophthalmology, Hospital Universitario y Politécnico La Fe, Valencia, Spain
| | - Katharina A Ponto
- Department of Ophthalmology, Johannes Gutenberg University Medical Center, Mainz, Germany
| | - Anthony Quinn
- Department of Ophthalmology, Royal Devon University Hospital, Exeter, UK
| | | | - Mario Salvi
- Department of Endocrinology, Graves' Orbitopathy Center, La Fondazione IRCCS Ca' Granda Ospedale Maggiore di Milano Policlinico, Milano, Italy
| | | | - Maria Laura Tanda
- Department of Medicine and Surgery, University of Insubria, Varese, Italy
| | - Fusun Toruner
- Department of Endocrinology and Metabolism, Gazi University Medical School, Ankara, Turkey
| | - Bijay Vaidya
- Department of Endocrinology, Royal Devon University Hospital, University of Exeter Medical School, Exeter, UK
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Singh G, Taylor B, Michalek S. Refractory Thyroid Eye Disease Unresponsive to Teprotumumab: A Case Report. Cureus 2023; 15:e48861. [PMID: 38111423 PMCID: PMC10727451 DOI: 10.7759/cureus.48861] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/14/2023] [Indexed: 12/20/2023] Open
Abstract
Thyroid eye disease (TED) is a complex autoimmune condition that can cause proptosis, ophthalmoplegia, diplopia, optic nerve compression, and vision loss. These clinical findings are caused by a complex pathological mechanism characterized by thyroid-stimulating hormone receptor autoantibodies activating thyroid-stimulating hormone receptors (TSH-Rs). Overexpressed insulin-like growth factor 1 (IGF-1) receptors found in orbital fibroblasts form complexes with these TSH-Rs, leading to the inflammation and expansion of these tissues. Teprotumumab, a human monoclonal antibody sold under the brand name Tepezza, is currently the only FDA-approved immunotherapy for the treatment of TED. Given as an intravenous infusion every three weeks, teprotumumab works by suppressing IGF-1 receptors, thereby interfering with TSH-R and IGF-1 complex-mediated actions in these fibroblasts. The efficacy of teprotumumab was established in randomized, placebo-controlled clinical trials, which demonstrated clinically meaningful improvements in proptosis, inflammation, and diplopia. While teprotumumab has been shown to be efficacious, our patient with TSHRAb-positive euthyroid thyroid-associated ophthalmopathy who presented with diplopia did not have any significant improvement following the standard treatment dose of eight infusions over a 24-week period. This case underscores not only barriers to treatment, such as the high cost of teprotumumab but also highlights the importance of identifying risks for nonresponse.
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Affiliation(s)
- Gurdeep Singh
- Endocrinology, Diabetes and Metabolism, Our Lady of Lourdes Memorial Hospital, Binghamton, USA
| | - Brittany Taylor
- Family Medicine, Our Lady of Lourdes Memorial Hospital, Binghamton, USA
| | - Samantha Michalek
- Family Medicine, Our Lady of Lourdes Memorial Hospital, Binghamton, USA
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Abstract
Importance Overt hyperthyroidism, defined as suppressed thyrotropin (previously thyroid-stimulating hormone) and high concentration of triiodothyronine (T3) and/or free thyroxine (FT4), affects approximately 0.2% to 1.4% of people worldwide. Subclinical hyperthyroidism, defined as low concentrations of thyrotropin and normal concentrations of T3 and FT4, affects approximately 0.7% to 1.4% of people worldwide. Untreated hyperthyroidism can cause cardiac arrhythmias, heart failure, osteoporosis, and adverse pregnancy outcomes. It may lead to unintentional weight loss and is associated with increased mortality. Observations The most common cause of hyperthyroidism is Graves disease, with a global prevalence of 2% in women and 0.5% in men. Other causes of hyperthyroidism and thyrotoxicosis include toxic nodules and the thyrotoxic phase of thyroiditis. Common symptoms of thyrotoxicosis include anxiety, insomnia, palpitations, unintentional weight loss, diarrhea, and heat intolerance. Patients with Graves disease may have a diffusely enlarged thyroid gland, stare, or exophthalmos on examination. Patients with toxic nodules (ie, in which thyroid nodules develop autonomous function) may have symptoms from local compression of structures in the neck by the thyroid gland, such as dysphagia, orthopnea, or voice changes. Etiology can typically be established based on clinical presentation, thyroid function tests, and thyrotropin-receptor antibody status. Thyroid scintigraphy is recommended if thyroid nodules are present or the etiology is unclear. Thyrotoxicosis from thyroiditis may be observed if symptomatic or treated with supportive care. Treatment options for overt hyperthyroidism from autonomous thyroid nodules or Graves disease include antithyroid drugs, radioactive iodine ablation, and surgery. Treatment for subclinical hyperthyroidism is recommended for patients at highest risk of osteoporosis and cardiovascular disease, such as those older than 65 years or with persistent serum thyrotropin level less than 0.1 mIU/L. Conclusions and Relevance Hyperthyroidism affects 2.5% of adults worldwide and is associated with osteoporosis, heart disease, and increased mortality. First-line treatments are antithyroid drugs, thyroid surgery, and radioactive iodine treatment. Treatment choices should be individualized and patient centered.
