The Efficacy of Rituximab Combined with 131I for Ophthalmic Outcomes of Graves' Ophthalmopathy Patients

The Relevance and Potential Role of Orbital Fat in Inflammatory Orbital Diseases: Implications for Diagnosis and Treatment

The orbit is an important structure within the skull that houses the eye, optic nerve, and extraocular muscles. It also contains adipose/fat tissue, which provides a protective cushion for these components. Inflammatory orbital disease can affect any or all components of the orbit, often arising from various underlying pathologic conditions, including autoimmune, infectious, and vascular diseases. Typical signs and symptoms of orbital inflammation include swelling, redness, pain, discomfort, and potential loss of function. The role of orbital fat in the pathogenesis of inflammatory orbital diseases has not been fully explored. This review aims to provide a comprehensive description of orbital fat, its relevance and the potential role in inflammatory diseases of the orbit, and the use of radiologic imaging studies for evaluating this fat depot in cases of as inflammatory orbital diseases. Additionally, this review discusses the various procedures available for the treatment and management of these conditions. A range of interventions, including pharmacotherapy and surgical procedures, will be evaluated as promising therapeutic options. This review also explores the characteristics and potential applications of orbital fat-derived stem cells, with an emphasis on their regenerative abilities and anti-inflammatory effects. Understanding the role of orbital fat and its contribution to inflammatory orbital diseases is essential for optimizing diagnostic and treatment strategies.

Non-coding RNA-mediated epigenetic alterations in Grave's ophthalmopathy: A scoping systematic review

Background

It is becoming more and more apparent that Grave's Ophthalmopathy (GO) pathogenesis may be aided by epigenetic processes such as DNA methylation modifications, histone tail covalent modifications, and non-coding RNA (ncRNA)-based epigenetic processes. In the present study, we aimed to focus more on the miRNAs rather than lncRNAs due to lack of investigations on these non-coding RNAs and their role in GO's pathogenesis.

Methods

A six-stage methodology framework and the PRISMA recommendation were used to conduct this scoping review. A comprehensive search was conducted across seven databases to discover relevant papers published until February 2022. The data extraction separately, and quantitative and qualitative analyses were conducted.

Results

A total of 20 articles were found to meet inclusion criteria. According to the results, ncRNA were involved in the regulation of inflammation (miR-146a, LPAL2/miR-1287-5p axis, LINC01820:13/hsa miR-27b-3p axis, and ENST00000499452/hsa-miR-27a-3p axis), regulation of T cell functions (miR-146a/miR-183/miR-96), regulation of glycosaminoglycan aggregation and fibrosis (miR-146a/miR-21), glucocorticoid sensitivity (miR-224-5p), lipid accumulation and adipogenesis (miR-27a/miR-27b/miR-130a), oxidative stress and angiogenesis (miR-199a), and orbital fibroblast proliferation (miR-21/miR-146a/miR-155). Eleven miRNAs (miR-146a/miR-224-5p/miR-Let7d-5p/miR-96-5p/miR-301a-3p/miR-21-5p) were also indicated to have the capacity to be used as biomarkers.

Conclusions

Regardless of the fact that there is significant documentation of ncRNA-mediated epigenetic dysfunction in GO, additional study is needed to thoroughly comprehend the epigenetic connections concerned in disease pathogenesis, paving the way for novel diagnostic and prognostic tools for epigenetic therapies among the patients.

Monoclonal Antibodies for the Treatment of Graves Orbitopathy: Precision Medicine?

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.

Overview of Graves Ophthalmopathy Literature From 1999 to 2019: Bibliometric Analysis

Background

Research on Graves ophthalmopathy has increased remarkably over the last 2 decades; however, few statistical analyses of the data presented in these publications have been conducted.

Objective

This study aims to detect and analyze emerging trends and collaboration networks in Graves ophthalmopathy research.

Methods

Graves ophthalmopathy–related publications from 1999 to 2019 were collected from the Web of Science Core Collection Database. Collected publications were restricted by category (article or review) and language (English). Bibliometric analyses included changes in the annual numbers of publications, journals, authors, countries, institutions, keywords, and references.

Results

In total, 3051 publications that met the criteria were collected. The number of annual publications has exhibited an increasing trend over the last 20 years. The journal Thyroid ranked first, publishing 183 Graves ophthalmopathy–related studies. There was no evidence of a relationship between impact factor (IF) and the number of publications (P=.69). The author Smith TJ had the largest number of publications on Graves ophthalmopathy (n=83). Of the countries that had published Graves ophthalmopathy–related articles, the United States had the largest number (n=784) and the highest centrality (0.18). Among institutions, the University of Pisa (Italy) contributed the most Graves ophthalmopathy–related articles (n=114). The most recent burst keywords (proliferation, rituximab, and selenium) and references may provide clues on emerging trends in research and clinical practice.

