1
|
Wolstenhulme F, Bibby I, Cole M, Grixti L, McGregor N, Bradley P, Maier RH, Walker J, Pearce SH, Wason J. Graves-PCD: protocol for a randomised, dose-finding, adaptive trial of the plasma cell-depleting agent daratumumab in severe Graves' disease. BMJ Open 2024; 14:e079158. [PMID: 38866568 PMCID: PMC11177693 DOI: 10.1136/bmjopen-2023-079158] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/23/2023] [Accepted: 05/31/2024] [Indexed: 06/14/2024] Open
Abstract
INTRODUCTION Severe Graves' disease is a life-changing condition with poor outcomes from currently available treatments. It is caused by directly pathogenic thyroid-stimulating hormone receptor-stimulating antibodies (TRAb), which are secreted from plasma cells. The human anti-CD38 monoclonal antibody daratumumab was developed to target plasma cells which express high levels of CD38, and is currently licensed for treatment of the plasma cell malignancy, myeloma. However, it can also deplete benign plasma cells with the potential to reduce TRAb and alter the natural history of severe Graves' disease. This study aims to establish proof of concept that daratumumab has efficacy in patients with severe Graves' disease and will provide important data to inform a choice of dosing regimen for subsequent trials. METHODS AND ANALYSIS The Graves-PCD trial aims to determine if daratumumab modulates the humoral immune response in patients with severe Graves' disease, and if so, over what time period, and to find an optimal dose. It is a single-blinded, randomised, dose-finding, adaptive trial using four different doses of daratumumab or placebo in 30 adult patients. Part 1 of the trial is dose-finding and, following an interim analysis, in part 2, the remaining patients will be randomised between the chosen dose(s) from the interim analysis or placebo. The primary outcome is the percentage change in serum TRAb from baseline to 12 weeks. ETHICS AND DISSEMINATION The trial received a favourable ethical opinion from London-Hampstead Research Ethics Committee (reference 21/LO/0449). The results of this trial will be disseminated at international meetings, in the peer-reviewed literature and through partner patient group newsletters and presentations at patient education events. TRIAL REGISTRATION NUMBER ISRCTN81162400.
Collapse
Affiliation(s)
- Faye Wolstenhulme
- Newcastle Clinical Trials Unit, Newcastle University, Newcastle upon Tyne, UK
| | - Irena Bibby
- Newcastle Clinical Trials Unit, Newcastle University, Newcastle upon Tyne, UK
| | - Michael Cole
- Population Health Sciences Institute, Newcastle University, Newcastle upon Tyne, UK
| | - Lydia Grixti
- Translational and Clinical Research Institute, Faculty of Medical Sciences, Biomedicine West, International Centre for Life, Newcastle University, Newcastle upon Tyne, UK
| | - Naomi McGregor
- Newcastle Clinical Trials Unit, Newcastle University, Newcastle upon Tyne, UK
| | - Penny Bradley
- Pharmacy Clinical Trials, Newcastle upon Tyne Hospitals NHS Foundation Trust, Newcastle upon Tyne, UK
| | - Rebecca H Maier
- Newcastle Clinical Trials Unit, Newcastle University, Newcastle upon Tyne, UK
| | - Jenn Walker
- Newcastle Clinical Trials Unit, Newcastle University, Newcastle upon Tyne, UK
| | - Simon H Pearce
- Translational and Clinical Research Institute, Faculty of Medical Sciences, Biomedicine West, International Centre for Life, Newcastle University, Newcastle upon Tyne, UK
| | - James Wason
- Population Health Sciences Institute, Newcastle University, Newcastle upon Tyne, UK
| |
Collapse
|
2
|
Rajabi MT, Rafizadeh SM, Ghahvehchian H. Exploring the Use of ChatGPT in Delivering Evidence-Based Information to Patients with Thyroid Eye Disease. Ophthalmic Plast Reconstr Surg 2024; 40:113-115. [PMID: 37995146 DOI: 10.1097/iop.0000000000002468] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2023]
|
3
|
Smith TJ, Hegedüs L, Lesser I, Perros P, Dorris K, Kinrade M, Troy-Ott P, Wuerth L, Nori M. How patients experience thyroid eye disease. Front Endocrinol (Lausanne) 2023; 14:1283374. [PMID: 38027128 PMCID: PMC10665908 DOI: 10.3389/fendo.2023.1283374] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/25/2023] [Accepted: 10/20/2023] [Indexed: 12/01/2023] Open
Abstract
Objective To determine the impact of thyroid eye disease (TED) on patients in various stages of the disease. Background TED is a debilitating and potentially sight-threatening inflammatory autoimmune disease that is frequently misdiagnosed. Challenging quality-of-life (QoL) issues can persist long after the active phase of disease has subsided. Methods A 62-question survey was designed as a hypothesis-generating instrument to identify key issues confronting patients ≥18 years old with physician-diagnosed TED. Questions focused primarily on physical and emotional status, and QoL experiences in the 2 months prior to the survey. Data for individual questions are presented as summary statistics. Correlations between questions were determined using χ2 analyses. Results The 443 respondents were 18 to >80 years old; >90% female, and >80% from the United States. Time since TED diagnosis ranged from <1 year to >10 years. Participants provided >500 free-form responses describing experiences of living with TED. Physical signs/symptoms were experienced by 307/443 (69%) patients. Of those responding to the QoL questions (N = 394), 53 (13%) reported symptoms improving, 73 (19%) reported symptoms worsening, and 255 (65%) reported no change in the 2 months prior to the survey. The most bothersome signs/symptoms were dry/gritty eyes, light sensitivity, bulging eyes, and pressure or pain behind the eyes. Respondents <60 years were significantly (p < 0.0001) more likely to report symptomatic TED than older patients. Of 394 respondents, 179 (45%) reported feeling depressed and/or anxious, 174 (44%) reported concern about their appearance, and 73 (19%) avoided public situations; 192 (49%) reported declines in confidence or feelings of general well-being, and 78 (20%) reported an inability to achieve goals. Activities limited by TED included reading, driving, and socializing. The proportion of respondents experiencing these negative QoL measures was higher when patients reported experiencing >5 symptoms, had been diagnosed within the last 5 years, or were <60 years of age. Conclusions Physical manifestations of TED impact QoL for patients through all phases of the disease. It is essential that physicians and healthcare professionals become more familiar with patient experiences such as those described here to better help patients manage their disease.
Collapse
Affiliation(s)
- Terry J. Smith
- Kellogg Eye Center, Department of Ophthalmology and Visual Sciences and Department of Internal Medicine, University of Michigan Medical School, Ann Arbor, MI, United States
| | - Laszlo Hegedüs
- Department of Endocrinology, Odense University Hospital, Odense, Denmark
| | - Ira Lesser
- Department of Psychiatry, Harbor-UCLA Medical Center, Torrance, CA, United States
| | - Petros Perros
- Institute of Translational and Clinical Research, Newcastle University, Newcastle upon Tyne, United Kingdom
| | - Kimberly Dorris
- Graves’ Disease and Thyroid Foundation, Rancho Santa Fe, CA, United States
| | - Michele Kinrade
- Scientific Solutions, RareLife Solutions, Inc., Westport, CT, United States
| | - Patti Troy-Ott
- Scientific Solutions, RareLife Solutions, Inc., Westport, CT, United States
| | - Laura Wuerth
- Scientific Solutions, RareLife Solutions, Inc., Westport, CT, United States
| | - Mukund Nori
- Scientific Solutions, RareLife Solutions, Inc., Westport, CT, United States
| |
Collapse
|
4
|
Karlin J, Gai L, LaPierre N, Danesh K, Farajzadeh J, Palileo B, Taraszka K, Zheng J, Wang W, Eskin E, Rootman D. Ensemble neural network model for detecting thyroid eye disease using external photographs. Br J Ophthalmol 2023; 107:1722-1729. [PMID: 36126104 DOI: 10.1136/bjo-2022-321833] [Citation(s) in RCA: 11] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2022] [Accepted: 08/22/2022] [Indexed: 11/03/2022]
Abstract
PURPOSE To describe an artificial intelligence platform that detects thyroid eye disease (TED). DESIGN Development of a deep learning model. METHODS 1944 photographs from a clinical database were used to train a deep learning model. 344 additional images ('test set') were used to calculate performance metrics. Receiver operating characteristic, precision-recall curves and heatmaps were generated. From the test set, 50 images were randomly selected ('survey set') and used to compare model performance with ophthalmologist performance. 222 images obtained from a separate clinical database were used to assess model recall and to quantitate model performance with respect to disease stage and grade. RESULTS The model achieved test set accuracy of 89.2%, specificity 86.9%, recall 93.4%, precision 79.7% and an F1 score of 86.0%. Heatmaps demonstrated that the model identified pixels corresponding to clinical features of TED. On the survey set, the ensemble model achieved accuracy, specificity, recall, precision and F1 score of 86%, 84%, 89%, 77% and 82%, respectively. 27 ophthalmologists achieved mean performance of 75%, 82%, 63%, 72% and 66%, respectively. On the second test set, the model achieved recall of 91.9%, with higher recall for moderate to severe (98.2%, n=55) and active disease (98.3%, n=60), as compared with mild (86.8%, n=68) or stable disease (85.7%, n=63). CONCLUSIONS The deep learning classifier is a novel approach to identify TED and is a first step in the development of tools to improve diagnostic accuracy and lower barriers to specialist evaluation.