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Affiliation(s)
- Sun Y. Lee
- Section of Endocrinology, Diabetes, Nutrition, and Weight Management, Boston University Chobanian and Avedisian School of Medicine, Boston, Massachusetts
| | - Elizabeth N. Pearce
- Section of Endocrinology, Diabetes, Nutrition, and Weight Management, Boston University Chobanian and Avedisian School of Medicine, Boston, Massachusetts
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Wiersinga WM, Poppe KG, Effraimidis G. Hyperthyroidism: aetiology, pathogenesis, diagnosis, management, complications, and prognosis. Lancet Diabetes Endocrinol 2023; 11:282-298. [PMID: 36848916 DOI: 10.1016/s2213-8587(23)00005-0] [Citation(s) in RCA: 23] [Impact Index Per Article: 23.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/06/2022] [Revised: 12/28/2022] [Accepted: 01/03/2023] [Indexed: 02/26/2023]
Abstract
Hyperthyroidism is a common condition with a global prevalence of 0·2-1·3%. When clinical suspicion of hyperthyroidism arises, it should be confirmed by biochemical tests (eg, low TSH, high free thyroxine [FT4], or high free tri-iodothyonine [FT3]). If hyperthyroidism is confirmed by biochemical tests, a nosological diagnosis should be done to find out which disease is causing the hyperthyroidism. Helpful tools are TSH-receptor antibodies, thyroid peroxidase antibodies, thyroid ultrasonography, and scintigraphy. Hyperthyroidism is mostly caused by Graves' hyperthyroidism (70%) or toxic nodular goitre (16%). Hyperthyroidism can also be caused by subacute granulomatous thyroiditis (3%) and drugs (9%) such as amiodarone, tyrosine kinase inhibitors, and immune checkpoint inhibitors. Disease-specific recommendations are given. Currently, Graves' hyperthyroidism is preferably treated with antithyroid drugs. However, recurrence of hyperthyroidism after a 12-18 month course of antithyroid drugs occurs in approximately 50% of patients. Being younger than 40 years, having FT4 concentrations that are 40 pmol/L or higher, having TSH-binding inhibitory immunoglobulins that are higher than 6 U/L, and having a goitre size that is equivalent to or larger than WHO grade 2 before the start of treatment with antithyroid drugs increase risk of recurrence. Long-term treatment with antithyroid drugs (ie, 5-10 years of treatment) is feasible and associated with fewer recurrences (15%) than short-term treatment (ie, 12-18 months of treatment). Toxic nodular goitre is mostly treated with radioiodine (131I) or thyroidectomy and is rarely treated with radiofrequency ablation. Destructive thyrotoxicosis is usually mild and transient, requiring steroids only in severe cases. Specific attention is given to patients with hyperthyroidism who are pregnant, have COVID-19, or have other complications (eg, atrial fibrillation, thyrotoxic periodic paralysis, and thyroid storm). Hyperthyroidism is associated with increased mortality. Prognosis might be improved by rapid and sustained control of hyperthyroidism. Innovative new treatments are expected for Graves' disease, by targeting B cells or TSH receptors.
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Affiliation(s)
- Wilmar M Wiersinga
- Department of Endocrinology and Metabolism, Academic Medical Center, University of Amsterdam, Netherlands
| | - Kris G Poppe
- Endocrine Unit, CHU Saint-Pierre, Université Libre de Bruxelles, Brussels, Belgium
| | - Grigoris Effraimidis
- Department of Endocrinology and Metabolic Diseases, Larissa University Hospital, Faculty of Medicine, School of Health Sciences, University of Thessaly, Larissa, Greece
- Department of Endocrinology and Metabolism, Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark.
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9
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Radziszewski M, Kuś A, Bednarczuk T. Genotype-phenotype correlations in Graves' disease. Best Pract Res Clin Endocrinol Metab 2023; 37:101745. [PMID: 36828713 DOI: 10.1016/j.beem.2023.101745] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/13/2023]
Abstract
Graves' disease (GD) is a heterogeneous autoimmune disease affecting with varying degrees of severity the thyroid gland, orbital tissues and skin. The pathogenesis of GD involves a complex interplay between multiple genetic, environmental and endogenous factors. Although the genetic predisposition to GD is well established, the significance of genotype-phenotype correlations and the role of epigenetic modifications in the disease pathogenesis remains largely unknown. In this review, we provide an up-to-date overview of genotype-phenotype correlations and summarize possible clinical implications of genetic and epigenetic markers in GD patients. We will specifically discuss the association of genetic markers and epigenetic modifications with age of GD onset, severity of Graves' hyperthyroidism and the development of clinically evident Graves' orbitopathy.
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Affiliation(s)
- Mikołaj Radziszewski
- Department of Internal Medicine and Endocrinology, Medical University of Warsaw, Warsaw, Poland.
| | - Aleksander Kuś
- Department of Internal Medicine and Endocrinology, Medical University of Warsaw, Warsaw, Poland.
| | - Tomasz Bednarczuk
- Department of Internal Medicine and Endocrinology, Medical University of Warsaw, Warsaw, Poland.
