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Lanzolla G, Marinò M, Menconi F. Graves disease: latest understanding of pathogenesis and treatment options. Nat Rev Endocrinol 2024:10.1038/s41574-024-01016-5. [PMID: 39039206 DOI: 10.1038/s41574-024-01016-5] [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] [Accepted: 06/20/2024] [Indexed: 07/24/2024]
Abstract
Graves disease is the most common cause of hyperthyroidism in iodine-sufficient areas. The main responsible mechanism is related to autoantibodies that bind and activate the thyrotropin receptor (TSHR). Although Graves hyperthyroidism is relatively common, no causal treatment options are available. Established treatment modalities are antithyroid drugs, which reduce thyroid hormone synthesis, radioactive iodine and surgery. However, emerging drugs that target the main autoantigen (monoclonal antibodies, small molecules, peptides) or block the immune pathway have been recently tested in clinical trials. Graves disease can involve the thyroid exclusively or it can be associated with extrathyroidal manifestations, among which Graves orbitopathy is the most common. The presence of Graves orbitopathy can change the management of the disease. An established treatment for moderate-to-severe Graves orbitopathy is intravenous glucocorticoids. However, recent advances in understanding the pathogenesis of Graves orbitopathy have allowed the development of new target-based therapies by blocking pro-inflammatory cytokine receptors, lymphocytic infiltration or the insulin-like growth factor 1 receptor (IGF1R), with several clinical trials providing promising results. This article reviews the new discoveries in the pathogenesis of Graves hyperthyroidism and Graves orbitopathy that offer several important tools in disease management.
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Affiliation(s)
- Giulia Lanzolla
- Department of Clinical and Experimental Medicine, Endocrinology Unit II, University of Pisa and University Hospital of Pisa, Pisa, Italy
- Department of Orthopaedic Surgery, University of Pennsylvania, Perelman School of Medicine, Philadelphia, PA, USA
| | - Michele Marinò
- Department of Clinical and Experimental Medicine, Endocrinology Unit II, University of Pisa and University Hospital of Pisa, Pisa, Italy
| | - Francesca Menconi
- U.O. Endocrinologia II, Azienda Ospedaliero Universitaria Pisana, University Hospital of Pisa, Pisa, Italy.
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2
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Moledina M, Damato EM, Lee V. The changing landscape of thyroid eye disease: current clinical advances and future outlook. Eye (Lond) 2024; 38:1425-1437. [PMID: 38374366 PMCID: PMC11126416 DOI: 10.1038/s41433-024-02967-9] [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: 10/08/2023] [Revised: 01/07/2024] [Accepted: 01/26/2024] [Indexed: 02/21/2024] Open
Abstract
AIMS This review aims to provide an overview of the current understanding of TED and its pathophysiology. To describe the evidence base for current consensus treatment recommendations and newer biological therapies available as well as to present future therapeutic research. METHODS We reviewed and assessed the peer-reviewed literature placing particular emphasis on recent studies evaluating the pathophysiology of TED, landmark trials forming the basis of current management and recent clinical trials informing future therapeutics. Searched were made in MEDLINE Ovid, Embase Ovid, US National Institutes of Health Ongoing Trials Register and EU Clinical Trials Register. Keywords included: "Thyroid Eye Disease", "Graves Orbitopathy", "Thyroid Orbitopathy" and "Graves' Ophthalmopathy". RESULTS AND CONCLUSIONS The pathophysiology of TED involves a complex array of cellular and humoral based autoimmune dysfunction. Previous therapies have been broad-based acting as a blunt instrument on this mechanism with varying efficacy but often accompanied with a significant side effect profile. The recent development of targeted therapy, spearheaded by Teprotumumab has led to an array of treatments focusing on specific components of the molecular pathway optimising their impact whilst possibly minimising their side effect profile. Future challenges involve identifying the most effective target for each patient rather than any single agent being a panacea. Long-term safety profiles will require clarification as unintended immunological consequence downstream may become manifest as seen in other diseases. Finally, future novel therapeutics will entail significant expenditure and may lead to a divergence of available treatment modalities between healthcare systems due to funding disparities.
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Affiliation(s)
- Malik Moledina
- Oculoplastics Service, Western Eye Hospital, Imperial College Healthcare NHS Trust, London, UK
| | - Erika M Damato
- Department of Ophthalmology, Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK
| | - Vickie Lee
- Oculoplastics Service, Western Eye Hospital, Imperial College Healthcare NHS Trust, London, UK.
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Beige A, Boustani J, Bouillet B, Truc G. Management of Graves' ophthalmopathy by radiotherapy: A literature review. Cancer Radiother 2024; 28:282-289. [PMID: 38906800 DOI: 10.1016/j.canrad.2023.09.004] [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: 01/13/2023] [Revised: 09/01/2023] [Accepted: 09/05/2023] [Indexed: 06/23/2024]
Abstract
Orbital radiotherapy for Graves' ophthalmopathy is an example of non-oncological radiotherapy. First introduced in the 1930s, this treatment has become widely used since the 1980s with several studies showing proof of both effectiveness and safety: a decrease of soft tissue involvement in 70 to 80% of patients and an improvement of ocular mobility in 30 to 80% of patients. Nowadays, it's one of the second line treatment options recognized by the European Group on Graves' orbitopathy in the management of a moderate to severe and active disease after failure of glucocorticoids. In that setting, orbital radiotherapy should be combined with glucocorticoids. To our knowledge, there are no practical recommendations on how orbital radiotherapy should be planned and conducted for Graves' ophthalmopathy. Optimal dose is not defined however the most frequent regimen consists of 20Gy in ten fractions of 2Gy, though other options may yield better results. Lastly, the use of modern technique of radiotherapy such as intensity-modulated radiation therapy may allow a better sparing of organs at risk compared to three-dimensional radiotherapy using lateral opposing fields.
