Overall safety and efficacy of high-dose and low-dose intravenous glucocorticoid therapy in patients with moderate-to-severe active Graves' ophthalmopathy

Thyroid-related ophthalmopathy development in concurrence with growth hormone administration

BACKGROUND

Thyroid stimulating hormone (TSH) receptor and local infiltrate lymphocytes have been considered as major pathological factors for developing thyroid-related ophthalmopathy. Overexpression of insulin-like growth factor-I (IGF-I) receptor has emerged as a promising therapeutic target for refractory patients. However, the relationship between activation of growth hormone (GH)/IGF-I receptor signaling and development or exacerbation of thyroid ophthalmopathy has not been elucidated. Herein we describe a case that provides further clarification into the association between thyroid-related ophthalmopathy and GH/IGF-I receptor signaling.

CASE PRESENTATION

A 62-year-old Japanese female diagnosed with thyroid-related ophthalmopathy was admitted to Kurume University Hospital. She had received daily administration of GH subcutaneously for severe GH deficiency; however, serum IGF-I levels were greater than + 2 standard deviation based on her age and sex. She exhibited mild thyrotoxicosis and elevation in levels of TSH-stimulating antibody. Discontinuation of GH administration attenuated the clinical activity scores of her thyroid-related ophthalmopathy. Additionally, concomitant use of glucocorticoid and radiation therapies resulted in further improvement of thyroid-related ophthalmopathy. The glucocorticoid administration was reduced sequentially, followed by successful termination. Thereafter, the patient did not undergo recurrence of thyroid-related ophthalmopathy and maintained serum IGF-I levels within normal physiological levels.

CONCLUSIONS

We describe here a case in which development of thyroid-related ophthalmopathy occurred upon initiation of GH administration. GH/IGF-I signaling was highlighted as a risk factor of developing thyroid-related ophthalmopathy. Additionally, aberrant TSH receptor expression was suggested to be a primary pathophysiological mechanism within the development of thyroid-related ophthalmopathy. Physicians should be aware of the risks incurred via GH administration, especially for patients of advanced age, for induction of thyroid-related ophthalmopathy.

Efficacy and Safety of Different Intravenous Glucocorticoid Regimens in the Treatment of Graves' Ophthalmopathy: A Meta-Analysis

Purpose

The intravenous glucocorticoid (iv GC) represents the mainstay of therapy for Graves' ophthalmopathy (GO), but uncertainty remains concerning the optimal regimen. Although the European Group on Graves' Orbitopathy (EUGOGO) regimen has been commonly employed, evidence for its superiority to other regimens is still lacking. The aim of this meta-analysis was to compare the efficacy and safety of the EUGOGO regimen with higher-dose regimens in the management of GO.

Methods

A systematic review and meta-analysis of randomized controlled trials (RCTs) and cohort studies comparing the EUGOGO regimen with higher-dose regimens was conducted. PubMed, Embase, and Web of Science databases were searched for relevant studies. The efficacy outcomes were response rate, change in clinical activity score (CAS), rate of proptosis improvement, and retreatment rate. The safety outcome was the incidence of adverse events.

Results

In the five included eligible trials, 136 participants in the EUGOGO regimen and 177 participants in higher-dose regimens were evaluated. Compared with the EUGOGO regimen, higher-dose regimens had no beneficial effect on the response rate, change of CAS, rate of proptosis improvement, and retreatment rate (OR: 1.3; 95% CI: 0.36–4.65; SMD: –0.04; 95% CI: –0.54, 0.45; OR: 0.79; 95% CI: 0.44–1.44; OR: 0.87; 95% CI: 0.27–2.77). For the incidence of adverse events, the results also showed no significant difference between the 2 groups (OR: 1.14; 95% CI: 0.62–2.09).

Conclusion

The current evidence showed that the efficacy of the EUGOGO regimen was comparable with higher-dose regimens. Since there was no significant difference in the incidence of adverse events between the two regimens, appropriate selection of patients and careful monitoring were required in both regimens. More well-designed, large-scale, and longer follow-up period studies were needed to further verify the finding of this analysis.

