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Hubschman S, Sojitra B, Ghiam S, Sears C, Hwangbo N, Goldberg RA, Rootman DB. Teprotumumab and Orbital Decompression for the Management of Proptosis in Patients With Thyroid Eye Disease. Ophthalmic Plast Reconstr Surg 2024; 40:270-275. [PMID: 37972968 DOI: 10.1097/iop.0000000000002563] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2023]
Abstract
PURPOSE To compare outcomes of patients with thyroid eye disease treated with teprotumumab or orbital decompression, or both in sequence. METHODS Patients with thyroid eye disease and treated with decompression, teprotumumab, or both were included. Four groups were defined: decompression only, teprotumumab only, teprotumumab first with decompression later, and decompression first with teprotumumab later. The primary outcome was change in exophthalmometry. Secondary outcomes included change in extraocular muscle motility, strabismus, diplopia, and side effects. RESULTS One hundred and thirty-nine patients were included. The mean duration for early follow-up was 1.2 months for both decompression and teprotumumab groups. The mean late follow-up was 14.4 and 8.2 months for the decompression and teprotumumab groups respectively. Mean change in exophthalmometry was significantly greater for the decompression group (3.5 mm) compared with teprotumumab (2.0 mm) at late follow-up. Improvement in total extraocular muscle restriction was significantly greater in the teprotumumab group (14.7 degrees) than in the decompression group (2.6 degrees). The teprotumumab group had a significantly higher percentage of patients with diplopia score >1 at baseline and late follow-up ( p < 0.01) compared with the decompression group. Additional treatment with teprotumumab or decompression when previously treated with the opposite had similar proptosis reduction effect as that therapy alone. CONCLUSIONS Surgical decompression has a greater proptosis reduction effect than teprotumumab, whereas teprotumumab better improves extraocular muscle motility. The addition of teprotumumab or decompression to a previous course of the opposite adds a similar effect to the supplemental treatment alone.
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Affiliation(s)
- Sasha Hubschman
- Division of Orbital and Ophthalmic Plastic Surgery, UCLA Stein Eye Institute
| | - Badal Sojitra
- Division of Orbital and Ophthalmic Plastic Surgery, UCLA Stein Eye Institute
| | - Sean Ghiam
- Division of Orbital and Ophthalmic Plastic Surgery, UCLA Stein Eye Institute
| | - Connie Sears
- Division of Orbital and Ophthalmic Plastic Surgery, UCLA Stein Eye Institute
| | - Nathan Hwangbo
- Department of Statistics, University of California, Los Angeles, California, U.S.A
| | - Robert A Goldberg
- Division of Orbital and Ophthalmic Plastic Surgery, UCLA Stein Eye Institute
| | - Daniel B Rootman
- Division of Orbital and Ophthalmic Plastic Surgery, UCLA Stein Eye Institute
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Tamhankar MA, Pradeep T, Chen Y, Briceño CA. Real-World Experience With Teprotumumab in Patients With Dysthyroid Optic Neuropathy. J Neuroophthalmol 2024; 44:74-79. [PMID: 37751310 PMCID: PMC10855992 DOI: 10.1097/wno.0000000000001994] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/28/2023]
Abstract
BACKGROUND Teprotumumab, an insulin-like growth factor I receptor inhibitory antibody, improved proptosis, diplopia, inflammatory signs/symptoms, and quality of life in patients with active thyroid eye disease (TED) in clinical trials. The trials excluded patients with dysthyroid optic neuropathy (DON). Recently, many case reports and case series have reported the successful use of teprotumumab to treat DON. Here, we review the data from published cases and our clinical experience in treating patients having DON with teprotumumab. METHODS A literature search was conducted of patients with DON treated with teprotumumab from January 2020 through September 2022. Data from DON patients from the authors' (M.A.T. and C.A.B.) clinical practice were included. Primary outcome measure was mean (SD) improvements for visual acuity, color vision, and visual fields. Improvements in proptosis and clinical activity score (CAS) and diplopia were compared before and after teprotumumab administration. RESULTS Ten observational studies/case reports were identified along with 2 patients in our practice. In all, there were 24 active TED patients with DON (37 eyes) who were treated with teprotumumab. Mean (SD) age was 66.5 (13.6) years and 13 (54%) were females, disease duration ranged from 2 months to >15 years. 22/24 patients had none, minimal improvement or progression of visual loss with intravenous/oral corticosteroids, orbital decompression (n = 9), and orbital radiation (n = 2). There were 2 patients who received teprotumumab as the only therapy. Overall, 88% (21/24) reported improvement in visual acuity after teprotumumab and in 75% (18/24), improvement in vision was observed after just 2 infusions of teprotumumab. Three eyes had decompression surgery in close proximity to teprotumumab infusions and were excluded from analyses. Mean (SD) improvement in visual acuity was 3.73 lines (SD 3.74), range 2-15 lines in 33 eyes. The mean (SD) improvement in the mean deviation on visual field testing in 15 eyes was 5.6 db (3.0 db). Mean (SD) improvement in proptosis was 4.37 mm (SD: 2.11) (20 patients, 32 eyes); and clinical activity score: mean reduction of 5.1 (1.3) for 18 patients. Teprotumumab was well tolerated in all but one patient. Adverse events reported included fatigue, dysgeusia, hearing loss, nausea, hyperglycemia, and muscle spasms. CONCLUSIONS Teprotumumab is an effective treatment for DON in our experience and in published cases in whom treatment with steroids, surgery, or orbital radiation was unsuccessful.