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Affiliation(s)
- A Beige
- Radiation therapy department, centre Georges-François-Leclerc, Dijon, France.
| | - J Boustani
- Radiation therapy department, centre hospitalier universitaire de Besançon, Besançon, France
| | - B Bouillet
- Department of endocrinology and diabetology, centre hospitalier universitaire de Dijon, Dijon, France
| | - G Truc
- Radiation therapy department, centre Georges-François-Leclerc, Dijon, France
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Ting MAJ, Topilow NJ, Ediriwickrema LS, Yoon JS, Liu CY, Korn BS, Kikkawa DO. A comparison of proptosis reduction with teprotumumab versus surgical decompression based on fat-to-muscle ratio in thyroid eye disease. Orbit 2024; 43:222-230. [PMID: 37978819 DOI: 10.1080/01676830.2023.2282509] [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: 07/12/2023] [Accepted: 11/07/2023] [Indexed: 11/19/2023]
Abstract
PURPOSE To explore if orbital fat-to-muscle ratio (FMR) is predictive of whether surgical decompression or teprotumumab leads to greater proptosis reduction in thyroid eye disease (TED). METHODS A single-center retrospective cohort study comparing surgical decompression with teprotumumab according to FMR. All TED patients completing an 8-dose course of teprotumumab between January 2020 and September 2022 and all patients undergoing bony orbital decompression from January 2017 to December 2019 were included. Subjects were excluded if they were <18 years, received both surgical decompression and teprotumumab, or lacked orbital imaging. The primary exposure variable was teprotumumab or surgical decompression. The secondary exposure variable was baseline FMR. The primary outcome measure was change in proptosis (mm). RESULTS Thirty-eight patients, mean age 53.5 years (±11.4), were included in the teprotumumab group and 160 patients, mean age 48 years (±11.1), in the surgical group. Average proptosis reduction after teprotumumab and surgical decompression was 3 mm (±1.44) and 5 mm (±1.75), respectively. The FMR was stratified at the median of 1.80. In subjects with FMR < 1.80, teprotumumab showed equivalent proptosis reduction compared to surgical decompression, -0.33 mm (SE 1.32) p = .802. In subjects with FMR ≥ 1.80, surgical decompression led to significantly more proptosis reduction than teprotumumab, 3.01 mm (SE 0.54), p < .001. CONCLUSIONS Baseline FMR can be used to counsel patients as to proptosis reduction with teprotumumab versus surgery. Subjects with low FMR obtain comparable proptosis reduction with teprotumumab or surgery, whereas high FMR is associated with more significant proptosis reduction following surgery over teprotumumab.
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Affiliation(s)
- Michelle A J Ting
- Division of Oculofacial Plastic and Reconstructive Surgery, University of California San Diego Viterbi Family Department of Ophthalmology, Shiley Eye Institute, San Diego, California, USA
| | - Nicole J Topilow
- Division of Oculofacial Plastic and Reconstructive Surgery, University of California San Diego Viterbi Family Department of Ophthalmology, Shiley Eye Institute, San Diego, California, USA
| | - Lilangi S Ediriwickrema
- Division of Oculofacial Plastic and Reconstructive Surgery, Department of Ophthalmology, Gavin Herbert Eye Institute, University of California Irvine, Irvine, California, USA
- Department of Ophthalmology, Gavin Herbert Eye Institute, University of California Irvine, Irvine, California, USA
| | - Jin Sook Yoon
- Department of Ophthalmology, Severance Hospital, Institute of Vision Research, Yonsei University College of Medicine, Seoul, Korea
| | - Catherine Y Liu
- Division of Oculofacial Plastic and Reconstructive Surgery, University of California San Diego Viterbi Family Department of Ophthalmology, Shiley Eye Institute, San Diego, California, USA
| | - Bobby S Korn
- Division of Oculofacial Plastic and Reconstructive Surgery, University of California San Diego Viterbi Family Department of Ophthalmology, Shiley Eye Institute, San Diego, California, USA
- Division of Plastic and Reconstructive Surgery, UC San Diego Department of Surgery, San Diego, California, USA
| | - Don O Kikkawa
- Division of Oculofacial Plastic and Reconstructive Surgery, University of California San Diego Viterbi Family Department of Ophthalmology, Shiley Eye Institute, San Diego, California, USA
- Division of Plastic and Reconstructive Surgery, UC San Diego Department of Surgery, San Diego, California, USA
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Mukit FA, Manley A, Patel AB, Hashemi M, Laplant JF, Fleming JC, Fowler BT. Side Effects and Adverse Events After Treatment With Teprotumumab for Thyroid Eye Disease: A Retrospective Observational Case Series. Cureus 2024; 16:e58585. [PMID: 38765324 PMCID: PMC11102658 DOI: 10.7759/cureus.58585] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/18/2024] [Indexed: 05/22/2024] Open
Abstract
As the use of teprotumumab for thyroid eye disease (TED) becomes more prolific, there remains a scarcity of literature regarding the associated side effects and adverse events of teprotumumab use. The authors present a single-center retrospective, observational case review of TED patients who received at least a single dose of teprotumumab infusion at the oculofacial plastic surgery service between February 2020 and July 2023. The most predominant recollected side effects were fatigue, brittle nails, dry eye symptoms, hair loss, muscle spasms, and dry mouth. Significant adverse events were limited to two cases of a blood clot and a single case of pulmonary embolism. This is the first retrospective study of patient-reported side effects and adverse events experienced by a cohort of teprotumumab users.