Severe Graves' disease-associated orbitopathy: A rare case of frontal bone hemangioma

Graves' orbitopathy might be severe, requiring treatment with high-dose glucocorticoids. A lytic bone lesion, malignant lesions, and diseases resulting from bone remodeling processes (eg, Paget's disease) must be excluded by markers and imagery. Outcomes of high-dose glucocorticoids and thyrotoxicosis must be screened and prevented.

The effects of bone metabolism in different methylprednisolone pulse treatments for Graves' ophthalmopathy

The aim of the present study was to analyze the effects of methylprednisolone pulse therapy (MPPT) courses on bone metabolism in patients with Graves' ophthalmopathy (GO). A retrospective analysis of 45 patients with moderate-to-severe active GO who received 1 or 2 courses of MPPT was performed. Of these, 16 patients underwent 2 courses of treatment. Bone metabolic markers and the density of the lumbar spine (L1-4), femoral neck and total hip were measured using a dual-energy X-ray bone density instrument, and the differences in bone metabolism prior to and after treatment were determined for each group and compared. The results indicated that serum I collagen N-terminal peptide (P1NP) and serum β-collagen crosslinked C-terminal peptide (CTX) were markedly decreased after the first pulse of treatment. In those patients who received a second course of MPPT, CTX levels were significantly decreased, but P1NP was not significantly different from the baseline value. CTX and P1NP levels remained unchanged between the first and second course of MPPT; similarly, there were no changes from baseline in 25(OH) vitamin D3 and bone mineral density after the first and second course of MPPT. However, the level of 25(OH) vitamin D3 was significantly elevated after the second course compared with the first course. In conclusion, the side effects of MPPT on bone metabolism were marginal and a second course of MPPT did not worsen bone metabolism. These MPPT regimens may therefore be considered to be a safe and effective treatment option for patients with moderate-to-severe active GO.

Glucocorticoids in Graves' orbitopathy: mechanisms of action and clinical application

BACKGROUND

Graves' orbitopathy (GO) is the most frequent extrathyroidal manifestation of the autoimmune Graves' disease. GO significantly impacts quality of life and has a psycho-social morbidity. Inflammation and swelling of the orbital tissue often leads to proptosis, diplopia, and decrease of visual acuity. Due to the inflammatory background of the disease, glucocorticoids (GC) have been used as a first-line treatment for decades.

METHODS

PubMed and MeSH database were searched for original articles, clinical trials, reviews, and meta-analyses published between 1 January 2000 and 31 March 2020 and pertaining to both the mechanism of action and immunological effects of GC as well as to the treatment of GO by GC. The publications were evaluated according to their setting and study design.

RESULTS

GC act through genomic (trans-activation and trans-repression) and rapid non-genomic mechanisms. GC in general, and the intravenous (IV) administration of GC in particular, markedly decrease the activity and number of the most potent antigen-presenting dendritic cells. According to the internationally acknowledged European Thyroid Association Guidelines for the management of GO, weekly IVGC application over 12 weeks is recommended as first-line treatment for patients with active and severe GO. The daily and cumulative dose should be tailored according to clinical severity, for example, 4.5 g of IV methylprednisolone for the inflammatory component versus 7.5 g in the presence of diplopia and severe proptosis. Fast and significant improvements in orbital symptoms and signs are noted in 65-70% of patients. Long-term experience over decades, and worldwide availability at low cost, underline the clinical and therapeutic relevance of GC. Adverse events are rarely severe, dose-dependent, and usually reversible, hence easy to handle by medical investigators. Oral GC application on a daily basis is characterized by high bioavailability but reduced efficacy and increased toxicity.

CONCLUSION

IVGC still represents the standard of care in active/severe GO. Innovative biologicals, like monoclonal antibodies targeting the thyrotropin/Insulin-like growth factor-1 receptors or pro-inflammatory cytokines (e.g., Interleukin-6) should be compared with standard GC treatment with respect to short- and long-term efficacy, safety, costs, and global availability.