Collapse
Affiliation(s)
- Justin Karlin
- Division of Orbital and Ophthalmic Plastic Surgery, Stein and Doheny Eye Institutes, University of California, Los Angeles, CA, USA
| | - Lisa Gai
- Department of Computer Science, University of California, Los Angeles, California, USA
| | - Nathan LaPierre
- Department of Computer Science, University of California, Los Angeles, California, USA
| | - Kayla Danesh
- Division of Orbital and Ophthalmic Plastic Surgery, Stein and Doheny Eye Institutes, University of California, Los Angeles, CA, USA
| | - Justin Farajzadeh
- Division of Orbital and Ophthalmic Plastic Surgery, Stein and Doheny Eye Institutes, University of California, Los Angeles, CA, USA
| | - Bea Palileo
- Division of Orbital and Ophthalmic Plastic Surgery, Stein and Doheny Eye Institutes, University of California, Los Angeles, CA, USA
| | - Kodi Taraszka
- Department of Computer Science, University of California, Los Angeles, California, USA
| | - Jie Zheng
- Department of Computer Science, University of California, Los Angeles, California, USA
| | - Wei Wang
- Department of Computer Science, University of California, Los Angeles, California, USA
| | - Eleazar Eskin
- Department of Computer Science, University of California, Los Angeles, California, USA
- Department of Human Genetics, University of California, Los Angeles, California, USA
| | - Daniel Rootman
- Division of Orbital and Ophthalmic Plastic Surgery, Stein and Doheny Eye Institutes, University of California, Los Angeles, CA, USA
| |
Collapse
|
5
|
Lee S, Yu J, Kim Y, Kim M, Lew H. Application of an Interpretable Machine Learning for Estimating Severity of Graves’ Orbitopathy Based on Initial Finding. J Clin Med 2023; 12:jcm12072640. [PMID: 37048722 PMCID: PMC10095042 DOI: 10.3390/jcm12072640] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/10/2023] [Revised: 03/15/2023] [Accepted: 03/27/2023] [Indexed: 04/05/2023] Open
Abstract
(1) Background: We constructed scores for moderate-to-severe and muscle-predominant types of Graves’ orbitopathy (GO) risk prediction based on initial ophthalmic findings. (2) Methods: 400 patients diagnosed with GO and followed up at both endocrinology and ophthalmology clinics with at least 6 months of follow-up. The Score for Moderate-to-Severe type of GO risk Prediction (SMSGOP) and the Score for Muscle-predominant type of GO risk Prediction (SMGOP) were constructed using the machine learning-based automatic clinical score generation algorithm. (3) Results: 55.3% were classified as mild type and 44.8% were classified as moderate-to-severe type. In the moderate-to-severe type group, 32.3% and 12.5% were classified as fat-predominant and muscle-predominant type, respectively. SMSGOP included age, central diplopia, thyroid stimulating immunoglobulin, modified NOSPECS classification, clinical activity score and ratio of the inferior rectus muscle cross-sectional area to total orbit in initial examination. SMGOP included age, central diplopia, amount of eye deviation, serum FT4 level and the interval between diagnosis of GD and GO in initial examination. Scores ≥46 and ≥49 had predictive value, respectively. (4) Conclusions: This is the first study to analyze factors in initial findings that can predict the severity of GO and to construct scores for risk prediction for Korean. We set the predictive scores using initial findings.
Collapse
Affiliation(s)
- Seunghyun Lee
- Department of Ophthalmology, Konyang University, Kim’s Eye Hospital, Myung-Gok Eye Research Institute, Seoul 07301, Republic of Korea
| | - Jaeyong Yu
- Department of Biomedical System Informatics, Yonsei University College of Medicine, Seoul 03722, Republic of Korea
| | - Yuri Kim
- Department of Ophthalmology, Bundang CHA Medical Center, CHA University, Seongnam 13496, Republic of Korea
| | - Myungjin Kim
- Department of Ophthalmology, Bundang CHA Medical Center, CHA University, Seongnam 13496, Republic of Korea
| | - Helen Lew
- Department of Ophthalmology, Bundang CHA Medical Center, CHA University, Seongnam 13496, Republic of Korea
| |
Collapse
|
6
|
Burch HB, Perros P, Bednarczuk T, Cooper DS, Dolman PJ, Leung AM, Mombaerts I, Salvi M, Stan MN. Management of Thyroid Eye Disease: A Consensus Statement by the American Thyroid Association and the European Thyroid Association. Thyroid 2022; 32:1439-1470. [PMID: 36480280 PMCID: PMC9807259 DOI: 10.1089/thy.2022.0251] [Citation(s) in RCA: 44] [Impact Index Per Article: 22.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
Thyroid eye disease (TED) remains challenging for clinicians to evaluate and manage. Novel therapies have recently emerged, and their specific roles are still being determined. Most patients with TED develop eye manifestations while being treated for hyperthyroidism and under the care of endocrinologists. Endocrinologists, therefore, have a key role in diagnosis, initial management, and selection of patients who require referral to specialist care. Given that the need for guidance to endocrinologists charged with meeting the needs of patients with TED transcends national borders, and to maximize an international exchange of knowledge and practices, the American Thyroid Association and European Thyroid Association joined forces to produce this consensus statement.
Collapse
Affiliation(s)
- Henry B. Burch
- National Institute of Diabetes and Digestive and Kidney Diseases, National Institutes of Health, Bethesda, Maryland, USA
- Department of Medicine, Uniformed Services University of the Health Sciences, Bethesda, Maryland, USA
- Endocrinology Division, Department of Medicine, Walter Reed National Military Medical Center, Bethesda, Maryland, USA
- Address correspondence to: Henry B. Burch, MD, National Institute of Diabetes and Digestive and Kidney Diseases, Division of Diabetes, Endocrinology, & Metabolic Diseases, National Institutes of Health, 6707 Democracy Blvd, Room 5053, Bethesda, MD 20892-0001, USA
| | - Petros Perros
- Department of Endocrinology, Leazes Wing, Royal Victoria Infirmary, Newcastle upon Tyne, United Kingdom
| | - Tomasz Bednarczuk
- Department of Internal Medicine and Endocrinology, Medical University of Warsaw, Warsaw, Poland
| | - David S. Cooper
- Department of Medicine, Division of Endocrinology, Diabetes, and Metabolism, The Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Peter J. Dolman
- Department of Ophthalmology and Visual Sciences, University of British Columbia, Vancouver, Canada
| | - Angela M. Leung
- Division of Endocrinology, Diabetes, and Metabolism, Department of Medicine, UCLA David Geffen School of Medicine, VA Greater Los Angeles Healthcare System, Los Angeles, California, USA
| | - Ilse Mombaerts
- Department of Ophthalmology, University Hospitals Leuven, Leuven, Belgium
| | - Mario Salvi
- Department of Clinical and Community Services, Graves' Orbitopathy Center, Endocrinology, Fondazione IRCCS Cà Granda, Milan, Italy
| | - Marius N. Stan
- Division of Endocrinology, Diabetes and Metabolism, Mayo Clinic, Rochester, Minnesota, USA
| |
Collapse
|
7
|
Burch HB, Perros P, Bednarczuk T, Cooper DS, Dolman PJ, Leung AM, Mombaerts I, Salvi M, Stan MN. Management of thyroid eye disease: a Consensus Statement by the American Thyroid Association and the European Thyroid Association. Eur Thyroid J 2022; 11:e220189. [PMID: 36479875 PMCID: PMC9727317 DOI: 10.1530/etj-22-0189] [Citation(s) in RCA: 12] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/19/2022] [Accepted: 10/19/2022] [Indexed: 11/30/2022] Open
Abstract
Thyroid eye disease (TED) remains challenging for clinicians to evaluate and manage. Novel therapies have recently emerged, and their specific roles are still being determined. Most patients with TED develop eye manifestations while being treated for hyperthyroidism and under the care of endocrinologists. Endocrinologists, therefore, have a key role in diagnosis, initial management, and selection of patients who require referral to specialist care. Given that the need for guidance to endocrinologists charged with meeting the needs of patients with TED transcends national borders, and to maximize an international exchange of knowledge and practices, the American Thyroid Association and European Thyroid Association joined forces to produce this Consensus Statement.