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Affiliation(s)
| | - Andrew Manley
- Ophthalmology, The University of Tennessee Health Science Center, Memphis, USA
| | - Akash B Patel
- Internal Medicine, University of Texas Southwestern Medical Center, Dallas, USA
| | - Marium Hashemi
- Ophthalmology, The University of Tennessee Health Science Center, Memphis, USA
| | - Jacquelyn F Laplant
- Ophthalmic Plastic and Reconstructive Surgery, Medical College of Wisconsin, Milwaukee, USA
| | - James C Fleming
- Oculofacial Plastic and Reconstructive Surgery, Hamilton Eye Institute, Memphis, USA
| | - Brian T Fowler
- Oculofacial Plastic and Reconstructive Surgery, Hamilton Eye Institute, Memphis, USA
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Nivean PD, Madhivanan N, Kumaramanikavel G, Berendschot TTJM, Webers CAB, Paridaens D. Understanding the clinical and molecular basis of thyroid orbitopathy: a review of recent evidence. Hormones (Athens) 2024; 23:25-34. [PMID: 37910311 PMCID: PMC10847210 DOI: 10.1007/s42000-023-00498-8] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/13/2023] [Accepted: 10/10/2023] [Indexed: 11/03/2023]
Abstract
Thyroid eye disease (TED) is an autoimmune orbital inflammatory disease which ranges from mild to severe. Tissue remodeling, fibrosis and fat proliferation cause changes in the orbital tissues which can affect esthetics and visual function. In its severe form, it is sight threatening, debilitating, and disfiguring and may lead to social stigma, the embarrassment about which has an impact on the quality of life of those affected and the family members. The pathogenesis of TED, which is influenced by genetic, immunological, and environmental factors, is complex and not fully elucidated. However, it remains unknown what factors determine the severity of the disease. Recent research has revealed a number of diagnostic and prognostic biomarkers of this disease. In this overview of TED, we focus on new insights and perspectives regarding biological agents that may provide a basis for new treatment modalities.
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Affiliation(s)
- Pratheeba Devi Nivean
- M.N Eye Hospital, Chennai, India.
- Maastricht University, Maastricht, The Netherlands.
| | | | | | | | | | - Dion Paridaens
- Department of Ophthalmology, Erasmus Medical Centre, Rotterdam, The Netherlands
- Orbital Service, Rotterdam Eye Hospital, Rotterdam, The Netherlands
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Cieplińska K, Niedziela E, Kowalska A. Immunological Processes in the Orbit and Indications for Current and Potential Drug Targets. J Clin Med 2023; 13:72. [PMID: 38202079 PMCID: PMC10780108 DOI: 10.3390/jcm13010072] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/12/2023] [Revised: 12/17/2023] [Accepted: 12/20/2023] [Indexed: 01/12/2024] Open
Abstract
Thyroid eye disease (TED) is an extrathyroidal manifestation of Graves' disease (GD). Similar to GD, TED is caused by an autoimmune response. TED is an autoimmune inflammatory disorder of the orbit and periorbital tissues, characterized by upper eyelid retraction, swelling, redness, conjunctivitis, and bulging eyes. The pathophysiology of TED is complex, with the infiltration of activated T lymphocytes and activation of orbital fibroblasts (OFs) and autoantibodies against the common autoantigen of thyroid and orbital tissues. Better understanding of the multifactorial pathogenesis of TED contributes to the development of more effective therapies. In this review, we present current and potential drug targets. The ideal treatment should slow progression of the disease with as little interference with patient immunity as possible. In the future, TED treatment will target the immune mechanism involved in the disease and will be based on a strategy of restoring tolerance to autoantigens.
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Affiliation(s)
| | - Emilia Niedziela
- Collegium Medicum, Jan Kochanowski University in Kielce, 25-317 Kielce, Poland; (E.N.); (A.K.)
- Department of Endocrinology, Holy Cross Cancer Center, 25-734 Kielce, Poland
| | - Aldona Kowalska
- Collegium Medicum, Jan Kochanowski University in Kielce, 25-317 Kielce, Poland; (E.N.); (A.K.)
- Department of Endocrinology, Holy Cross Cancer Center, 25-734 Kielce, Poland
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8
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Abeillon-du Payrat J, Caron P. The key data from the 2022 European Thyroid Association congress: Toward personalized treatment of Graves' orbitopathy. ANNALES D'ENDOCRINOLOGIE 2023; 84:756-757. [PMID: 37285956 DOI: 10.1016/j.ando.2023.05.007] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/15/2023] [Accepted: 05/22/2023] [Indexed: 06/09/2023]
Affiliation(s)
| | - Philippe Caron
- Department of Endocrinology and Metabolic Diseases, Cardiovascular and Metabolic Unit, CHU Larrey, 24, chemin de Pouvourville, TSA 30030, 31059 Toulouse cedex, France.