Conclusions

This bibliometric analysis highlights countries, institutions, and authors who contributed to Graves ophthalmopathy–related publications. Emerging trends in Graves ophthalmopathy research, based on burst keywords and references, may provide clues relevant to clinical practice and future research.

[Monoclonal antibodies in the treatment of thyroid eye disease]

Thyroid eye disease (TED) is an autoimmune condition affecting extraocular muscles and orbital fat that is most often a manifestation of the Graves' disease or Hashimoto thyroiditis. This disease significantly worsens the quality of life of patients, and therefore requires the use of effective treatment methods. Traditional therapy involves glucocorticosteroids and x-rays aimed at reducing the inflammatory process, rather than proptosis and diplopia, while targeted therapy is better able to influence the clinical course of the disease. The review presents a modern understanding of the pathogenesis of TED and analysis of clinical studies concerning the use of monoclonal antibodies for its treatment.

Intravenous rituximab therapy for active Graves' ophthalmopathy: a meta-analysis

AIM

The successful treatment of Graves' ophthalmopathy (GO) remains a challenge, while the efficacy of rituximab (RTX) is at present controversial. The aim of this meta-analysis was to investigate the potential impact of intravenous RTX therapy in patients with GO.

METHODS

We performed a search in the PubMed, Embase, and Web of Science databases for relevant studies published before July 2020. The primary outcome was the change of clinical activity score (CAS), and secondary outcomes were the change of proptosis and TSH receptor antibodies (TRAb). A meta-analysis was conducted to calculate the standard mean difference (SMD) for these outcomes by using fixed- or random-effect models.

RESULTS

Analysis of outcomes in 152 patients collected from 12 published articles was conducted. Compared to baseline value, CAS was significantly decreased at 1, 6, 12, and >12 months after RTX treatment. For proptosis, the results revealed no significant decrease at 1-3, 6, and ≥12 months. Moreover, the pooled analysis employed in this meta-analysis showed no significant difference of TRAb at 1 month, but significant declines were observed at 6 and ≥12 months.

CONCLUSION

Our results strongly suggest that intravenous RTX treatment has an acute and long-lasting beneficial effect on decreasing both CAS and TRAb. The study also indicates that the effect of RTX on proptosis is limited. There is evidently a need to investigate the mechanism behind RTX ineffectiveness on proptosis and explore other therapeutic regimens for the reduction of proptosis.

Advances in steroid sparing medical management of active thyroid eye disease

Thyroid eye disease (TED) is an autoimmune inflammatory disease of the orbit and the most common extrathyroidal manifestation of Graves disease. The release of pro-inflammatory cytokines is associated with inflammation of the ocular surface and lacrimal gland along with periorbital skin erythema and edema. Resultant tissue remodeling, fibrosis, and fat deposition can impart permanent physical changes to the ocular adnexa with effects on function and cosmesis. These changes occur in the active phase of disease, and it is during this time that steroids are often relied on to help alleviate symptoms. Due to the common and predictable side effects of long-term and high-dose steroid use, there has been a continuous effort to find alternative steroid-sparing medical management options for TED. This review highlights the various research studies that support the use of these medications.

Treatment strategies for Graves’ ophthalmopathy: a network meta-analysis

Purpose

Various treatments have been investigated for Graves’ ophthalmopathy (GO). We aimed to provide an overall profile of the efficacy and tolerability of various interventions for active and moderate to severe GO.

Methods

PubMed, Embase and the Cochrane Central Register of Controlled Trials were searched on 6 July 2018. Randomised controlled trials (RCT) investigating GO treatments were included. Two researchers independently extracted data according to a predefined form. A random effects network meta-analysis was performed using a frequentist approach. The primary outcome was efficacy, and the secondary outcome was tolerability (side effect discontinuation).