Collapse
Affiliation(s)
- Henry B Burch
- National Institute of Diabetes and Digestive and Kidney Diseases, National Institutes of Health, Bethesda, Maryland, USA
- Department of Medicine, Uniformed Services University of the Health Sciences, Bethesda, Maryland, USA
- Endocrinology Division, Department of Medicine, Walter Reed National Military Medical Center, Bethesda, Maryland, USA
| | - Petros Perros
- Department of Endocrinology, Leazes Wing, Royal Victoria Infirmary, Newcastle upon Tyne, United Kingdom
| | - Tomasz Bednarczuk
- Department of Internal Medicine and Endocrinology, Medical University of Warsaw, Warsaw, Poland
| | - David S Cooper
- Division of Endocrinology, Diabetes, and Metabolism, Department of Medicine, The Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Peter J Dolman
- Department of Ophthalmology and Visual Sciences, University of British Columbia, Vancouver, Canada
| | - Angela M Leung
- Division of Endocrinology, Diabetes, and Metabolism, Department of Medicine, UCLA David Geffen School of Medicine, VA Greater Los Angeles Healthcare System, Los Angeles, California, USA
| | - Ilse Mombaerts
- Department of Ophthalmology, University Hospitals Leuven, Leuven, Belgium
| | - Mario Salvi
- Department of Clinical and Community Services, Graves’ Orbitopathy Center, Endocrinology, Fondazione IRCCS Cà Granda, Milan, Italy
| | - Marius N Stan
- Division of Endocrinology, Diabetes and Metabolism, Mayo Clinic, Rochester, Minnesota, USA
| |
Collapse
|
8
|
Brito JP, Nagy EV, Singh Ospina N, Zˇarković M, Dosiou C, Fichter N, Lucarelli MJ, Hegedüs L. A Survey on the Management of Thyroid Eye Disease Among American and European Thyroid Association Members. Thyroid 2022; 32:1535-1546. [PMID: 35946071 DOI: 10.1089/thy.2022.0172] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/09/2023]
Abstract
Background: The thyroid eye disease (TED) treatment landscape is rapidly evolving. How new treatment options have impacted practice is unknown. Methods: We conducted a cross-sectional electronic survey of American and European Thyroid Association members between June 2 and June 30, 2021. The survey included TED questions about resources for its management, index cases for different severities and presentations of TED, barriers for the management of TED, and participants' concerns about TED. We classified respondents into three geographic categories: North America, Europe, or other regions. Results: Two hundred fifty-two eligible participants started the survey (15% response rate), and 227 completed it. Participants were mostly men (50.2%, 114/227), white (79.7%, 181/227), endocrinologists with a thyroid focus (66.1%, 150/227), practicing in a tertiary academic center (46.7%, 106/227), caring for 10 or more TED patients over the last 12 months (40.5%, 92/227), and reported not having a multidisciplinary TED clinic in their institution (52.8%, 120/227). The majority reported that new TED cases per annum have not changed in the past 10 years (47.5%, 108/227), and that TED patients are found in practice during the management of hyperthyroidism (41.8%, 95/227). For mild active TED, participants from Europe reported a higher use of selenium (73%[96/132] vs. 32%[20/62] of respondents from North America and 24%[8/33] of respondents from other regions). For moderate-to-severe active TED, there was a modest preference for teprotumumab as first-line therapy (37%, 23/62) among North American participants and intravenous (IV) steroids (73%[96/132], and 42%[14/33]) for participants from Europe and other regions, respectively. These treatment preferences did not change in patients with moderate-to-severe active TED with poorly controlled diabetes. In contrast, participants from the three geographic categories preferred IV steroids for optic neuropathy and women planning pregnancy. The three top "very important" concerns about TED management according to participants were: the cost of TED treatment (31.3%, 71/227), lack of effective TED treatments (19.8%, 45/227), and difficulty in predicting whether TED will develop (18.9%, 43/227). Conclusions: There is a marked geographic practice variation in the management of TED. Clinicians' concerns about TED management demand ongoing research on more effective treatment, TED predictive tools, and policy changes to improve the affordability of new TED therapies.
Collapse
Affiliation(s)
- Juan P Brito
- Division of Endocrinology, Diabetes, Metabolism, Nutrition, Department of Internal Medicine, Mayo Clinic, Rochester, Minnesota, USA
| | - Endre V Nagy
- Division of Endocrinology, Department of Medicine, Faculty of Medicine, University of Debrecen, Debrecen, Hungary
| | - Naykky Singh Ospina
- Division of Endocrinology, Department of Medicine, University of Florida, Gainesville, Florida
| | | | - Chrysoula Dosiou
- Division of Endocrinology, Department of Medicine, Stanford University School of Medicine, Stanford, California, USA
| | - Nicole Fichter
- ADMEDICO Orbital Centre, Olten and University Eye Department, Basel, Switzerland
| | - Mark J Lucarelli
- Oculoplastic, Facial Cosmetic and Orbital Surgery, Department of Ophthalmology and Visual Sciences, University of Wisconsin-Madison, Madison, Wisconsin, USA
| | - Laszlo Hegedüs
- Department of Endocrinology, Odense University Hospital, University of Southern Denmark, Odense C, Denmark
| |
Collapse
|
9
|
Abstract
Graves' orbitopathy (GO) is an orbital autoimmune disorder and the main extrathyroidal manifestation of Graves' disease, the most common cause of hyperthyroidism. GO affects about 30% of Graves' patients, although fewer than 10% have severe forms requiring immunosuppressive treatments. Management of GO requires a multidisciplinary approach. Medical therapies for active moderate-to-severe forms of GO (traditionally, high-dose glucocorticoids) often provide unsatisfactory results, and subsequently surgeries are often needed to cure residual manifestations. The aim of this review is to provide an updated overview of current concepts regarding the epidemiology, pathogenesis, assessment, and treatment of GO, and to present emerging targeted therapies and therapeutic perspectives. Original articles, clinical trials, systematic reviews, and meta-analyses from 1980 to 2021 were searched using the following terms: Graves' disease, Graves' orbitopathy, thyroid eye disease, glucocorticoids, orbital radiotherapy, rituximab, cyclosporine, azathioprine, teprotumumab, TSH-receptor antibody, smoking, hyperthyroidism, hypothyroidism, thyroidectomy, radioactive iodine, and antithyroid drugs. Recent studies suggest a secular trend toward a milder phenotype of GO. Standardized assessment at a thyroid eye clinic allows for a better general management plan. Treatment of active moderate-to-severe forms of GO still relies in most cases on high-dose systemic-mainly intravenous-glucocorticoids as monotherapy or in combination with other therapies-such as mycophenolate, cyclosporine, azathioprine, or orbital radiotherapy-but novel biological agents-including teprotumumab, rituximab, and tocilizumab-have achieved encouraging results.