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Stan MN, Krieger CC. The Adverse Effects Profile of Teprotumumab. J Clin Endocrinol Metab 2023; 108:e654-e662. [PMID: 37071658 PMCID: PMC10686693 DOI: 10.1210/clinem/dgad213] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/02/2023] [Revised: 03/29/2023] [Accepted: 04/11/2023] [Indexed: 04/19/2023]
Abstract
CONTEXT Teprotumumab therapy for thyroid eye disease (TED) patients represents a major step forward. It targets and inhibits the insulin-like growth factor-1 receptor (IGF-1R), and its effectiveness is based on its interconnectedness with the thyrotropin receptor. However, IGF-1R has a ubiquitous expression and several adverse effects have been reported with teprotumumab use. OBJECTIVE Describing these adverse effects for better understanding is the purpose of this review. METHODS We reviewed the oncological studies in which teprotumumab was initially used. Subsequently we reviewed the clinical trials for TED and then the case series and case reports associated with teprotumumab use since it is US Food and Drug Administration approval (January 2020). We focused on common and/or serious adverse effects reported with the use of teprotumumab. RESULTS We described the common occurrence of hyperglycemia (10%-30% incidence), its risk factors and suggested management. Hearing changes are described, a broad spectrum from mild ear pressure to hearing loss (sensorineural mechanism). Risk factors, suggested monitoring, and possible upcoming therapies are reviewed. We also reviewed data on fatigue, muscle spasms, hair loss, weight loss, gastrointestinal disturbances, menstrual changes, and infusion reactions. We noted some discrepancies between adverse effects in oncological studies vs studies focused on TED, and we aimed to explain these differences. CONCLUSION The use of teprotumumab should consider patient's values and preferences in balancing the expected benefit with these potential risks. Future drugs targeting IGF-1R should investigate these adverse effects for a possible class effect. Combination therapies with different agents hopefully will be identified that maximize benefits and minimize risks.
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Affiliation(s)
- Marius N Stan
- Division of Endocrinology, Mayo Clinic Rochester, Rochester, MN 55905, USA
| | - Christine C Krieger
- Laboratory of Endocrinology and Receptor Biology, National Institute of Diabetes and Digestive and Kidney Diseases, National Institutes of Health, Bethesda, MD 20892, USA
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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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11
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Truong T, Silkiss RZ. The Role of Insulin-like Growth Factor-1 and Its Receptor in the Eye: A Review and Implications for IGF-1R Inhibition. Ophthalmic Plast Reconstr Surg 2023; 39:4-12. [PMID: 36598389 DOI: 10.1097/iop.0000000000002146] [Citation(s) in RCA: 7] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
Abstract
PURPOSE FDA approval of teprotumumab for thyroid eye disease in January 2020 reinforced interest in the pharmacologic potential of insulin-like growth factor-1 (IGF-1) and its receptor, IGF-1R. Despite recent approval and adaptation for ophthalmic use, IGF-1R inhibitors are not a new therapeutic class. In 1986, Yamashita described aIR3, a monoclonal antibody to IGF-1R (anti-IGF-1R), that inhibited the effect of IGF-1 on growth hormone release. Given the widespread presence of IGF-1R, interrupting this receptor can lead to systemic physiologic effects, some adverse. We aim to review what is known about IGF-1/IGF-1R in the eye and consider the possible local side effects, unintended consequences, and potential uses of this medication class. METHODS A PubMed database search utilizing the keywords "insulin-like growth factor-1, eye, inhibitor, antibody, side effect" was performed to identify publications discussing IGF-1 in the human eye from January 2011 to August 2021. Criteria for acceptance included studies discussing human subjects or human tissue specifically related to the eye. RESULTS Out of a total of 230 articles, 47 were organized in 3 subject groups for discussion: thyroid-associated orbitopathy, cornea and the ocular surface, and the retina and neovascularization. Review of the literature demonstrated that IGF-1 affects growth and development of the eye, epithelial proliferation, retinal angiogenesis, inflammation, and is associated with thyroid-associated orbitopathy. CONCLUSIONS IGF-1R exists throughout in the human body, including the cornea, retina, and orbit. Research regarding ocular effects of IGF-1/IGF-1R outside thyroid eye disease is limited. Carefully designed studies and clinical assessments of patients undergoing treatment with anti-IGF-1R may identify ocular side effects and foster consideration of the role of anti-IGF-1R in ocular therapeutics. Given the increasing use of anti-IGF-1R antibodies, understanding their ocular effects, side effects, and potential systemic implications for use in disease is critical.
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Affiliation(s)
- Timothy Truong
- Department of Ophthalmology, Division of Oculofacial Plastic Surgery, California Pacific Medical Center, San Francisco, California, U.S.A
| | - Rona Z Silkiss
- Department of Ophthalmology, Division of Oculofacial Plastic Surgery, California Pacific Medical Center, San Francisco, California, U.S.A
- Department of Ophthalmology, Division of Oculofacial Plastic Surgery, Silkiss Eye Surgery, San Francisco, California, U.S.A
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12
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Bartalena L. Role of teprotumumab in the treatment of active moderate-to-severe Graves' orbitopathy. Eur Thyroid J 2022; 11:e220185. [PMID: 36479873 PMCID: PMC9716370 DOI: 10.1530/etj-22-0185] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/12/2022] [Accepted: 10/17/2022] [Indexed: 12/14/2022] Open
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Abstract
CONTEXT Thyroid eye disease (TED), a vision-threatening and disfiguring autoimmune process, has thwarted our efforts to understand its pathogenesis and develop effective and safe treatments. Recent scientific advances have facilitated improved treatment options. OBJECTIVE Review historically remote and recent advances in understanding TED. DESIGN/SETTING/PARTICIPANTS PubMed was scanned using search terms including thyroid-associated ophthalmopathy, thyroid eye disease, Graves' orbitopathy, autoimmune thyroid disease, and orbital inflammation. MAIN OUTCOME MEASURES Strength of scientific evidence, size, scope, and controls of clinical trials/observations. RESULTS Glucocorticoid steroids are widely prescribed systemic medical therapy. They can lessen inflammation-related manifestations of TED but fail to reliably reduce proptosis and diplopia, 2 major causes of morbidity. Other current therapies include mycophenolate, rituximab (anti-CD20 B cell-depleting monoclonal antibody), tocilizumab (interleukin-6 receptor antagonist), and teprotumumab (IGF-I receptor inhibitor). Several new therapeutic approaches have been proposed including targeting prostaglandin receptors, vascular endothelial growth factor, mTOR, and cholesterol pathways. Of potentially greater long-term importance are attempts to restore immune tolerance. CONCLUSION Despite their current wide use, steroids may no longer enjoy first-tier status for TED as more effective and better tolerated medical options become available. Multiple current and emerging therapies, the rationales for which are rooted in theoretical and experimental science, promise better options. These include teprotumumab, rituximab, and tocilizumab. Restoration of immune tolerance could ultimately become the most effective and safe medical management for TED.