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Hai YP, Lee ACH, Chen K, Kahaly GJ. Traditional Chinese medicine in thyroid-associated orbitopathy. J Endocrinol Invest 2023; 46:1103-1113. [PMID: 36781592 DOI: 10.1007/s40618-023-02024-4] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/02/2023] [Accepted: 01/24/2023] [Indexed: 02/15/2023]
Abstract
PURPOSE Orbital fibroblasts (OF) are considered the central target cells in the pathogenesis of thyroid-associated orbitopathy (TAO), which comprises orbital inflammation, orbital tissue edema, adipogenesis, fibrosis, oxidative stress and autophagy. Certain active ingredients of traditional Chinese medicine (TCM) demonstrated inhibition of TAO-OF in pre-clinical studies and they could be translated into novel therapeutic strategies. METHODS The pertinent and current literature of pre-clinical studies on TAO investigating the effects of active ingredients of TCM was reviewed using the NCBI PubMed database. RESULTS Eleven TCM compounds demonstrated inhibition of TAO-OF in-vitro and three of them (polydatin, curcumin, and gypenosides) resulted in improvement in TAO mouse models. Tanshinone IIA reduced inflammation, oxidative stress and adipogenesis. Both resveratrol and its precursor polydatin displayed anti-oxidative and anti-adipogenic properties. Celastrol inhibited inflammation and triptolide prevented TAO-OF activation, while icariin inhibited autophagy and adipogenesis. Astragaloside IV reduced inflammation via suppressing autophagy and inhibited fat accumulation as well as collagen deposition. Curcumin displayed multiple actions, including anti-inflammatory, anti-oxidative, anti-adipogenic, anti-fibrotic and anti-angiogenic effects via multiple signaling pathways. Gypenosides reduced inflammation, oxidative stress, tissue fibrosis, as well as oxidative stress mediated autophagy and apoptosis. Dihydroartemisinin inhibited OF proliferation, inflammation, hyaluronan (HA) production, and fibrosis. Berberine attenuated inflammation, HA production, adipogenesis, and fibrosis. CONCLUSIONS Clinical trials of different phases with adequate power and sound methodology will be warranted to evaluate the appropriate dosage, safety and efficacy of these compounds in the management of TAO.
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Affiliation(s)
- Y P Hai
- Molecular Thyroid Research Laboratory, Department of Medicine I, Johannes Gutenberg University (JGU) Medical Center, Langenbeckstreet 1, 55131, Mainz, Germany
- Department of Endocrinology, Hainan General Hospital, Hainan Affiliated Hospital of Hainan Medical University, Haikou, China
| | - A C H Lee
- Division of Endocrinology and Metabolism, Department of Medicine, LKS Faculty of Medicine, The University of Hong Kong, Queen Mary Hospital, Hong Kong SAR, China
| | - K Chen
- Department of Endocrinology, Hainan General Hospital, Hainan Affiliated Hospital of Hainan Medical University, Haikou, China
| | - G J Kahaly
- Molecular Thyroid Research Laboratory, Department of Medicine I, Johannes Gutenberg University (JGU) Medical Center, Langenbeckstreet 1, 55131, Mainz, Germany.
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11
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Ozturk M, Konuk O, Tarlan B, Yalcın MM, Arıbas YK, Toruner FB, Unal M, Ayvaz G. Clinical characteristics and the treatment modalities of Graves' orbitopathy in a tertiary referral center in Turkey: changes over two decades. Int Ophthalmol 2023; 43:643-653. [PMID: 36030455 DOI: 10.1007/s10792-022-02468-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/09/2022] [Accepted: 08/20/2022] [Indexed: 11/30/2022]
Abstract
PURPOSE To evaluate the changes in demographics, clinical findings, and treatment modalities in Graves' orbitopathy (GO) patients at a tertiary referral center in Turkey over the last two decades. METHODS The clinical data of 752 GO patients were evaluated retrospectively. Patients were divided into 2 groups according to the first ophthalmic examination date; Group 1(n:344) between January 1998 and December 2007 and Group 2(n:408) between January 2008 and December 2017. RESULTS The number of nonsmokers was significantly higher in Group 2 (44.0 vs. 26.5%, p < 0.001). The time from the diagnosis of thyroid dysfunction and referral to our center was 32.4 months in Group 1 and 34.8 months in Group 2, (p = 0.166). The most common treatment of hyperthyroidism was antithyroid medications. Radioiodine ablation treatment rate was significantly lower in Group 2 (14.8 vs. 9.1%, p < 0.001). The time between the diagnosis of thyroid disease and orbital involvement was 22.0 vs. 26.6 months in Groups 1 and 2, respectively (p = 0.009). The time elapsed between the diagnosis of orbital disease and referral to our clinic was 21.0 months vs. 22.4 months in Group 1 and 2, respectively (p = 0.068). Orbital disease was most commonly mild, and inactive. Mild and moderate to severe GO and the mean Clinical Activity Score significantly increased, and the rate of sight-threatening disease and orbital decompression surgery significantly decreased in Group 2 (p = 0.042; p < 0.001, respectively). CONCLUSIONS Mild and inactive orbital disease was the most common form of GO. The severity of GO is declining over the last two decades in Turkey.
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Affiliation(s)
- Mine Ozturk
- Department of Ophthalmology, Haseki Training and Research Hospital, University of Health Sciences, Millet Street, 34096, Istanbul, Turkey.