Collapse
Affiliation(s)
- Luigi Bartalena
- Department of Medicine and SurgeryUniversity of InsubriaVareseItaly
| | | |
Collapse
|
10
|
Automated detection of enlarged extraocular muscle in Graves' ophthalmopathy with computed tomography and deep neural network. Sci Rep 2022; 12:16036. [PMID: 36163451 PMCID: PMC9512911 DOI: 10.1038/s41598-022-20279-4] [Citation(s) in RCA: 11] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/04/2022] [Accepted: 09/12/2022] [Indexed: 11/17/2022] Open
Abstract
This study aimed to develop a diagnostic software system to evaluate the enlarged extraocular muscles (EEM) in patients with Graves’ ophthalmopathy (GO) by a deep neural network.This prospective observational study involved 371 participants (199 EEM patients with GO and 172 controls with normal extraocular muscles) whose extraocular muscles were examined with orbital coronal computed tomography. When at least one rectus muscle (right or left superior, inferior, medial, or lateral) in the patients was 4.0 mm or larger, it was classified as an EEM patient with GO. We used 222 images of the data from patients as the training data, 74 images as the validation test data, and 75 images as the test data to “train” the deep neural network to judge the thickness of the extraocular muscles on computed tomography. We then validated the performance of the network. In the test data, the area under the curve was 0.946 (95% confidence interval (CI) 0.894–0.998), and receiver operating characteristic analysis demonstrated 92.5% (95% CI 0.796–0.984) sensitivity and 88.6% (95% CI 0.733–0.968) specificity. The results suggest that the deep learning system with the deep neural network can detect EEM in patients with GO.
Collapse
|
11
|
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.
Collapse
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
| |
Collapse
|
12
|
Huang X, Ju L, Li J, He L, Tong F, Liu S, Li P, Zhang Y, Wang X, Yang Z, Xiong J, Wang L, Zhao X, He W, Huang Y, Ge Z, Yao X, Yang W, Wei R. An Intelligent Diagnostic System for Thyroid-Associated Ophthalmopathy Based on Facial Images. Front Med (Lausanne) 2022; 9:920716. [PMID: 35755054 PMCID: PMC9226318 DOI: 10.3389/fmed.2022.920716] [Citation(s) in RCA: 13] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/15/2022] [Accepted: 05/25/2022] [Indexed: 11/22/2022] Open
Abstract
Background Thyroid-associated ophthalmopathy (TAO) is one of the most common orbital diseases that seriously threatens visual function and significantly affects patients’ appearances, rendering them unable to work. This study established an intelligent diagnostic system for TAO based on facial images. Methods Patient images and data were obtained from medical records of patients with TAO who visited Shanghai Changzheng Hospital from 2013 to 2018. Eyelid retraction, ocular dyskinesia, conjunctival congestion, and other signs were noted on the images. Patients were classified according to the types, stages, and grades of TAO based on the diagnostic criteria. The diagnostic system consisted of multiple task-specific models. Results The intelligent diagnostic system accurately diagnosed TAO in three stages. The built-in models pre-processed the facial images and diagnosed multiple TAO signs, with average areas under the receiver operating characteristic curves exceeding 0.85 (F1 score >0.80). Conclusion The intelligent diagnostic system introduced in this study accurately identified several common signs of TAO.
Collapse
Affiliation(s)
- Xiao Huang
- Department of Ophthalmology, Changzheng Hospital, Naval Medical University, Shanghai, China
| | - Lie Ju
- Airdoc LLC, Beijing, China.,Faculty of Engineering, Monash University, Clayton, VIC, Australia
| | - Jian Li
- Department of Ophthalmology, Changzheng Hospital, Naval Medical University, Shanghai, China
| | - Linfeng He
- Department of Ophthalmology, Changzheng Hospital, Naval Medical University, Shanghai, China
| | - Fei Tong
- Department of Ophthalmology, Changzheng Hospital, Naval Medical University, Shanghai, China
| | - Siyu Liu
- Department of Ophthalmology, Changzheng Hospital, Naval Medical University, Shanghai, China.,Department of Ophthalmology, Naval Medical Center of the People's Liberation Army, Naval Medical University, Shanghai, China
| | - Pan Li
- Department of Ophthalmology, Changzheng Hospital, Naval Medical University, Shanghai, China
| | - Yun Zhang
- Department of Ophthalmology, Changzheng Hospital, Naval Medical University, Shanghai, China
| | | | | | | | | | | | | | | | - Zongyuan Ge
- Airdoc LLC, Beijing, China.,Faculty of Engineering, Monash University, Clayton, VIC, Australia
| | | | - Weihua Yang
- The Laboratory of Artificial Intelligence and Bigdata in Ophthalmology, The Affiliated Eye Hospital of Nanjing Medical University, Nanjing, China
| | - Ruili Wei
- Department of Ophthalmology, Changzheng Hospital, Naval Medical University, Shanghai, China
| |
Collapse
|
13
|
Cockerham KP, Padnick-Silver L, Stuertz N, Francis-Sedlak M, Holt RJ. Quality of Life in Patients with Chronic Thyroid Eye Disease in the United States. Ophthalmol Ther 2021; 10:975-987. [PMID: 34478126 PMCID: PMC8589903 DOI: 10.1007/s40123-021-00385-8] [Citation(s) in RCA: 25] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/12/2021] [Accepted: 08/09/2021] [Indexed: 12/20/2022] Open
Abstract
INTRODUCTION Thyroid eye disease (TED) is an autoimmune condition producing ocular pain, dysmotility, and ocular structure and function changes. As disease activity changes, redness, swelling, and pain can improve, but eye comfort, appearance, and motility alterations often persist. There are limited data on chronic TED patient-reported outcomes. This study examined chronic US TED patient-reported symptoms and quality of life (QOL). METHODS Existing data from an online survey regarding chronic TED signs/symptoms and patient QOL were retrospectively examined. The Graves' Ophthalmopathy QOL instrument (GO-QOL; 0-100, 100 = highest QOL) evaluated overall, appearance, and vision-related QOL. Influencing factors were examined by stratifying patients into low (overall QOL ≤ 50), moderate (> 50 and < 75), and high (≥ 75) QOL categories. RESULTS One hundred patients (47 women, 81 Caucasian, 45.2 ± 7.6 years) were included. The duration of inactive TED was 3.0 ± 4.6 years and total duration of TED was 5.8 ± 5.9 years. Patients reported an average of 20 doctor visits/year and high prevalence of anxiety (34%) and depression (28%). Prior TED treatments for the polled population included systemic corticosteroids during active TED (25%), orbital radiation (5%), and surgery (25%). The overall GO-QOL score was 60.5 ± 21.8 (vision-related: 58.6 ± 24.0, appearance-related: 62.3 ± 25.1). Patients with low QOL more frequently reported hypothyroidism, anxiety, and a larger number of chronic TED signs/symptoms (average: 4.2). Compared to high QOL patients, low QOL patients had more pain (39% vs. 13%), blurry vision (30% vs. 17%), and diplopia (27% vs. 3%, all p ≤ 0.025). Additionally, the low QOL group more often had TED-specific surgical history (45% vs. 10%, p = 0.002), more often reported disability/unemployment (21% vs. 3%, p = 0.055), and had a higher number of doctor visits (40 vs. 5 visits/person/year, p < 0.001). CONCLUSION TED severely impacts patient QOL, despite becoming stable and chronic. Patients reported vision and appearance impairment and psychosocial impact long after acute TED had subsided.