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Affiliation(s)
- Terry J Smith
- Department of Ophthalmology and Visual Sciences, Kellogg Eye Center, Division of Metabolism, Endocrinology, and Diabetes, Department of Internal Medicine, University of Michigan Medical School, Ann Arbor, MI 48105, USA
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14
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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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15
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Yu CY, Ford RL, Wester ST, Shriver EM. Update on thyroid eye disease: Regional variations in prevalence, diagnosis, and management. Indian J Ophthalmol 2022; 70:2335-2345. [PMID: 35791115 PMCID: PMC9426067 DOI: 10.4103/ijo.ijo_3217_21] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
Abstract
Thyroid eye disease (TED) is a rare disease that can lead to decreased quality of life, permanent disfigurement, and vision loss. Clinically, TED presents with exophthalmos, periorbital edema, extraocular muscle dysfunction, and eyelid retraction, and can lead to vision-threatening complications such as exposure to keratopathy and dysthyroid optic neuropathy (DON). Over the last several years, significant advancements have been made in the understanding of its pathophysiology as well as optimal management. Ethnic variations in the prevalence, clinical presentation, and risk of vision-threatening complications of TED are summarized, and risk factors associated with TED are discussed. Additionally, significant advances have been made in the management of TED. The management of TED traditionally included anti-inflammatory medications, orbital radiation therapy, orbital surgical decompression, and biologic therapies. Most recently, targeted therapies such as teprotumumab, an insulin-like growth factor-1 receptor antagonist, have been studied in the context of TED, with promising initial data. In this review, updates in the understanding and management of TED are presented with a focus on the international variations in presentation and management.
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Affiliation(s)
- Caroline Y Yu
- Department of Ophthalmology and Visual Sciences, University of Iowa, Iowa City, IA, USA
| | - Rebecca L Ford
- Department of Ophthalmology, Bristol Eye Hospital, University Hospitals Bristol NHS Foundation Trust, Bristol, UK
| | - Sara T Wester
- Department of Ophthalmology, Bascom Palmer Eye Institute, University of Miami Miller School of Medicine, Miami, FL, USA
| | - Erin M Shriver
- Department of Ophthalmology and Visual Sciences, University of Iowa, Iowa City, IA, USA
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16
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Bartalena L, Marinò M, Marcocci C, Tanda ML. Teprotumumab for Graves' orbitopathy and ototoxicity: moving problems from eyes to ears? J Endocrinol Invest 2022; 45:1455-1457. [PMID: 35403994 DOI: 10.1007/s40618-022-01791-w] [Citation(s) in RCA: 19] [Impact Index Per Article: 9.5] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/14/2022] [Accepted: 03/22/2022] [Indexed: 02/01/2023]
Affiliation(s)
- L Bartalena
- Emeritus Professor of Endocrinology, Department of Medicine and Surgery, University of Insubria, Via Guicciardini, 9, 21100, Varese, Italy.
| | - M Marinò
- Department of Clinical and Experimental Medicine, University of Pisa, Pisa, Italy
| | - C Marcocci
- Department of Clinical and Experimental Medicine, University of Pisa, Pisa, Italy
| | - M L Tanda
- Emeritus Professor of Endocrinology, Department of Medicine and Surgery, University of Insubria, Via Guicciardini, 9, 21100, Varese, Italy
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17
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Hoang TD, Stocker DJ, Chou EL, Burch HB. 2022 Update on Clinical Management of Graves Disease and Thyroid Eye Disease. Endocrinol Metab Clin North Am 2022; 51:287-304. [PMID: 35662442 PMCID: PMC9174594 DOI: 10.1016/j.ecl.2021.12.004] [Citation(s) in RCA: 20] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Abstract
The management of hyperthyroidism and extrathyroidal manifestations of Graves disease remains complex. Considerations that include patient preference, age, comorbidity, pregnancy, tobacco smoking, and social determinants of health must all be weaved into a cohesive management plan. A multidisciplinary team is required to manage all aspects of Graves disease, particularly thyroid eye disease, for which new therapeutic options are now available.