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Potvin ARGG, Pakdel F, Saeed P. Dysthyroid Optic Neuropathy. Ophthalmic Plast Reconstr Surg 2023; 39:S65-S80. [PMID: 38054987 DOI: 10.1097/iop.0000000000002555] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/07/2023]
Abstract
PURPOSE Dysthyroid optic neuropathy (DON) is a sight-threatening complication of thyroid eye disease (TED). This review provides an overview of the epidemiology, pathogenesis, diagnosis, and current therapeutic options for DON. METHODS A literature review. RESULTS DON occurs in about 5% to 8% of TED patients. Compression of the optic nerve at the apex is the most widely accepted pathogenic mechanism. Excessive stretching of the nerve might play a role in a minority of cases. Increasing age, male gender, smoking, and diabetes mellitus have been identified as risk factors. Diagnosis of DON is based on a combination of ≥2 clinical findings, including decreased visual acuity, decreased color vision, relative afferent pupillary defect, visual field defects, or optic disc edema. Orbital imaging supports the diagnosis by confirming apical crowding or optic nerve stretching. DON should be promptly treated with high-dose intravenous glucocorticoids. Decompression surgery should be performed, but the response is incomplete. Radiotherapy might play a role in the prevention of DON development and may delay or avoid the need for surgery. The advent of new biologic-targeted agents provides an exciting new array of therapeutic options, though more research is needed to clarify the role of these medications in the management of DON. CONCLUSIONS Even with appropriate management, DON can result in irreversible loss of visual function. Prompt diagnosis and management are pivotal and require a multidisciplinary approach. Methylprednisolone infusions still represent first-line therapy, and surgical decompression is performed in cases of treatment failure. Biologics may play a role in the future.
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Affiliation(s)
- Arnaud R G G Potvin
- Orbital Center Amsterdam, Department of Ophthalmology, Amsterdam University Medical Center, location AMC, The Netherlands
| | - Farzad Pakdel
- Department of Oculo-Facial Plastic Surgery, Tehran University of Medical Sciences, Farabi Hospital, Tehran, Iran
| | - Peerooz Saeed
- Orbital Center Amsterdam, Department of Ophthalmology, Amsterdam University Medical Center, location AMC, The Netherlands
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Armeni AK, Markantes GΚ, Stathopoulou A, Saltiki K, Zampakis P, Assimakopoulos SF, Michalaki MA. Thyroid Eye Disease as Initial Manifestation of Graves' Disease Following Viral Vector SARS-CoV-2 Vaccine: Report of a Case and Review of the Literature. Vaccines (Basel) 2023; 11:1574. [PMID: 37896977 PMCID: PMC10611184 DOI: 10.3390/vaccines11101574] [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: 08/29/2023] [Revised: 09/30/2023] [Accepted: 10/07/2023] [Indexed: 10/29/2023] Open
Abstract
COVID-19, a contagious disease caused by the novel coronavirus SARS-CoV-2, emerged in 2019 and quickly became a pandemic, infecting more than 700 million people worldwide. The disease incidence, morbidity and mortality rates have started to decline since the development of effective vaccines against the virus and the widespread immunization of the population. SARS-CoV-2 vaccines are associated with minor local or systemic adverse reactions, while serious adverse effects are rare. Thyroid-related disorders have been reported after vaccination for COVID-19, and Graves' disease (GD) is the second most common amongst them. Thyroid eye disease (TED), an extrathyroidal manifestation of GD, is rarely observed post-COVID-19 vaccination. All TED cases followed mRNA-based vaccinations, but two new onset mild TED cases post-viral vector vaccine (ChAdox1nCoV-19) have also been reported. We report the case of a 63-year-old woman who presented with new onset hyperthyroidism and moderate-to-severe and active TED 10 days after she received the first dose of a viral vector vaccine against SARS-CoV-2. This is the first case of moderate-to-severe TED after such a vaccine. Our patient was initially treated with intravenous glucocorticoids, and subsequently with intravenous rituximab, due to no response. The disease was rendered inactive after rituximab, but constant diplopia persisted, and the patient was referred for rehabilitative surgery.