Collapse
Affiliation(s)
- Kimberly P. Cockerham
- Central Valley Eye Medical Group, 36 W Yokuts Avenue, Suite 2, Stockton, CA 95207 USA
- Department of Ophthalmology, Stanford School of Medicine, 2454 Watson Court, Palo Alto, CA 94303 USA
| | | | - Noel Stuertz
- Horizon Therapeutics plc, 1 Horizon Way, Deerfield, IL 60015 USA
| | | | - Robert J. Holt
- Horizon Therapeutics plc, 1 Horizon Way, Deerfield, IL 60015 USA
| |
Collapse
|
14
|
Douglas RS, Wang Y, Dailey RA, Harris GJ, Wester ST, Schiffman JS, Tang RA, Fowler B, Fleming J, Smith TJ. Teprotumumab in Clinical Practice: Recommendations and Considerations From the OPTIC Trial Investigators. J Neuroophthalmol 2021; 41:461-468. [PMID: 33417417 PMCID: PMC8584196 DOI: 10.1097/wno.0000000000001134] [Citation(s) in RCA: 17] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND Thyroid eye disease (TED) is a vision-threatening and debilitating condition that until very recently had no Food and Drug Administration (FDA)-approved medical therapies. Teprotumumab has recently been approved to treat TED. We aim to provide guidance for its use, based on the input of the US investigators who participated in Phase 2 and Phase 3 clinical trials. METHODS An expert panel was convened on October 11th and November 16th of 2019. All panel members had extensive experience as investigators in the Phase 2 and/or Phase 3 clinical trials of teprotumumab. Consensus among those investigators was reached to determine patient characteristics most appropriate for teprotumumab treatment. Safety guidelines were also reviewed and agreed on. RESULTS The authors recommend that teprotumumab be considered first-line therapy for patients with clinically significant ophthalmopathy, including those with disease duration exceeding 9 months. The clinical activity score (CAS) may be useful for longitudinal monitoring but should not be used to determine treatment eligibility. Criteria will likely be expanded after more experience with the drug. Using teprotumumab for patients with TED with substantial signs, symptoms, or morbidity without a CAS score of >4 (e.g., progressive proptosis, diplopia, and early compressive optic neuropathy) or more, could be considered. Diabetes mellitus and inflammatory bowel disease comorbidities should not be exclusionary, but stringent monitoring in these patients is recommended. Drug dosing, administration interval, and duration should adhere to the study protocol: 8 infusions, separated by 3 weeks. Patients with more severe disease may benefit from additional doses. Corticosteroids can be used before or during teprotumumab therapy. Clinical and laboratory monitoring should be consistent with good clinical practice for patients receiving teprotumumab. CONCLUSIONS Confirming the efficacy of teprotumumab usage outside the narrow parameters of the completed clinical trials will require rigorous scientific validation. As a step in that direction, we believe its on-label usage is appropriately applied to all patients with TED with substantial symptoms or morbidity, as judged by their physician.
Collapse
Affiliation(s)
- Raymond S Douglas
- Department of Surgery (RSD, YW), Division of Ophthalmology, Cedars Sinai Medical Center, Los Angeles, California; State Key Laboratory of Ophthalmology (RSD), Zhongshan Ophthalmic Center, Sun Yat-sen University, Guangzhou, China; Department of Ophthalmology (RAD), Casey Eye Institute, Portland, Oregon; Department of Ophthalmology (GJH), Medical College of Wisconsin, Milwaukee, Wisconsin; Bascom Palmer Eye Institute (STW), University of Miami, Miami, Florida; Eye Wellness Center-Neuro-Eye Clinical Trials (JSS, RAT), Inc, Houston, Texas; Hamilton Eye Institute (BF, JF), University of Tennessee Health Science Center, Memphis, Tennessee; and Department of Ophthalmology and Visual Sciences (TJS), Kellogg Eye Center, and Division of Metabolism, Endocrinology and Diabetes, University of Michigan Medical School, Ann Arbor, Michigan
| | | | | | | | | | | | | | | | | | | |
Collapse
|
15
|
Abstract
Thyroid eye disease (TED) is a complex inflammatory disease that can have a long clinical course with sight-threatening and debilitating ocular sequelae. Until recently, there were limited therapeutic options available. In the last decade we have gained a deeper understanding of the underlying pathophysiology, which has led to the development of novel effective targeted therapies. This article discusses the challenges encountered in the clinical evaluation and treatment of TED patients, with the goal to empower endocrinologists and ophthalmologists to work together to provide effective multidisciplinary care. We will review recommendations of past clinical guidelines around evaluation and management of TED patients, discuss the randomized controlled trials of new biologic therapies, and explore how to navigate the emerging therapeutic landscape.
Collapse
Affiliation(s)
- Chrysoula Dosiou
- Division of Endocrinology, Stanford University School of Medicine, Stanford, California 94305, USA
| | - Andrea Lora Kossler
- Department of Ophthalmology, Stanford University School of Medicine, Stanford, California 94305, USA
| |
Collapse
|
16
|
Thyroid eye disease: current and potential medical management. Int Ophthalmol 2020; 40:1035-1048. [PMID: 31919775 DOI: 10.1007/s10792-019-01258-7] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/27/2019] [Accepted: 12/28/2019] [Indexed: 12/13/2022]
Abstract
INTRODUCTION Thyroid eye disease (TED) is the most frequent extra-thyroid manifestation of Graves' disease and it is more frequent in middle age and in female gender. Nowadays, the causal mechanisms of this disease are not completely understood, but the current available studies suggest that the main causative factor is the thyroid stimulating hormone receptor. MATERIALS AND METHODS To collect reports on TED medical management, a thorough literature search was performed in PubMed database. An additional search was made in Google Scholar to complete the collected items. RESULTS Among the indentified risk factors, tobacco habit is the most relevant. The main criteria to choose a suitable treatment are the activity and severity of the disease. Support measures can be used to improve the patient's symptoms in any phase of the disease. There is a large number of drugs proposed to manage TED, although with different reported rates of success. CONCLUSIONS Currently, the drugs of choice are corticosteroids in moderate-to-severe and in sight-threatening forms. The main problem of corticosteroids is their spectrum of side effects. Therefore, other alternatives are being suggested for medical management of this disease. The efficacy of these alternatives remains unclear.
Collapse
|
17
|
Lee V, Avari P, Williams B, Perros P, Dayan C. A survey of current practices by the British Oculoplastic Surgery Society (BOPSS) and recommendations for delivering a sustainable multidisciplinary approach to thyroid eye disease in the United Kingdom. Eye (Lond) 2019; 34:1662-1671. [PMID: 31836832 PMCID: PMC7608203 DOI: 10.1038/s41433-019-0664-z] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/26/2019] [Revised: 09/27/2019] [Accepted: 10/14/2019] [Indexed: 12/03/2022] Open
Abstract
Background The Royal College of Physicians (RCP) and Thyroid Eye Disease Amsterdam Declaration Implementation Group (TEAMeD-5) have the common goal of improving access to high quality care for thyroid eye disease (TED). The TEAMeD-5 programme recommends all patients with moderate-to-severe TED should have access to multidisciplinary clinics (MDT) with combined Ophthalmology and Endocrinology expertise. Methods The British Oculoplastic Surgery Society represents oculoplastic surgeons who usually lead TED care in the UK. A two-stage survey of the membership was conducted to ascertain current practice of existing resources. Results Seventy percent (45/65) of respondents in Survey 1 were aware of current RCP guidance, but only 49% (22/45) rated it as a good means of improving access to comprehensive TED service. Sixty percent (39/65) of respondents are working in a multidisciplinary TED clinic with co-location of ophthalmologists and endocrinologists. Care for TED appears not to be provided in a multidisciplinary context in up to 31% (20/65). Thirty five (54%) of the respondents rated their relationship with endocrinology colleagues as good. Best practice guidelines recommend routine quality of life assessments but only 6/28 (21%) of respondents use this modality in current practice. Six percent (4/65) of areas appear not to be using intravenous steroids. In many areas (25%, 16/65), second-line immunosuppression is provided in a different trust and in 8% (5/65), it appears not to be used at all. Conclusion This survey is a ‘snapshot’ of current TED management in the UK and findings suggest scope for improvement. We recommend a framework for more robust collaboration across specialties and propose standards endorsed by multidisciplinary stakeholder societies.
Collapse
Affiliation(s)
- Vickie Lee
- Department of Ophthalmology, Imperial College London NHS Trust, London, UK.