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Affiliation(s)
- Thanh D Hoang
- Division of Diabetes, Endocrinology and Metabolism, Walter Reed National Military Medical Center, 8901 Wisconsin Avenue, Bethesda, MD 20819, USA; Uniformed Services University of the Health Sciences, Bethesda, MD 20814, USA
| | - Derek J Stocker
- Department of Radiology, Nuclear Medicine Service, Walter Reed National Military Medical Center, 8901 Wisconsin Avenue, Bethesda, MD 20819, USA; Departments of Internal Medicine, Pathology, and Radiologic Sciences Uniformed Services University of the Health Sciences, Bethesda, MD 20814, USA
| | - Eva L Chou
- Department of Ophthalmology, Oculoplastic Service, Walter Reed National Military Medical Center, 8901 Wisconsin Avenue, Bethesda, MD 20819, USA; Uniformed Services University of the Health Sciences, Bethesda, MD 20814, USA
| | - Henry B Burch
- Division of Diabetes, Endocrinology and Metabolic Diseases, National Institute of Diabetes and Digestive and Kidney Diseases, National Institutes of Health, 6707 Democracy Boulevard, Room 6054, Bethesda, MD 20892-5460, USA; Uniformed Services University of the Health Sciences, Bethesda, MD 20814, USA.
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18
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Furmaniak J, Sanders J, Sanders P, Li Y, Rees Smith B. TSH receptor specific monoclonal autoantibody K1-70 TM targeting of the TSH receptor in subjects with Graves' disease and Graves' orbitopathy-Results from a phase I clinical trial. Clin Endocrinol (Oxf) 2022; 96:878-887. [PMID: 35088429 PMCID: PMC9305464 DOI: 10.1111/cen.14681] [Citation(s) in RCA: 21] [Impact Index Per Article: 10.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/26/2021] [Revised: 01/24/2022] [Accepted: 01/26/2022] [Indexed: 11/30/2022]
Abstract
OBJECTIVES In Graves' disease (GD), autoantibodies to the thyroid stimulating hormone receptor (TSHR) cause hyperthyroidism. The condition is often associated with eye signs including proptosis, oedema, and diplopia (collectively termed Graves' orbitopathy [GO]). The safety profile of K1-70TM (a human monoclonal TSHR specific autoantibody, which blocks ligand binding and stimulation of the receptor) in patients with GD was evaluated in a phase I clinical trial. PATIENTS AND STUDY DESIGN Eighteen GD patients stable on antithyroid drug medication received a single intramuscular (IM) or intravenous (IV) dose of K1-70TM during an open label phase I ascending dose, safety, tolerability, pharmacokinetic and pharmacodynamic (PD) study. Immunogenic effects of K1-70TM were also determined. RESULTS K1-70TM was well-tolerated in all subjects at all doses and no significant immunogenic response was observed. There were no deaths or serious adverse events. Increased systemic exposure to K1-70TM was observed following a change to IV dosing, indicating this was the correct dosage route. Expected PD effects occurred after a single IM dose of 25 mg or single IV dose of 50 mg or 150 mg with fT3, fT4, and TSH levels progressing into hypothyroid ranges. There were also clinically significant improvements in symptoms of both GD (reduced tremor, improved sleep, improved mental focus, reduced toilet urgency) and GO (reduced exophthalmos measurements, reduced photosensitivity). CONCLUSIONS K1-70TM was safe, well tolerated and produced the expected PD effects with no immunogenic responses. It shows considerable promise as a new drug to block the actions of thyroid stimulators on the TSHR.
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Affiliation(s)
- Jadwiga Furmaniak
- AV7 Limited, FIRS Laboratories, Parc Ty GlasCardiffUK
- RSR Limited, FIRS Laboratories, Parc Ty GlasCardiffUK
| | - Jane Sanders
- AV7 Limited, FIRS Laboratories, Parc Ty GlasCardiffUK
- RSR Limited, FIRS Laboratories, Parc Ty GlasCardiffUK
| | - Paul Sanders
- RSR Limited, FIRS Laboratories, Parc Ty GlasCardiffUK
| | - Yang Li
- RSR Limited, FIRS Laboratories, Parc Ty GlasCardiffUK
| | - Bernard Rees Smith
- AV7 Limited, FIRS Laboratories, Parc Ty GlasCardiffUK
- RSR Limited, FIRS Laboratories, Parc Ty GlasCardiffUK
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19
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Längericht J, Mitka KI, Hubalewska-Dydejczyk A, Krämer I, Kahaly GJ. Drug safety in thyroid eye disease - a systematic review. Expert Opin Drug Saf 2022; 21:881-912. [PMID: 35447047 DOI: 10.1080/14740338.2022.2069239] [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: 11/04/2022]
Abstract
INTRODUCTION The autoimmune-induced thyroid eye disease (TED) is a frequent extrathyroidal manifestation of Graves' disease and less frequently of Hashimoto's thyroiditis. Pathognomonic clinical signs, i.e. exophthalmos, double vision, and inflammation of the orbital tissue cause physical, ophthalmic, and socio-psychological limitations. AREAS COVERED PubMed and MeSH database were searched for specific guidelines, randomized controlled trials, prospective clinical studies, systematic reviews and meta-analyses pertaining to the safety profile of currently administered immunosuppressive agents for the treatment of TED. Occurred adverse events (AE), severe AE (SAE), side effects (SE), and severe SE (SSE) were classified according to the standardized medical dictionary for regulatory activities (MedDRA). EXPERT OPINION This novel systematic analysis offers an overview of potential AE, SAE and SE for currently recommended immunosuppressive drugs for the treatment of TED. Non-specific, anti-inflammatory drugs and more specific, targeted biologicals are treatment options for active and severe TED. Critical evaluation of the pertinent literature confirms an evidence-based, beneficial efficacy/risk ratio of the current first-line and second-line treatment recommendations endorsed by the European Society of Endocrinology. However, further large, well-conceived trials are mandatory to enhance our knowledge and experience with novel specific small molecules and/or monoclonal antibodies targeting the key autoantigens in TED.