Results

Thirty-three studies with 1846 patients with GO were included. Orbital radiotherapy (ORT) plus intravenous glucocorticoids (IVGC) (OR 27.11; 95% CI 4.57 to 160.92), mycophenolate mofetil (MMF) (24.40, 95% CI 5.28 to 112.67), oral glucocorticoids (OGC) plus ciclosporin (20.22, 95% CI 1.60 to 255.20), IVGC plus MMF (12.08, 95% CI 2.96 to 49.35), teprotumumab (8.92, 95% CI 2.51 to 31.77), ORT plus OGC (4.88, 95% CI 1.25 to 19.06), rituximab (RTX) (4.85, 95% CI 1.18 to 19.86), somatostatin analogues (4.23, 95% CI 1.60 to 11.16), OGC plus azathioprine (AzA) (5.77, 95% CI 1.17 to 28.47) and IVGC (4.96, 95% CI 1.96 to 12.55) showed significantly better improvement than no treatment. ORT plus IVGC ranked first, followed by MMF. High heterogeneity and significant local inconsistency were observed in the RTX studies. The results of the sensitivity analyses were similar to those of the main analysis.

Conclusion

A robust recommendation regarding the best treatment cannot be made, because most evidence was rated as low or very low quality according to the Grading of Recommendations, Assessment, Development and Evaluations framework. Large RCTs and individual participant data meta-analyses are necessary to confirm these results and explore potential moderators.

PROPERO trial registration number

CRD42018103029.

Efficacy and Safety of Rituximab for the Treatment of Graves' Orbitopathy: A Meta-analysis of Randomized Controlled Trials

STUDY OBJECTIVE

To investigate the efficacy and safety of rituximab in patients with Graves' orbitopathy (GO).

DESIGN

Systematic review and meta-analysis of four randomized controlled trials.

PATIENTS

A total of 293 patients with GO who received rituximab or control (either glucocorticoids, the established first-line therapy [three trials], or saline [one trial]).

MEASUREMENTS AND RESULTS

Relevant studies published before February 2018 were identified from the PubMed, EMBASE, Cochrane Library, and Scopus databases and the ClinicalTrials.gov registry. Individual effect sizes were standardized, and a meta-analysis was conducted to calculate the pooled effect size by using a random-effects model. Treatment efficacy was assessed by measuring the following outcomes: clinical activity score (CAS), sight visual acuity reduction (NOSPECS) score, proptosis, diplopia, changes in eye volume, quality of life, and adverse events. In the four included trials, 113 patients in the rituximab group and 108 patients in the control group were evaluated. Compared with the control group, CAS (weighted mean difference 0.57, 95% confidence interval 0.25-0.89) was significantly reduced at 24 weeks in the rituximab group. Compared with the control group, considerable proptosis reduction was also observed in the rituximab group; however, the difference was not significant. The proportion of adverse events in the rituximab group was not significantly higher than that in the glucocorticoid control group, but one of the included trials indicated that the rituximab group had more serious adverse events than the saline control group.

CONCLUSION

Rituximab is a relatively safe and viable treatment that is superior to glucocorticoids or saline for patients with moderate to severe GO. However, the incidence of serious adverse events was disparate among the included trials. Additional studies involving a larger sample size and investigating the optimal rituximab dosage, frequency, and method of administration are warranted.

Does rituximab improve clinical outcomes of patients with thyroid-associated ophthalmopathy? A systematic review and meta-analysis

BACKGROUND

The current therapies of thyroid-associated ophthalmopathy (TAO) were still a challenging matter. In this study, we aimed to contrast the impact of before- after rituximab (RTX) therapy in the patients with TAO.

METHODS

We searched the PubMed, EMBASE, and SCOPUS databases for articles published up to July 3, 2017. Fixed- or random-effects meta-analysis was used to provide pooled estimates of standard mean difference (SMD) both the primary outcome from clinical activity score (CAS), and secondary outcomes from thyrotropin receptor antibody (TRAb), proptosis, thyroid stimulating hormone (TSH), and interleukin-6 (IL-6) levels. In addition, the quality and each study was assessed using either the Newcastle Ottawa Scale (NOS) or the Cochrane Risk of Bias tool, and reliability of the meta-analytic result using the Grading of Recommendations Assessment, Development and Evaluation (GRADE).

RESULTS

Of the 839 articles initially searched, 11 studies were finally eligible for inclusion. Subgroup analysis results showed that comparing with initial value, there was a decline in CAS at 1,3,6,12 month after RTX treatment, decreased TRAbs level at 6,12 month, proptosis improvement at least 1 month, unchanged IL-6 level at 6 month, decreased TSH level at 3 month but unchanged at 12 month. All included studies were classified as good quality.

CONCLUSIONS

The pooled data suggested that the preliminary effects of RTX treatment on TAO might be promising. However, more large-sample and high-quality studies targeting RTX use during this disease and long-term surveillance of prognosis are urgently needed.