| | - Onur Konuk
- Department of Ophthalmology, Faculty of Medicine, Gazi University, Ankara, Turkey
| | - Bercin Tarlan
- Department of Ophthalmology, Faculty of Medicine, Gazi University, Ankara, Turkey
| | - Mehmet Muhittin Yalcın
- Department of Endocrinology and Metabolism, Faculty of Medicine, Gazi University, Ankara, Turkey
| | - Yavuz Kemal Arıbas
- Department of Ophthalmology, Gaziantep Abdulkadir Yuksel State Hospital, Gaziantep, Turkey
| | - Fusun Balos Toruner
- Department of Endocrinology and Metabolism, Faculty of Medicine, Gazi University, Ankara, Turkey
| | - Mehmet Unal
- Ophthalmology, Private Practice, Ankara, Turkey
| | - Goksun Ayvaz
- Endocrinology and Metabolism, Private Practice, Ankara, Turkey
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12
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Machine learning-assisted system using digital facial images to predict the clinical activity score in thyroid-associated orbitopathy. Sci Rep 2022; 12:22085. [PMID: 36543834 PMCID: PMC9772205 DOI: 10.1038/s41598-022-25887-8] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/29/2022] [Accepted: 12/06/2022] [Indexed: 12/24/2022] Open
Abstract
Although the clinical activity score (CAS) is a validated scoring system for identifying disease activity of thyroid-associated orbitopathy (TAO), it may produce differing results depending on the evaluator, and an experienced ophthalmologist is required for accurate evaluation. In this study, we developed a machine learning (ML)-assisted system to mimic an expert's CAS assessment using digital facial images and evaluated its accuracy for predicting the CAS and diagnosing active TAO (CAS ≥ 3). An ML-assisted system was designed to assess five CAS components related to inflammatory signs (redness of the eyelids, redness of the conjunctiva, swelling of the eyelids, inflammation of the caruncle and/or plica, and conjunctival edema) in patients' facial images and to predict the CAS by considering two components of subjective symptoms (spontaneous retrobulbar pain and pain on gaze). To train and test the system, 3,060 cropped images from 1020 digital facial images of TAO patients were used. The reference CAS for each image was scored by three ophthalmologists, each with > 15 years of clinical experience. We repeated the experiments for 30 randomly split training and test sets at a ratio of 8:2. The sensitivity and specificity of the ML-assisted system for diagnosing active TAO were 72.7% and 83.2% in the test set constructed from the entire dataset. For the test set constructed from the dataset with consistent results for the three ophthalmologists, the sensitivity and specificity for diagnosing active TAO were 88.1% and 86.9%. In the test sets from the entire dataset and from the dataset with consistent results, 40.0% and 49.9% of the predicted CAS values were the same as the reference CAS, respectively. The system predicted the CAS within 1 point of the reference CAS in 84.6% and 89.0% of cases when tested using the entire dataset and in the dataset with consistent results, respectively. An ML-assisted system estimated the clinical activity of TAO and detect inflammatory active TAO with reasonable accuracy. The accuracy could be improved further by obtaining more data. This ML-assisted system can help evaluate the disease activity consistently as well as accurately and enable the early diagnosis and timely treatment of active TAO.
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13
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Burch HB, Perros P, Bednarczuk T, Cooper DS, Dolman PJ, Leung AM, Mombaerts I, Salvi M, Stan MN. Management of Thyroid Eye Disease: A Consensus Statement by the American Thyroid Association and the European Thyroid Association. Thyroid 2022; 32:1439-1470. [PMID: 36480280 PMCID: PMC9807259 DOI: 10.1089/thy.2022.0251] [Citation(s) in RCA: 26] [Impact Index Per Article: 13.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
Thyroid eye disease (TED) remains challenging for clinicians to evaluate and manage. Novel therapies have recently emerged, and their specific roles are still being determined. Most patients with TED develop eye manifestations while being treated for hyperthyroidism and under the care of endocrinologists. Endocrinologists, therefore, have a key role in diagnosis, initial management, and selection of patients who require referral to specialist care. Given that the need for guidance to endocrinologists charged with meeting the needs of patients with TED transcends national borders, and to maximize an international exchange of knowledge and practices, the American Thyroid Association and European Thyroid Association joined forces to produce this consensus statement.
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Affiliation(s)
- Henry B. Burch
- National Institute of Diabetes and Digestive and Kidney Diseases, National Institutes of Health, Bethesda, Maryland, USA
- Department of Medicine, Uniformed Services University of the Health Sciences, Bethesda, Maryland, USA
- Endocrinology Division, Department of Medicine, Walter Reed National Military Medical Center, Bethesda, Maryland, USA
- Address correspondence to: Henry B. Burch, MD, National Institute of Diabetes and Digestive and Kidney Diseases, Division of Diabetes, Endocrinology, & Metabolic Diseases, National Institutes of Health, 6707 Democracy Blvd, Room 5053, Bethesda, MD 20892-0001, USA
| | - Petros Perros
- Department of Endocrinology, Leazes Wing, Royal Victoria Infirmary, Newcastle upon Tyne, United Kingdom
| | - Tomasz Bednarczuk
- Department of Internal Medicine and Endocrinology, Medical University of Warsaw, Warsaw, Poland
| | - David S. Cooper
- Department of Medicine, Division of Endocrinology, Diabetes, and Metabolism, The Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Peter J. Dolman
- Department of Ophthalmology and Visual Sciences, University of British Columbia, Vancouver, Canada
| | - Angela M. Leung
- Division of Endocrinology, Diabetes, and Metabolism, Department of Medicine, UCLA David Geffen School of Medicine, VA Greater Los Angeles Healthcare System, Los Angeles, California, USA
| | - Ilse Mombaerts
- Department of Ophthalmology, University Hospitals Leuven, Leuven, Belgium
| | - Mario Salvi
- Department of Clinical and Community Services, Graves' Orbitopathy Center, Endocrinology, Fondazione IRCCS Cà Granda, Milan, Italy
| | - Marius N. Stan
- Division of Endocrinology, Diabetes and Metabolism, Mayo Clinic, Rochester, Minnesota, USA
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14
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Burch HB, Perros P, Bednarczuk T, Cooper DS, Dolman PJ, Leung AM, Mombaerts I, Salvi M, Stan MN. Management of thyroid eye disease: a Consensus Statement by the American Thyroid Association and the European Thyroid Association. Eur Thyroid J 2022; 11:e220189. [PMID: 36479875 PMCID: PMC9727317 DOI: 10.1530/etj-22-0189] [Citation(s) in RCA: 12] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/19/2022] [Accepted: 10/19/2022] [Indexed: 11/30/2022] Open
Abstract
Thyroid eye disease (TED) remains challenging for clinicians to evaluate and manage. Novel therapies have recently emerged, and their specific roles are still being determined. Most patients with TED develop eye manifestations while being treated for hyperthyroidism and under the care of endocrinologists. Endocrinologists, therefore, have a key role in diagnosis, initial management, and selection of patients who require referral to specialist care. Given that the need for guidance to endocrinologists charged with meeting the needs of patients with TED transcends national borders, and to maximize an international exchange of knowledge and practices, the American Thyroid Association and European Thyroid Association joined forces to produce this Consensus Statement.