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Affiliation(s)
- Jan Längericht
- Department of Medicine I., Johannes Gutenberg University (JGU) Medical Center, Mainz, Germany
| | - Kamila I Mitka
- Department of Medicine I., Johannes Gutenberg University (JGU) Medical Center, Mainz, Germany.,Department of Endocrinology, Jagiellonian University Medical College, Cracow, Poland
| | | | - Irene Krämer
- Department of Pharmacy, Johannes Gutenberg University (JGU) Medical Center, Mainz, Germany
| | - George J Kahaly
- Department of Medicine I., Johannes Gutenberg University (JGU) Medical Center, Mainz, Germany
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20
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Ugradar S, Kossler AL, Douglas R, Cockerham K. A Paradigm Shift in the Management of Thyroid Eye Disease How Teprotumumab Has Changed the Therapeutic Interface. J Neuroophthalmol 2022; 42:26-34. [PMID: 35500236 DOI: 10.1097/wno.0000000000001515] [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: 11/25/2022]
Abstract
BACKGROUND Teprotumumab, a monoclonal antibody that blocks the insulin-like growth factor-1 receptor, has recently been approved by the US Food and Drug Administration (FDA) for the treatment of thyroid eye disease (TED). Since its approval, aside from data on the safety and clinical efficacy of teprotumumab from Phase-2 and Phase-3 trials, only a handful of reports have been published regarding its use in the wider population. In this review, we briefly describe the mechanism of action of teprotumumab and review the literature to provide an overview of published clinical experience. This information was used to provide recommendations for patient selection, management of patient expectations, infusion details and site options, tips to optimize the authorization process, and how to monitor and mitigate side effects. EVIDENCE ACQUISITION A systemic review of the literature was performed regarding teprotumumab, focusing on its mechanisms of action and published reports on its use on patients with TED. A review of Embase, Medline (PubMed), Web of Science, and Google Scholar was conducted. RESULTS Clinical experience following the approval of teprotumumab has confirmed its efficacy in reducing inflammation and proptosis in patients with acute TED (<2 years). The reduction in proptosis occurs due to a reduction in orbital fat and muscle volume. Furthermore, there is evidence for its use in patients with compressive optic neuropathy. There are also reports that show its efficacy in reducing proptosis, inflammation, and diplopia in patients with chronic TED (>2 years). Teprotumumab was associated with side effects, such as muscle spasm, hearing loss, and hyperglycemia. To date, 2 case reports have shown a possible association with flares of inflammatory bowel disease. CONCLUSIONS Teprotumumab is a powerful therapeutic option for the treatment of TED. Clinical experience following FDA approval has demonstrated efficacy in treating patients with acute and chronic TED. It is the only therapeutic option that has been shown to reduce orbital soft tissue expansion in TED. However, it is expensive, and sometimes, obtaining insurance authorization can be time consuming and difficult. Further work will reveal its full side effect profile and help to establish its role in the armamentarium used to treat TED.
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Affiliation(s)
- Shoaib Ugradar
- Department of ophthalmology (SU), the Jules Stein Eye Institute, University of California, Los Angeles, California; Byers Eye Institute at Stanford University School of Medicine (ALK, KC), Palo Alto, California; Cedars Sinai Medical Center (RD), Los Angeles, California; Central Valley Eye Medical Group (KC), Stockton, California
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21
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Teo HM, Smith TJ, Joseph SS. Efficacy and Safety of Teprotumumab in Thyroid Eye Disease. Ther Clin Risk Manag 2021; 17:1219-1230. [PMID: 34858025 PMCID: PMC8630371 DOI: 10.2147/tcrm.s303057] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/26/2021] [Accepted: 11/07/2021] [Indexed: 11/24/2022] Open
Abstract
Thyroid eye disease (TED; also known as thyroid-associated ophthalmopathy) is an autoimmune condition with disabling and disfiguring consequences. Teprotumumab is the first and only medication approved by the United States Food and Drug Administration for the treatment of TED. We review the efficacy and safety of teprotumumab in TED, highlighting results from the 2 randomized, double-masked, placebo-controlled trials. Post-approval case reports of teprotumumab use in patients with compressive optic neuropathy (CON) and inactive TED were similarly favorable to those from the trials. The preliminarily results of teprotumumab for CON and inactive TED should be investigated in formal clinical trials. Teprotumumab should be avoided in pregnancy. Evidence also suggests that teprotumumab may exacerbate pre-existing inflammatory bowel disease, worsen hyperglycemia, and be associated with hearing impairment. Patients at risk for these adverse events need to be closely monitored with baseline and periodic assessments.