| | - Parizad Avari
- Department of Diabetes and Endocrinology, Imperial College London, London, UK
| | - Ben Williams
- Department of Website Support, MediSites, Bournemouth, UK
| | - Petros Perros
- Department of Endocrinology, Newcastle Upon Tyne Hospitals NHS Foundation Trust, Newcastle Upon Tyne, UK.,TEAMed Thyroid Eye Disease Amsterdam Declaration Implementation Group, Cardiff, UK
| | - Colin Dayan
- TEAMed Thyroid Eye Disease Amsterdam Declaration Implementation Group, Cardiff, UK.,Thyroid Research Group, Cardiff University School of Medicine, Cardiff, UK
| | | |
Collapse
|
18
|
Draman MS, Morris DS, Evans S, Haridas A, Pell J, Greenwood R, Foy C, Taylor P, Pooprasert P, Muller I, Zhang L, Lane C, Okosieme O, Ludgate M, Dayan C. Prostaglandin F2-Alpha Eye Drops (Bimatoprost) in Graves' Orbitopathy: A Randomized Controlled Double-Masked Crossover Trial (BIMA Trial). Thyroid 2019; 29:563-572. [PMID: 30880626 DOI: 10.1089/thy.2018.0506] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
BACKGROUND Previous in vitro experiments have demonstrated that prostaglandin F2-alpha (PF2α) reduced proliferation and adipogenesis in a murine cell line and human orbital fibroblasts derived from subjects with inactive Graves' orbitopathy (GO). The objective of this study was to determine if the PGF2α analogue bimatoprost is effective at reducing proptosis in this population. METHODS A randomized controlled double-masked crossover trial was conducted in a single tertiary care academic medical center. Patients with long-standing, inactive GO but persistent proptosis (>20 mm in at least one eye) were recruited. Allowing for a 15% dropout rate, 31 patients (26 females) were randomized in order to identify a treatment effect of 2.0 mm (p = 0.05; power 0.88). Following informed consent, participants were randomized to receive bimatoprost or placebo for three months, after which they underwent a two-month washout before switching to the opposite treatment. The primary outcome was the change in exophthalmometry readings over the two three-month treatment periods. RESULTS The mean exophthalmometer at baseline was 23.6 mm (range 20.0-30.5 mm), and the mean age of the patients was 55 years (range 28-74 years). The median duration of GO was 7.6 years (interquartile range 3.6-12.3 years). The majority were still suffering from diplopia (61.3%) with bilateral involvement (61.3%). Using multi-level modeling adjusted for baseline, period, and carry-over, bimatoprost resulted in a -0.17 mm (reduction) exophthalmometry change ([confidence interval -0.67 to +0.32]; p = 0.490). There was a mean change in intraocular pressure of -2.7 mmHg ([confidence interval -4.0 to -1.4]; p = 0.0070). One patient showed periorbital fat atrophy on treatment, which resolved on stopping treatment. Independent analysis of proptosis by photographic images (all subjects) and subgroup analysis on monocular disease (n = 12) did not show any apparent benefit. CONCLUSIONS In inactive GO, bimatoprost treatment over a three-month period does not result in an improvement in proptosis.
Collapse
Affiliation(s)
- Mohd Shazli Draman
- 1 Thyroid Research Group, Cardiff University School of Medicine, Cardiff, United Kingdom
- 2 Faculty of Medicine, Universiti Sultan Zainal Abidin, Kuala Terengganu, Malaysia
| | - Daniel S Morris
- 3 Department of Ophthalmology, University Hospital of Wales, Cardiff, United Kingdom
| | - Sam Evans
- 3 Department of Ophthalmology, University Hospital of Wales, Cardiff, United Kingdom
| | - Anjana Haridas
- 3 Department of Ophthalmology, University Hospital of Wales, Cardiff, United Kingdom
| | - Julie Pell
- 1 Thyroid Research Group, Cardiff University School of Medicine, Cardiff, United Kingdom
| | - Rosemary Greenwood
- 4 Research Design Service-South West, University Hospitals Bristol NHS Foundation Trust, Bristol, United Kingdom
| | - Chris Foy
- 5 Gloucestershire Research Support Service, Gloucestershire Royal Hospital, Gloucester, United Kingdom
| | - Peter Taylor
- 1 Thyroid Research Group, Cardiff University School of Medicine, Cardiff, United Kingdom
| | - Pakinee Pooprasert
- 1 Thyroid Research Group, Cardiff University School of Medicine, Cardiff, United Kingdom
| | - Ilaria Muller
- 1 Thyroid Research Group, Cardiff University School of Medicine, Cardiff, United Kingdom
| | - Lei Zhang
- 1 Thyroid Research Group, Cardiff University School of Medicine, Cardiff, United Kingdom
| | - Carol Lane
- 3 Department of Ophthalmology, University Hospital of Wales, Cardiff, United Kingdom
| | - Onyebuchi Okosieme
- 1 Thyroid Research Group, Cardiff University School of Medicine, Cardiff, United Kingdom
| | - Marian Ludgate
- 1 Thyroid Research Group, Cardiff University School of Medicine, Cardiff, United Kingdom
| | - Colin Dayan
- 1 Thyroid Research Group, Cardiff University School of Medicine, Cardiff, United Kingdom
| |
Collapse
|
19
|
Clinical utility of TSH receptor antibody levels in Graves' orbitopathy: a comparison of two TSH receptor antibody immunoassays. Cent Eur J Immunol 2018; 43:405-412. [PMID: 30799988 PMCID: PMC6384424 DOI: 10.5114/ceji.2018.80224] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/09/2018] [Accepted: 05/11/2018] [Indexed: 01/06/2023] Open
Abstract
Introduction Thyroid stimulating hormone (TSH) receptor antibodies (TRAB) play a role in the development of Graves’ orbitopathy (GO), and measurements of the TRAB level may be helpful in monitoring GO treatment. Aim of the study To assess the correlation of TRAB levels measured with two different assays: third-generation TRAB assay (TRAB Cobas) and novel Immulite assay (TRAB Immulite), in patients with moderate-to-severe GO treated with intravenous glucocorticoid pulse therapy (ivGCs). Material and methods Forty patients with active, moderate-to-severe GO underwent clinical and laboratory evaluation before, in the middle, and after ivGCs therapy. The correlation of TRAB levels with GO signs was evaluated. Laboratory and clinical findings were compared according to the response to ivGCs. TRAB concentration was measured with Immulite TSI assay and with Elecsys IMA. Results All patients were TRAB positive in both assays at the beginning of the treatment. The decrease of both TRAB Immulite and Cobas levels in serum during ivGCs was statistically significant. We observed strong correlation between both TRAB levels before and after ivGCs. There was no statistically significant difference in antibody levels between patients with good response and no response to the treatment. We did not find any correlation between antibody levels and GO features before the therapy, but measurements during ivGCs showed comparable correlation of both TRAB levels with GO activity. Conclusions We found similarity between Immulite assay and third-generation TRAB assay in the assessment of patients with GO treated with ivGCs. Both TRAB levels showed comparable correlation with GO activity during ivGCs therapy.
Collapse
|
20
|
Medghalchi A, Akbari M, Alizadeh Y, Moghadam RS. The epidemiological characteristics of patients with thyroid eye disease in a referral center in northern Iran. J Curr Ophthalmol 2018; 30:353-358. [PMID: 30555970 PMCID: PMC6276727 DOI: 10.1016/j.joco.2018.07.001] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/07/2018] [Revised: 06/19/2018] [Accepted: 07/02/2018] [Indexed: 01/09/2023] Open
Abstract
Purpose This study was conducted to determine the demographics, clinical features, severity, and activity of thyroid eye disease (TED) in patients of a referral center in the north of Iran. Methods Patients with TED who were referred to Amir-Almomenin Hospital, Rasht, Iran from March 2012 to March 2014 were enrolled in this cross-sectional study. The measurements of proptosis, lid width, lagophthalmos, extraocular muscle function, and visual acuity were recorded. The activity of ophthalmopathy was scored according to the clinical activity score (CAS). Results TED was diagnosed in 103 patients with a mean age of 42.1 ± 13.91 years. Of those patients, 52.4% were women, and 80% had hyperthyroidism. The mean duration of TED was 36.5 ± 53.12 months. Extraocular muscle involvement (98%) and eyelid retraction (88.3%) were the most common manifestations. Per the CAS results, 86 (83.5%) patients were at stage 0, and there was a significant difference in CAS scores between male and female patients, P = 0.02. Conclusions The characteristics of TED in patients of the studied referral center during a two-year period, including common signs and symptoms, disease duration, treatment, an activity of disease were determined. Notably, many patients in this study had orbital squeal of TED meaning that they had inactive TED. Proper management of this serious complication requires close cooperation between endocrinologists and ophthalmologists to ensure timely referrals for appropriate care.