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Affiliation(s)
- Henry B Burch
- National Institute of Diabetes and Digestive and Kidney Diseases, National Institutes of Health, Bethesda, Maryland, USA
- Department of Medicine, Uniformed Services University of the Health Sciences, Bethesda, Maryland, USA
- Endocrinology Division, Department of Medicine, Walter Reed National Military Medical Center, Bethesda, Maryland, USA
| | - Petros Perros
- Department of Endocrinology, Leazes Wing, Royal Victoria Infirmary, Newcastle upon Tyne, United Kingdom
| | - Tomasz Bednarczuk
- Department of Internal Medicine and Endocrinology, Medical University of Warsaw, Warsaw, Poland
| | - David S Cooper
- Division of Endocrinology, Diabetes, and Metabolism, Department of Medicine, The Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Peter J Dolman
- Department of Ophthalmology and Visual Sciences, University of British Columbia, Vancouver, Canada
| | - Angela M Leung
- Division of Endocrinology, Diabetes, and Metabolism, Department of Medicine, UCLA David Geffen School of Medicine, VA Greater Los Angeles Healthcare System, Los Angeles, California, USA
| | - Ilse Mombaerts
- Department of Ophthalmology, University Hospitals Leuven, Leuven, Belgium
| | - Mario Salvi
- Department of Clinical and Community Services, Graves’ Orbitopathy Center, Endocrinology, Fondazione IRCCS Cà Granda, Milan, Italy
| | - Marius N Stan
- Division of Endocrinology, Diabetes and Metabolism, Mayo Clinic, Rochester, Minnesota, USA
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15
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Brito JP, Nagy EV, Singh Ospina N, Zˇarković M, Dosiou C, Fichter N, Lucarelli MJ, Hegedüs L. A Survey on the Management of Thyroid Eye Disease Among American and European Thyroid Association Members. Thyroid 2022; 32:1535-1546. [PMID: 35946071 DOI: 10.1089/thy.2022.0172] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/09/2023]
Abstract
Background: The thyroid eye disease (TED) treatment landscape is rapidly evolving. How new treatment options have impacted practice is unknown. Methods: We conducted a cross-sectional electronic survey of American and European Thyroid Association members between June 2 and June 30, 2021. The survey included TED questions about resources for its management, index cases for different severities and presentations of TED, barriers for the management of TED, and participants' concerns about TED. We classified respondents into three geographic categories: North America, Europe, or other regions. Results: Two hundred fifty-two eligible participants started the survey (15% response rate), and 227 completed it. Participants were mostly men (50.2%, 114/227), white (79.7%, 181/227), endocrinologists with a thyroid focus (66.1%, 150/227), practicing in a tertiary academic center (46.7%, 106/227), caring for 10 or more TED patients over the last 12 months (40.5%, 92/227), and reported not having a multidisciplinary TED clinic in their institution (52.8%, 120/227). The majority reported that new TED cases per annum have not changed in the past 10 years (47.5%, 108/227), and that TED patients are found in practice during the management of hyperthyroidism (41.8%, 95/227). For mild active TED, participants from Europe reported a higher use of selenium (73%[96/132] vs. 32%[20/62] of respondents from North America and 24%[8/33] of respondents from other regions). For moderate-to-severe active TED, there was a modest preference for teprotumumab as first-line therapy (37%, 23/62) among North American participants and intravenous (IV) steroids (73%[96/132], and 42%[14/33]) for participants from Europe and other regions, respectively. These treatment preferences did not change in patients with moderate-to-severe active TED with poorly controlled diabetes. In contrast, participants from the three geographic categories preferred IV steroids for optic neuropathy and women planning pregnancy. The three top "very important" concerns about TED management according to participants were: the cost of TED treatment (31.3%, 71/227), lack of effective TED treatments (19.8%, 45/227), and difficulty in predicting whether TED will develop (18.9%, 43/227). Conclusions: There is a marked geographic practice variation in the management of TED. Clinicians' concerns about TED management demand ongoing research on more effective treatment, TED predictive tools, and policy changes to improve the affordability of new TED therapies.