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Affiliation(s)
- Anastasia K. Armeni
- Division of Endocrinology—Department of Internal Medicine, School of Health Sciences, University of Patras, 26504 Patras, Greece; (A.K.A.); (G.K.M.); (A.S.)
| | - Georgios Κ. Markantes
- Division of Endocrinology—Department of Internal Medicine, School of Health Sciences, University of Patras, 26504 Patras, Greece; (A.K.A.); (G.K.M.); (A.S.)
| | - Alexandra Stathopoulou
- Division of Endocrinology—Department of Internal Medicine, School of Health Sciences, University of Patras, 26504 Patras, Greece; (A.K.A.); (G.K.M.); (A.S.)
| | - Katerina Saltiki
- Endocrine Unit, Department of Clinical Therapeutics, National and Kapodistrian University, 11528 Athens, Greece;
| | - Petros Zampakis
- Department of Radiology, University Hospital of Patras, 26504 Patras, Greece;
| | - Stelios F. Assimakopoulos
- Division of Infectious Diseases—Department of Internal Medicine, School of Health Sciences, University of Patras, 26504 Patras, Greece;
| | - Marina A. Michalaki
- Division of Endocrinology—Department of Internal Medicine, School of Health Sciences, University of Patras, 26504 Patras, Greece; (A.K.A.); (G.K.M.); (A.S.)
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Xavier NF, Lucena DT, Cruz AAV. Monoclonal Antibodies for the Treatment of Graves Orbitopathy: Precision Medicine? Ophthalmic Plast Reconstr Surg 2023; 39:307-315. [PMID: 36727923 DOI: 10.1097/iop.0000000000002315] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
PURPOSE To summarize the development, nomenclature, and rationale of the reported use of monoclonal antibodies (Mabs) in Graves Orbitopathy (GO) and to undertake a systematic review of the management of GO with Mabs. METHODS The Pubmed and Embase databases and the Federal Brazilian searching site (Periódicos-CAPES) were screened. The authors searched all the keywords "monoclonal antibodies," "adalimumab," "belimumab," "infliximab," "rituximab," "teprotumumab," and "tocilizumab" combined with the terms "Graves Orbitopathy," "Graves eye disease" and "thyroid eye disease." All the articles published in English, French, and Spanish from 2000 to May 2022 were screened. Only publications with quantitative data on the activity of orbitopathy, proptosis, or both were included. RESULTS Seventy-six articles of the 954 screened records met the inclusion criteria. Seven Mabs were described for treating GO. The three most reported Mabs were Rituximab, Tocilizumab, and Teprotumumab. Only eight randomized clinical trials compared the effect of these three Mabs and Belimumab with the effect of steroids or placebos. Adalimumab, Infliximab, and K1-70 only appeared in a few case series and case reports. Frequent mild-to-moderate and few major side effects occurred with the three most used Mabs. Relapse rates ranged from 7.4% for Tocilizumab to at least 29.4% for Teprotumumab. No randomized clinical trials compared Mabs head-to-head. CONCLUSION Considering the lack of head-to-head comparisons between Mabs, the relapse rate, the possibility of severe collateral effects, and the cost of Mabs, it is not clear which Mab is the safest and most useful to treat GO.