Collapse
Affiliation(s)
| | - Mitra Akbari
- Eye Research Center, Guilan University of Medical Sciences, Rasht, Iran
| | - Yousef Alizadeh
- Eye Research Center, Guilan University of Medical Sciences, Rasht, Iran
| | | |
Collapse
|
21
|
Esperidião MA, Viera-da-Silva LM. A satisfação do usuário na avaliação de serviços de saúde: ensaio sobre a imposição de problemática. SAÚDE EM DEBATE 2018. [DOI: 10.1590/0103-11042018s223] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
RESUMO Pesquisas de satisfação de usuários encontram-se colocadas atualmente como uma das principais estratégias para a participação, proteção e defesa dos direitos do usuário dos serviços públicos, a despeito da existência de um conjunto de evidências reportadas na literatura internacional há mais de quatro décadas, que questionam a validade de tais abordagens. O presente ensaio tem por objetivo contribuir para a compreensão de alguns aspectos negligenciados sobre o significado dos inquéritos de satisfação do usuário e seus resultados, particularmente sobre o paradoxo da elevada satisfação encontrada como resultado dessas pesquisas. Esse fenômeno será analisado por meio de uma analogia com as sondagens de opinião, discutindo a hipótese de que a elevada satisfação, descrita na literatura, pode representar um artefato de pesquisa decorrente de uma imposição de problemática, no sentido discutido por Bourdieu (1973) e Champagne (1998). As respostas obtidas não correspondem necessariamente a representações sociais ou percepções relativas aos serviços, mas às reações dos usuários à situação de pesquisa, caracterizando-se como uma resposta forçada frente às condições de realização dos inquéritos.
Collapse
|
22
|
Xu L, Li L, Xie C, Guan M, Xue Y. Thickness of Extraocular Muscle and Orbital Fat in MRI Predicts Response to Glucocorticoid Therapy in Graves' Ophthalmopathy. Int J Endocrinol 2017; 2017:3196059. [PMID: 28845157 PMCID: PMC5563423 DOI: 10.1155/2017/3196059] [Citation(s) in RCA: 30] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/03/2017] [Revised: 06/27/2017] [Accepted: 07/17/2017] [Indexed: 12/16/2022] Open
Abstract
33 patients with active, moderate-severe Graves' ophthalmopathy (GO) received 4.5 g methylprednisolone for 12 weeks and were divided by efficacy into two groups (responsive and unresponsive). All patients and 10 controls underwent orbital MRI examination at baseline. No significant difference was seen in baseline clinical characteristics between the two GO groups. The values of exophthalmos were higher in both GO groups than in the control and were higher in the responsive group versus the unresponsive group. Compared to the unresponsive group, the responsive group had a thicker inferior rectus as well as thinner orbital fat. The inferior rectus/fat ratio was significantly higher in the responsive group versus the unresponsive group. Multivariate logistic regression analysis showed that the exophthalmos value and inferior rectus/fat ratio were significantly associated with the response to glucocorticoid (GC). ROC analysis revealed that the cut-off points of the inferior rectus/fat ratio combined with the exophthalmos value to indicate efficacy were 1.42 and 20.78. For moderate-severe GO patients with CAS > 3, the combined inferior rectus/fat ratio and exophthalmos value in MRI may be a valuable indicator to predict the response to GC therapy.
Collapse
Affiliation(s)
- Lingling Xu
- Department of Endocrinology, Nanfang Hospital, Southern Medical University, Guangzhou, Guangdong 510515, China
| | - Linna Li
- Department of Endocrinology, Nanfang Hospital, Southern Medical University, Guangzhou, Guangdong 510515, China
| | - Cuihua Xie
- Department of Endocrinology, Nanfang Hospital, Southern Medical University, Guangzhou, Guangdong 510515, China
| | - Meiping Guan
- Department of Endocrinology, Nanfang Hospital, Southern Medical University, Guangzhou, Guangdong 510515, China
| | - Yaoming Xue
- Department of Endocrinology, Nanfang Hospital, Southern Medical University, Guangzhou, Guangdong 510515, China
| |
Collapse
|
23
|
Li Q, Ye H, Ding Y, Chen G, Liu Z, Xu J, Chen R, Yang H. Clinical characteristics of moderate-to-severe thyroid associated ophthalmopathy in 354 Chinese cases. PLoS One 2017; 12:e0176064. [PMID: 28472149 PMCID: PMC5417486 DOI: 10.1371/journal.pone.0176064] [Citation(s) in RCA: 35] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/16/2016] [Accepted: 04/05/2017] [Indexed: 12/13/2022] Open
Abstract
Thyroid associated ophthalmopathy (TAO) is an autoimmune inflammatory disorder which disfigures appearance, threatens vision, and results in a pronounced loss of quality of life. The diversity and ethnic difference of the disease manifestations have made it difficult to tailor therapies for each patient. Few studies have analyzed its characteristics in Chinese populations. We therefore enrolled 354 patients with moderate-to-severe TAO from February 2015 to July 2016. A single ophthalmologist consistently performed detailed ophthalmic examinations. Orbital computed tomography or magnetic resonance imaging scans were performed to verify enlarged extraocular muscles. Multiple linear regression was used to analyze the association between sex, age, smoking, family history of thyroid diseases, degree of proptosis and disease severity. The mean age of males (46.56±11.08 years) was significantly higher than that of females (41.39±years), with a female-to-male ratio of 1.09. The females and males between 31~40 and 41~50 years, respectively, had the highest incidence of TAO. 81.48% of the patients suffered hyperthyroidism. TAO was diagnosed either after (47.17%) or simultaneously with thyroid dysfunction (27.68%). Proptosis (91.24%), eyelid retraction (83.33%), together with eyelid swelling (79.38%) and extraocular muscle enlargement (75.42%), were the most common clinical sign. 19.77% of patients manifested lower eyelid retraction. The mean values of exophthalmos and asymmetry on proptosis were 19.94±3.45mm and 2.18±2.06mm, respectively in males, 18.58±3.31mm and 1.61±1.53mm, respectively in females. The severity of disease was significantly associated with male, older age, smoking, family history of thyroid diseases and degree of proptosis. We found several differences in Chinese compared with White. The female-to-male ratio and mean value of exophthalmos were significantly lower than the data of White. Inferior and superior rectus became the most common extraocular muscles. Lower eyelid retraction should be included in diagnostic criteria in Asian patients. Understanding these differences, may allow better identification and treatment for TAO in China.
Collapse
Affiliation(s)
- Qian Li
- Zhongshan Ophthalmic Center, State Key laboratory of Ophthalmology, Sun Yat-sen University, Guangzhou, Guangdong, P.R. China
| | - Huijing Ye
- Zhongshan Ophthalmic Center, State Key laboratory of Ophthalmology, Sun Yat-sen University, Guangzhou, Guangdong, P.R. China
| | - Yungang Ding
- Zhongshan Ophthalmic Center, State Key laboratory of Ophthalmology, Sun Yat-sen University, Guangzhou, Guangdong, P.R. China
- Qingdao Ludong Eye Hospital, Qingdao, Shandong, P.R. China
| | - Guo Chen
- Zhongshan Ophthalmic Center, State Key laboratory of Ophthalmology, Sun Yat-sen University, Guangzhou, Guangdong, P.R. China
| | - Zhichang Liu
- Zhongshan Ophthalmic Center, State Key laboratory of Ophthalmology, Sun Yat-sen University, Guangzhou, Guangdong, P.R. China
| | - Jianan Xu
- Zhongshan Ophthalmic Center, State Key laboratory of Ophthalmology, Sun Yat-sen University, Guangzhou, Guangdong, P.R. China
| | - Rongxin Chen
- Zhongshan Ophthalmic Center, State Key laboratory of Ophthalmology, Sun Yat-sen University, Guangzhou, Guangdong, P.R. China
| | - Huasheng Yang
- Zhongshan Ophthalmic Center, State Key laboratory of Ophthalmology, Sun Yat-sen University, Guangzhou, Guangdong, P.R. China
| |
Collapse
|
24
|
Bartalena L, Veronesi G, Krassas GE, Wiersinga WM, Marcocci C, Marinò M, Salvi M, Daumerie C, Bournaud C, Stahl M, Sassi L, Azzolini C, Boboridis KG, Mourits MP, Soeters MR, Baldeschi L, Nardi M, Currò N, Boschi A, Bernard M, von Arx G, Perros P, Kahaly GJ. Does early response to intravenous glucocorticoids predict the final outcome in patients with moderate-to-severe and active Graves' orbitopathy? J Endocrinol Invest 2017; 40:547-553. [PMID: 28176220 DOI: 10.1007/s40618-017-0608-z] [Citation(s) in RCA: 46] [Impact Index Per Article: 6.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/01/2017] [Accepted: 01/02/2017] [Indexed: 10/20/2022]
Abstract
PURPOSE Intravenous glucocorticoids (ivGCs) given as 12-weekly infusions are the first-line treatment for moderate-to-severe and active Graves' orbitopathy (GO), but they are not always effective. In this study, we evaluated whether response at 6 weeks correlated with outcomes at 12 (end of intervention) and 24 (follow-up) weeks, particularly in patients initially unresponsive. METHODS Our database (Bartalena et al. J Clin Endocrinol Metab 97:4454-4463, 10), comprising 159 patients given three different cumulative doses of methylprednisolone (2.25, 4.98, 7.47 g) was analyzed, pooling data for analyses. Responses at 6 weeks were compared with those at 12 and 24 weeks using three outcomes: overall ophthalmic involvement [composite index (CI)]; quality of life (QoL); Clinical Activity Score (CAS). Responses were classified as "Improved", "Unchanged", "Deteriorated", compared to baseline. RESULTS Deteriorated patients at 6 weeks for CI (n = 8) remained in the same category at 12 weeks and 7/8 at 24 weeks. Improved patients at 6 weeks for CI (n = 51) remained in the same category in 63% and 53% of cases at 12 and 24 weeks, respectively. Unchanged patients at 6 weeks (n = 100) eventually improved in 28% of cases (CI), 58% (CAS), 32% (QoL). There was no glucocorticoid dose-dependent difference in the influence of early response on later outcomes. CONCLUSIONS Patients who deteriorate at 6 weeks after ivGCs are unlikely to benefit from continuing ivGCs. Patients unresponsive at 6 weeks still have a significant possibility of improvement later. Accordingly, they may continue ivGC treatment, or, alternatively, possibly stop ivGCs and be switched to a second-line treatment.