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Affiliation(s)
- Juan P Brito
- Division of Endocrinology, Diabetes, Metabolism, Nutrition, Department of Internal Medicine, Mayo Clinic, Rochester, Minnesota, USA
| | - Endre V Nagy
- Division of Endocrinology, Department of Medicine, Faculty of Medicine, University of Debrecen, Debrecen, Hungary
| | - Naykky Singh Ospina
- Division of Endocrinology, Department of Medicine, University of Florida, Gainesville, Florida
| | | | - Chrysoula Dosiou
- Division of Endocrinology, Department of Medicine, Stanford University School of Medicine, Stanford, California, USA
| | - Nicole Fichter
- ADMEDICO Orbital Centre, Olten and University Eye Department, Basel, Switzerland
| | - Mark J Lucarelli
- Oculoplastic, Facial Cosmetic and Orbital Surgery, Department of Ophthalmology and Visual Sciences, University of Wisconsin-Madison, Madison, Wisconsin, USA
| | - Laszlo Hegedüs
- Department of Endocrinology, Odense University Hospital, University of Southern Denmark, Odense C, Denmark
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16
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Abstract
Graves' orbitopathy (GO) is an orbital autoimmune disorder and the main extrathyroidal manifestation of Graves' disease, the most common cause of hyperthyroidism. GO affects about 30% of Graves' patients, although fewer than 10% have severe forms requiring immunosuppressive treatments. Management of GO requires a multidisciplinary approach. Medical therapies for active moderate-to-severe forms of GO (traditionally, high-dose glucocorticoids) often provide unsatisfactory results, and subsequently surgeries are often needed to cure residual manifestations. The aim of this review is to provide an updated overview of current concepts regarding the epidemiology, pathogenesis, assessment, and treatment of GO, and to present emerging targeted therapies and therapeutic perspectives. Original articles, clinical trials, systematic reviews, and meta-analyses from 1980 to 2021 were searched using the following terms: Graves' disease, Graves' orbitopathy, thyroid eye disease, glucocorticoids, orbital radiotherapy, rituximab, cyclosporine, azathioprine, teprotumumab, TSH-receptor antibody, smoking, hyperthyroidism, hypothyroidism, thyroidectomy, radioactive iodine, and antithyroid drugs. Recent studies suggest a secular trend toward a milder phenotype of GO. Standardized assessment at a thyroid eye clinic allows for a better general management plan. Treatment of active moderate-to-severe forms of GO still relies in most cases on high-dose systemic-mainly intravenous-glucocorticoids as monotherapy or in combination with other therapies-such as mycophenolate, cyclosporine, azathioprine, or orbital radiotherapy-but novel biological agents-including teprotumumab, rituximab, and tocilizumab-have achieved encouraging results.
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Affiliation(s)
- Luigi Bartalena
- Department of Medicine and SurgeryUniversity of InsubriaVareseItaly
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17
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Kossler AL, Douglas R, Dosiou C. Teprotumumab and the Evolving Therapeutic Landscape in Thyroid Eye Disease. J Clin Endocrinol Metab 2022; 107:S36-S46. [PMID: 36346685 PMCID: PMC9359446 DOI: 10.1210/clinem/dgac168] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/17/2021] [Indexed: 02/13/2023]
Abstract
CONTEXT Thyroid eye disease (TED) is a sight-threatening and debilitating autoimmune condition, with limited therapies available, that often poses diagnostic and therapeutic challenges. In recent years, the treatment landscape has shifted to early intervention with targeted therapy. METHODS A PubMed review of the literature was conducted for the period between 1979 and 2021. Search terms included thyroid eye disease, teprotumumab, targeted therapy, Graves disease, Graves ophthalmopathy, dysthyroid optic neuropathy, and related terms in different combinations. Novel biologic therapies for TED have emerged as alternatives to traditional steroid regimens in recent years. New insights into TED pathophysiology have uncovered the role of the insulin-like growth factor 1 receptor (IGF-1R) and led to the development of teprotumumab, an IGF-1R-inhibiting monoclonal antibody. RESULTS Randomized clinical trials demonstrating the efficacy of teprotumumab for TED led to Food and Drug Administration approval. Teprotumumab is gradually replacing immunosuppressive agents as first-line therapy in the United States for active moderate-to-severe TED, while emerging reports also show its use in other stages of the disease. Recent data highlight risk factors for adverse events and screening protocols to maximize patient safety. Personalized therapeutic plans developed through effective partnership between endocrinologists and ophthalmologists aim to enhance the safety and outcomes of TED treatments and improve care for this complex disease. CONCLUSION TED management is shifting to an era of targeted therapy with multidisciplinary care. Teprotumumab has demonstrated superior efficacy to conventional treatments and has transformed our therapeutic and surgical algorithms. Clinical guidelines and additional studies are needed to further guide and refine therapy.
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Affiliation(s)
- Andrea Lora Kossler
- Correspondence: Andrea Lora Kossler, MD, Department of Ophthalmology, Stanford University School of Medicine, 2452 Watson Ct, Palo Alto, CA 94303, USA.
| | - Raymond Douglas
- Cedars–Sinai Medical Center, Los Angeles, California 90048, USA
| | - Chrysoula Dosiou
- Division of Endocrinology, Stanford University School of Medicine, Palo Alto, California 94305, USA
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18
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Lu TJ, Amarikwa L, Sears CM, Kossler AL. Advances in the Treatment of Thyroid Eye Disease Associated Extraocular Muscle Myopathy and Optic Neuropathy. Curr Neurol Neurosci Rep 2022; 22:313-325. [PMID: 35614367 PMCID: PMC10812872 DOI: 10.1007/s11910-022-01194-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/28/2022] [Indexed: 11/03/2022]
Abstract
PURPOSE OF REVIEW To review emerging treatments for thyroid eye disease (TED) associated extraocular muscle myopathy and dysthyroid optic neuropathy (DON). RECENT FINDINGS Emerging targeted biologic therapies may alter the disease course in TED. Teprotumumab, a type I insulin-like growth factor receptor inhibitor, is the most recent addition to the treatments available for TED-associated extraocular muscle myopathy causing diplopia. Small studies also suggest a potential therapeutic benefit for DON. Various recent studies have also expanded our knowledge on conventional TED therapies. The therapeutic landscape of TED and its sequelae has evolved in recent years. New targeted therapies have the potential to reduce the extraocular muscle and orbital volume expansion which can lead to diplopia and vision loss from optic nerve compression. Longer term efficacy and durability data is needed to determine the role biologics, such as teprotumumab, should play in the treatment of TED patients compared to the current standard of care.