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Affiliation(s)
| | - Terry J Smith
- Department of Ophthalmology and Visual Sciences, W.K. Kellogg Eye Center, University of Michigan Medical School, Ann Arbor, MI, USA.,Division of Metabolism, Endocrinology and Diabetes, Department of Internal Medicine, University of Michigan Medical School, Ann Arbor, MI, USA
| | - Shannon S Joseph
- Department of Ophthalmology and Visual Sciences, W.K. Kellogg Eye Center, University of Michigan Medical School, Ann Arbor, MI, USA
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22
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Brenner MJ, Shenson JA, Rose AS, Valdez TA, Takashima M, Ahmed OG, Weissbrod PA, Hong RS, Djalilian H, Wolf JS, Morrison RJ, Santa Maria PL, Erbele ID. New Medical Device and Therapeutic Approvals in Otolaryngology: State of the Art Review 2020. OTO Open 2021; 5:2473974X211057035. [PMID: 34790883 PMCID: PMC8591653 DOI: 10.1177/2473974x211057035] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/30/2021] [Accepted: 10/11/2021] [Indexed: 11/24/2022] Open
Abstract
Objectives To evaluate new drugs and devices relevant to otolaryngology–head and neck surgery that were approved by the US Food and Drug Administration (FDA) in 2020. Data Sources Publicly available device and therapeutic approvals from ENT (ear, nose, and throat), anesthesia, neurology (neurosurgery), and plastic and general surgery FDA committees. Review Methods Members of the American Academy of Otolaryngology–Head and Neck Surgery’s Medical Devices and Drugs Committee reviewed new therapeutics and medical devices from a query of the FDA’s device and therapeutic approvals. Two independent reviewers assessed the drug’s or device’s relevance to otolaryngology, classified to subspecialty field, with a critical review of available scientific literature. Conclusions The Medical Devices and Drugs Committee reviewed 53 new therapeutics and 1094 devices (89 ENT, 140 anesthesia, 511 plastic and general surgery, and 354 neurology) approved in 2020. Ten drugs and 17 devices were considered relevant to the otolaryngology community. Rhinology saw significant improvements around image guidance systems; indications for cochlear implantation expanded; several new monoclonal therapeutics were added to head and neck oncology’s armamentarium; and several new approvals appeared for facial plastics surgery, pediatric otolaryngology, and comprehensive otolaryngology. Implications for Practice New technologies and pharmaceuticals offer the promise of improving how we care for otolaryngology patients. However, judicious introduction of innovations into practice requires a nuanced understanding of safety, advantages, and limitations. Working knowledge of new drugs and medical devices approved for the market helps clinicians tailor patient care accordingly.
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Affiliation(s)
- Michael J Brenner
- Medical Devices and Drugs Committee, American Academy of Otolaryngology-Head and Neck Surgery, Alexandria, Virginia, USA.,Department of Otolaryngology-Head and Neck Surgery, University of Michigan Medical School, Ann Arbor, Michigan, USA
| | - Jared A Shenson
- Medical Devices and Drugs Committee, American Academy of Otolaryngology-Head and Neck Surgery, Alexandria, Virginia, USA.,Department of Otolaryngology-Head and Neck Surgery, Stanford University, Palo Alto, California, USA
| | - Austin S Rose
- Medical Devices and Drugs Committee, American Academy of Otolaryngology-Head and Neck Surgery, Alexandria, Virginia, USA.,Department of Otolaryngology-Head and Neck Surgery, School of Medicine, University of North Carolina, Chapel Hill, North Carolina, USA
| | - Tulio A Valdez
- Medical Devices and Drugs Committee, American Academy of Otolaryngology-Head and Neck Surgery, Alexandria, Virginia, USA.,Department of Otolaryngology-Head and Neck Surgery, Stanford University, Palo Alto, California, USA
| | - Masayoshi Takashima
- Medical Devices and Drugs Committee, American Academy of Otolaryngology-Head and Neck Surgery, Alexandria, Virginia, USA.,Department of Otolaryngology-Head and Neck Surgery, Houston Methodist Hospital, Houston, Texas, USA
| | - Omar G Ahmed
- Medical Devices and Drugs Committee, American Academy of Otolaryngology-Head and Neck Surgery, Alexandria, Virginia, USA.,Department of Otolaryngology-Head and Neck Surgery, Houston Methodist Hospital, Houston, Texas, USA
| | - Philip A Weissbrod
- Medical Devices and Drugs Committee, American Academy of Otolaryngology-Head and Neck Surgery, Alexandria, Virginia, USA.,Division of Otolaryngology, Department of Surgery, University of California San Diego, La Jolla, California, USA
| | - Robert S Hong
- Medical Devices and Drugs Committee, American Academy of Otolaryngology-Head and Neck Surgery, Alexandria, Virginia, USA.,Department of Otolaryngology-Head and Neck Surgery, Wayne State University, Detroit, Michigan, USA.,Michigan Ear Institute, Farmington Hills, Michigan, USA
| | - Hamid Djalilian
- Medical Devices and Drugs Committee, American Academy of Otolaryngology-Head and Neck Surgery, Alexandria, Virginia, USA.,Department of Otolaryngology-Head and Neck Surgery and Biomedical Engineering, University of California-Irvine, Irvine, California, USA
| | - Jeffrey S Wolf
- Medical Devices and Drugs Committee, American Academy of Otolaryngology-Head and Neck Surgery, Alexandria, Virginia, USA.,Department of Otolaryngology-Head and Neck Surgery, School of Medicine, University of Maryland, Baltimore, Maryland, USA
| | - Robert J Morrison
- Medical Devices and Drugs Committee, American Academy of Otolaryngology-Head and Neck Surgery, Alexandria, Virginia, USA.,Department of Otolaryngology-Head and Neck Surgery, University of Michigan Medical School, Ann Arbor, Michigan, USA
| | - Peter L Santa Maria
- Medical Devices and Drugs Committee, American Academy of Otolaryngology-Head and Neck Surgery, Alexandria, Virginia, USA.,Department of Otolaryngology-Head and Neck Surgery, Stanford University, Palo Alto, California, USA
| | - Isaac D Erbele
- Medical Devices and Drugs Committee, American Academy of Otolaryngology-Head and Neck Surgery, Alexandria, Virginia, USA.,Department of Otolaryngology, Brooke Army Medical Center, Fort Sam Houston, Texas, USA.,Department of Surgery, Uniformed Services University of the Health Sciences, Bethesda, Maryland, USA
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