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Affiliation(s)
- Naiara F Xavier
- Department of Ophthalmology, School of Medicine of Ribeirão Preto - University of São Paulo, Brasil
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Mohamed A, Tzoulis P, Kossler AL, Dosiou C. New Onset or Deterioration of Thyroid Eye Disease After mRNA SARS-CoV-2 Vaccines: Report of 2 Cases and Literature Review. J Clin Endocrinol Metab 2023; 108:979-985. [PMID: 36251747 PMCID: PMC9619817 DOI: 10.1210/clinem/dgac606] [Citation(s) in RCA: 8] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/25/2022] [Revised: 10/13/2022] [Indexed: 11/19/2022]
Abstract
CONTEXT Occurrence of Graves' disease (GD) has been reported following SARS-CoV-2 vaccine administration, but little is known about thyroid eye disease (TED) after SARS-CoV-2 vaccination. OBJECTIVE We describe 2 cases of TED activation following mRNA SARS-CoV-2 vaccination and review additional cases reported in the literature. METHODS We report 2 cases of TED activation following SARS-CoV-2 vaccination: 1 case of TED worsening in a patient with GD, and 1 of de novo active TED progressing to dysthyroid optic neuropathy in a patient with a history of Hashimoto hypothyroidism. Our literature search revealed 8 additional reported TED cases associated with SARS-CoV-2 vaccination until June 2022. We review the characteristics, duration, and management of TED following SARS-CoV-2 vaccination in these cases. RESULTS Of all 10 reported TED cases following SARS-CoV-2 vaccination, 4 developed new-onset TED and 6 previously stable TED cases experienced significant deterioration. Six patients had known GD and 2 patients had Hashimoto thyroiditis. Two cases progressed to dysthyroid optic neuropathy, 6 had moderate/severe active disease, and 2 had mild disease that did not require treatment. Seven TED cases received teprotumumab and had a favorable response, 2 of whom had prior limited response to initial prednisone or methylprednisolone and tocilizumab therapy. CONCLUSION New diagnosis or deterioration of TED after mRNA SARS-CoV-2 vaccination can occur, with most cases described in patients with underlying autoimmune thyroid disease. Our report raises awareness to this potential complication to promote early recognition and prompt management of TED associated with mRNA SARS-CoV-2 vaccines. Further studies are needed to explore the mechanism, risk factors, prevention, and treatment of TED following mRNA SARS-CoV-2 vaccination.
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Affiliation(s)
- Abubakr Mohamed
- Corresponding Author: Abubakr Mohamed, MD, Division of Endocrinology, Stanford University School of Medicine, 300 Pasteur Drive Stanford, CA 94304, USATel.: (650) 723-6054, E-mail:
| | - Ploutarchos Tzoulis
- Department of Metabolism & Experimental Therapeutics, Division of Medicine, University College London, London, UK
- Department of Endocrinology, IASO General Clinic, Athens, Greece
| | - Andrea Lora Kossler
- Department of Ophthalmology, Stanford University School of Medicine, Stanford, CA, USA
| | - Chrysoula Dosiou
- Division of Endocrinology, Stanford University School of Medicine, Stanford, CA, USA
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Pelewicz-Sowa M, Miśkiewicz P. Dysthyroid optic neuropathy: emerging treatment strategies. J Endocrinol Invest 2023:10.1007/s40618-023-02036-0. [PMID: 36802028 DOI: 10.1007/s40618-023-02036-0] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/24/2022] [Accepted: 02/06/2023] [Indexed: 02/21/2023]
Abstract
PURPOSE Dysthyroid optic neuropathy (DON) is a rare sight-threatening complication of Graves' disease. First-line treatment for DON consists of high-dose intravenous methylprednisolone (ivMP), followed by immediate orbital decompression (OD) if the response is poor or absent as recommended by the 2021 European Group on Graves' orbitopathy guidelines. The safety and efficacy of the proposed therapy have been proven. However, consensus regarding possible therapeutic options for patients with contraindications to ivMP/OD or resistant form of disease is missing. This paper aims to provide and summarize all available data regarding possible alternative treatment strategies for DON. METHODS A comprehensive literature search within an electronic database was performed including data published until December 2022. RESULTS Overall, 52 articles describing use of emerging therapeutic strategies for DON were identified. Collected evidence indicates that biologics, including teprotumumab and tocilizumab, may be considered as an important possible treatment option for DON patients. Rituximab should be avoided in DON due to conflicting data and risk of adverse events. Orbital radiotherapy could be beneficial for patients with restricted ocular motility classified as poor surgical candidates. CONCLUSION Only a limited number of studies have been dedicated to the therapy of DON, mostly retrospective with a small sample size. Clear criteria regarding diagnosis and resolution of DON do not exist, which restricts comparison of therapeutic outcomes. Randomized clinical trials and comparison studies with long-term follow-ups are necessary to verify the safety and efficacy of each therapeutic option for DON.
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Affiliation(s)
- M Pelewicz-Sowa
- Department of Internal Medicine and Endocrinology, Medical University of Warsaw, 02-091, Warsaw, Poland
| | - P Miśkiewicz
- Department of Internal Medicine and Endocrinology, Medical University of Warsaw, 02-091, Warsaw, Poland.
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Elasomeran/teprotumumab. REACTIONS WEEKLY 2022. [PMCID: PMC9023662 DOI: 10.1007/s40278-022-13734-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
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