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Affiliation(s)
- Tracy J Lu
- Department of Ophthalmology, Byers Eye Institute, Stanford University School of Medicine, 2452 Watson Court, Palo Alto, CA, 94303, USA
| | - Linus Amarikwa
- Department of Ophthalmology, Byers Eye Institute, Stanford University School of Medicine, 2452 Watson Court, Palo Alto, CA, 94303, USA
| | - Connie M Sears
- Department of Ophthalmology, Byers Eye Institute, Stanford University School of Medicine, 2452 Watson Court, Palo Alto, CA, 94303, USA
| | - Andrea L Kossler
- Department of Ophthalmology, Byers Eye Institute, Stanford University School of Medicine, 2452 Watson Court, Palo Alto, CA, 94303, USA.
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19
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Bartalena L, Piantanida E, Gallo D, Ippolito S, Tanda ML. Management of Graves' hyperthyroidism: present and future. Expert Rev Endocrinol Metab 2022; 17:153-166. [PMID: 35287535 DOI: 10.1080/17446651.2022.2052044] [Citation(s) in RCA: 12] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/16/2022] [Accepted: 03/08/2022] [Indexed: 10/18/2022]
Abstract
INTRODUCTION Graves' disease (GD) is an autoimmune disorder due to loss of tolerance to the thyrotropin receptor (TSHR) and ultimately caused by stimulatory TSHR antibodies (TSHR-Ab). GD may be associated with extrathyroidal manifestations, mainly Graves' orbitopathy. Treatment of GD relies on antithyroid drugs (ATDs), radioactive iodine (RAI), thyroidectomy. The major ATD limitation is the high recurrence rate after treatment. The major drawback of RAI and thyroidectomy is the inevitable development of permanent hypothyroidism. AREAS COVERED Original articles, clinical trials, systematic reviews, meta-analyses from 1980 to 2021 were searched using the following terms: Graves' disease, management of Graves' disease, antithyroid drugs, radioactive iodine, thyroidectomy, Graves' orbitopathy, thyroid-eye disease. EXPERT OPINION ATDs are the first-line treatment worldwide, are overall safe and usually given for 18-24 months, long-term treatment may decrease relapses. RAI is safe, although associated with a low risk of GO progression, particularly in smokers. Thyroidectomy requires skilled and high-volume surgeons. Patients play a central role in the choice of treatment within a shared decision-making process. Results from targeted therapies acting on different steps of the autoimmune process, including iscalimab, ATX-GD-59, rituximab, blocking TSHR-Ab, small molecules acting as antagonists of the TSHR, are preliminary or preclinical, but promising in medium-to-long perspective.
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Affiliation(s)
- Luigi Bartalena
- Department of Medicine and Surgery, University of Insubria, Varese, Italy
| | - Eliana Piantanida
- Department of Medicine and Surgery, University of Insubria, Varese, Italy
| | - Daniela Gallo
- Department of Medicine and Surgery, University of Insubria, Varese, Italy
| | - Silvia Ippolito
- Department of Medicine and Surgery, University of Insubria, Varese, Italy
| | - Maria Laura Tanda
- Department of Medicine and Surgery, University of Insubria, Varese, Italy
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20
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Draman MS, Zhang L, Dayan C, Ludgate M. Orbital Signaling in Graves' Orbitopathy. Front Endocrinol (Lausanne) 2021; 12:739994. [PMID: 34899596 PMCID: PMC8660111 DOI: 10.3389/fendo.2021.739994] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/12/2021] [Accepted: 10/21/2021] [Indexed: 11/13/2022] Open
Abstract
Graves' orbitopathy (GO) is a complex and poorly understood disease in which extensive remodeling of orbital tissue is dominated by adipogenesis and hyaluronan production. The resulting proptosis is disfiguring and underpins the majority of GO signs and symptoms. While there is strong evidence for the thyrotropin receptor (TSHR) being a thyroid/orbit shared autoantigen, the insulin-like growth factor 1 receptor (IGF1R) is also likely to play a key role in the disease. The pathogenesis of GO has been investigated extensively in the last decade with further understanding of some aspects of the disease. This is mainly derived by using in vitro and ex vivo analysis of the orbital tissues. Here, we have summarized the features of GO pathogenesis involving target autoantigens and their signaling pathways.
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Affiliation(s)
- Mohd Shazli Draman
- Thyroid Research Group, Cardiff University School of Medicine, Cardiff, United Kingdom
- KPJ Healthcare University College, Nilai, Malaysia
| | - Lei Zhang
- Thyroid Research Group, Cardiff University School of Medicine, Cardiff, United Kingdom
| | - Colin Dayan
- Thyroid Research Group, Cardiff University School of Medicine, Cardiff, United Kingdom
| | - Marian Ludgate
- Thyroid Research Group, Cardiff University School of Medicine, Cardiff, United Kingdom
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21
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Tanda ML, Trimarchi F. Graves' orbitopathy in Natalie Frank's oeuvre. J Endocrinol Invest 2021; 44:2533-2534. [PMID: 33786753 DOI: 10.1007/s40618-021-01564-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/22/2021] [Accepted: 03/26/2021] [Indexed: 11/29/2022]
Affiliation(s)
- M L Tanda
- Department of Medicine and Surgery, University of Insubria, Varese, Italy.
| | - F Trimarchi
- Department of Clinical and Experimental Medicine, University of Messina, Messina, Italy
- Accademia Peloritana dei Pericolanti, Messina, Italy
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22
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Ruggeri RM, Trimarchi F. Iodine nutrition optimization: are there risks for thyroid autoimmunity? J Endocrinol Invest 2021; 44:1827-1835. [PMID: 33683664 DOI: 10.1007/s40618-021-01548-x] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/24/2021] [Accepted: 03/01/2021] [Indexed: 12/21/2022]
Abstract
Iodine deficiency is still the main cause of preventable thyroid disorders, worldwide. To optimize iodine intake, programs of voluntary or mandatory iodization of salt have been implemented in several iodine-deficient countries and iodine sufficiency has been achieved in many. Despite the clear beneficial effects on thyroid health, some concerns have been raised on the presumed detriment of iodine prophylaxis on thyroid autoimmunity. Very recent studies aimed at evaluating the long-term consequences of iodine supplementation on thyroid autoimmunity and related dysfunction, have clearly demonstrated that the early post-iodization increase in thyroid antibody positivity is largely transient and not clinically relevant, since the prevalence of overt thyroid dysfunction has remained reassuring low over two decades. The recommended iodine intake is therefore safe with regard to thyroid autoimmunity, the benefits largely outweighing the risks in a population with a stable median iodine concentration not exceeding 300 μg/L. Thus, a possible increase in thyroid autoimmunity should not represent a limitation to promoting iodine supplementation in the general population, also taking into account the steady rise in prevalence of autoimmune disorders which has occurred in the last few decades because of environmental factors other than iodine.
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Affiliation(s)
- R M Ruggeri
- Department of Clinical and Experimental Medicine, University of Messina, via Consolare Valeria, 1, 98125, Messina, Italy.
- Endocrine Unit At University Hospital "AOU Policlinico G.Martino", Messina, Italy.
| | - F Trimarchi
- Department of Clinical and Experimental Medicine, University of Messina, via Consolare Valeria, 1, 98125, Messina, Italy
- Accademia Peloritana Dei Pericolanti at the University of Messina, Messina, Italy
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Ferraù F, Ceccato F, Cannavò S, Scaroni C. What we have to know about corticosteroids use during Sars-Cov-2 infection. J Endocrinol Invest 2021; 44:693-701. [PMID: 32860209 PMCID: PMC7454136 DOI: 10.1007/s40618-020-01384-5] [Citation(s) in RCA: 16] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/01/2020] [Accepted: 08/02/2020] [Indexed: 12/23/2022]
Abstract
PURPOSE Glucocorticoids (GCs), alone or associated to other drugs, were widely used in the management of patients affected by severe acute respiratory syndrome caused by SARS-CoV-2 infection, during the recent COVID-19 outbreak. This review summarizes the available data on HPA axis impairment in GC-treated SARS-CoV-2 patients, focusing on the risk of adrenal insufficiency and on potential drug interactions during concomitant treatments. METHODS Literature on the impact of GCs therapy on HPA axis and on the consequences of coadministration of GCs and other drugs in SARS-CoV-2 patients has been reviewed. RESULTS GC treatment can cause symptoms of hypercortisolism, especially in patients with individual hypersensibility, or hypoadrenalism after drug withdrawal, due to hypothalamic-pituitary-adrenal (HPA) axis suppression, with consequences in terms of increased morbidity and mortality risk. On the other hand, in SARS-CoV-2-infected patient's cortisol secretion could be insufficient also due to critical illness-related corticosteroid insufficiency (CIRCI). In addition, in this clinical context, the co-administration of antiretroviral drugs and corticosteroids may trigger drug-drug interaction and enhance the exposure to the latter ones, metabolized through the CYP450 CYP3A pathway, severely impacting on HPA axis. CONCLUSION Physicians involved in the management of patients affected by COVID-19 should be aware of the need of an appropriate GC dose tapering, and of potential interaction of GCs with antiviral therapy and drugs used to treat associated co-morbidities.
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Affiliation(s)
- F Ferraù
- Department of Human Pathology of Adulthood and Childhood 'G. Barresi', AOU Policlinico Gaetano Martino, UOC di Endocrinologia, University of Messina, Pad. H, 4° piano, Via Consolare Valeria, 1, 98125, Messina, Italy.
- Endocrine Unit, University Hospital G. Martino, Messina, Italy.
| | - F Ceccato
- Endocrinology Unit, Department of Medicine DIMED, University-Hospital of Padova, Padova, Italy
- Department of Neuroscience DNS, University of Padova, Padova, Italy
| | - S Cannavò
- Department of Human Pathology of Adulthood and Childhood 'G. Barresi', AOU Policlinico Gaetano Martino, UOC di Endocrinologia, University of Messina, Pad. H, 4° piano, Via Consolare Valeria, 1, 98125, Messina, Italy
- Endocrine Unit, University Hospital G. Martino, Messina, Italy
| | - C Scaroni
- Endocrinology Unit, Department of Medicine DIMED, University-Hospital of Padova, Padova, Italy
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