Collapse
Affiliation(s)
- L Bartalena
- Department of medicine and surgery, University of Insubria, Endocrine Unit, ASST dei Sette Laghi, Viale Borri, 57, 21100, Varese, Italy.
| | - G Veronesi
- Department of medicine and surgery, University of Insubria, Endocrine Unit, ASST dei Sette Laghi, Viale Borri, 57, 21100, Varese, Italy
| | | | - W M Wiersinga
- Academic Medical Center, University of Amsterdam, Amsterdam, The Netherlands
| | | | | | - M Salvi
- Fondazione Policlinico, University of Milan, Milan, Italy
| | - C Daumerie
- CatholicUniversity of Louvain, Brussels, Belgium
| | | | - M Stahl
- Kantonsspital Baselland, University Clinic of Internal Medicine, Bruderholz, Switzerland
| | - L Sassi
- Department of medicine and surgery, University of Insubria, Endocrine Unit, ASST dei Sette Laghi, Viale Borri, 57, 21100, Varese, Italy
| | - C Azzolini
- Department of medicine and surgery, University of Insubria, Endocrine Unit, ASST dei Sette Laghi, Viale Borri, 57, 21100, Varese, Italy
| | - K G Boboridis
- University Department of Ophthalmology, AHEPA Hospital, Thessaloniki, Greece
| | - M P Mourits
- Academic Medical Center, University of Amsterdam, Amsterdam, The Netherlands
| | - M R Soeters
- Academic Medical Center, University of Amsterdam, Amsterdam, The Netherlands
| | - L Baldeschi
- CatholicUniversity of Louvain, Brussels, Belgium
| | - M Nardi
- University of Pisa, Pisa, Italy
| | - N Currò
- Fondazione Policlinico, University of Milan, Milan, Italy
| | - A Boschi
- CatholicUniversity of Louvain, Brussels, Belgium
| | | | - G von Arx
- Admedico Orbital Center, Olten, Switzerland
| | - P Perros
- Newcastle upon Tyne Hospitals NHS Trust, Newcastle upon Tyne, UK
| | - G J Kahaly
- Gutenberg University Medical Center, Mainz, Germany
| |
Collapse
|
25
|
Mellington FE, Dayan CM, Dickinson AJ, Hickey JL, MacEwen CJ, McLaren J, Perros P, Rose GE, Uddin J, Vaidya B, Foley P, Lazarus JH, Mitchell A, Ezra DG. Management of thyroid eye disease in the United Kingdom: A multi-centre thyroid eye disease audit. Orbit 2017; 36:159-169. [PMID: 28296512 DOI: 10.1080/01676830.2017.1280057] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
This article aims to provide baseline data and highlight any major deficiencies in the current level of care provided for adult patients with thyroid eye disease (TED). We undertook a prospective, nonrandomized cross-sectional multicenter observational study. During a 3-month period June-August 2014, consecutive adult patients with TED who presented to nominated specialist eye clinics in the United Kingdom, completed a standardized questionnaire. Main outcome measures were: demographics, time from diagnosis to referral to tertiary centre, time from referral to review in specialist eye clinic, management of thyroid dysfunction, radioiodine and provision of steroid prophylaxis, smoking, and TED classification. 91 patients (mean age 47.88 years) were included. Female-to-male ratio was 6:1. Mean time since first symptoms of TED = 27.92 (73.71) months; from first visit to any doctor with symptoms to diagnosis = 9.37 (26.03) months; from hyperthyroidism diagnosis to euthyroidism 12.45 (16.81) months. First, 13% had received radioiodine. All those with active TED received prophylactic steroids. Seven patients who received radioiodine and did not have TED at the time went on to develop it. Then, 60% patients were current or ex-smokers. 63% current smokers had been offered smoking cessation advice. 65% patients had active TED; 4% had sight-threatening TED. A large proportion of patients (54%) were unaware of their thyroid status. Not enough patients are being provided with smoking cessation advice and information on the impact of smoking on TED and control of thyroid function.
Collapse
Affiliation(s)
| | - C M Dayan
- b Institute of Molecular and Experimental Medicine , Cardiff University School of Medicine , Cardiff , United Kingdom
| | - A J Dickinson
- c Newcastle Eye Centre , Newcastle upon Tyne Hospitals NHS Foundation Trust , Newcastle upon Tyne , United Kingdom
| | - J L Hickey
- d British Thyroid Foundation , Harrogate , United Kingdom
| | - C J MacEwen
- e Department of Ophthalmology , Ninewells Hospital , Dundee , United Kingdom
| | - J McLaren
- f Thyroid Eye Disease Charitable Trust , Bristol , United Kingdom
| | - P Perros
- c Newcastle Eye Centre , Newcastle upon Tyne Hospitals NHS Foundation Trust , Newcastle upon Tyne , United Kingdom
| | - G E Rose
- a Moorfields Eye Hospital , London , United Kingdom.,g UCL Institute of Ophthalmology Biomedical Research Centre for Ophthalmology , London , United Kingdom
| | - J Uddin
- a Moorfields Eye Hospital , London , United Kingdom.,g UCL Institute of Ophthalmology Biomedical Research Centre for Ophthalmology , London , United Kingdom
| | - B Vaidya
- h Department of Endocrinology , Royal Devon and Exeter Hospital and University of Exeter Medical School , Exeter , United Kingdom
| | - P Foley
- i Members of TEAMeD and organisations represented: A. J. Dickinson, J. L. Hickey, G. E. Rose and P. Foley - British Thyroid Foundation, J. McLaren and C. M. Dayan - Thyroid Eye Disease Charitable Trust, D. G. Ezra - Royal College of Ophthalmologists, J. Uddin - British Oculoplastic Surgery Society, C. J. MacEwen - Scottish Ophthalmologists Club, J. H. Lazarus - Royal College of Physicians, P. Perros - Society for Endocrinology and B. Vaidya - British Thyroid Association
| | - J H Lazarus
- i Members of TEAMeD and organisations represented: A. J. Dickinson, J. L. Hickey, G. E. Rose and P. Foley - British Thyroid Foundation, J. McLaren and C. M. Dayan - Thyroid Eye Disease Charitable Trust, D. G. Ezra - Royal College of Ophthalmologists, J. Uddin - British Oculoplastic Surgery Society, C. J. MacEwen - Scottish Ophthalmologists Club, J. H. Lazarus - Royal College of Physicians, P. Perros - Society for Endocrinology and B. Vaidya - British Thyroid Association
| | - A Mitchell
- i Members of TEAMeD and organisations represented: A. J. Dickinson, J. L. Hickey, G. E. Rose and P. Foley - British Thyroid Foundation, J. McLaren and C. M. Dayan - Thyroid Eye Disease Charitable Trust, D. G. Ezra - Royal College of Ophthalmologists, J. Uddin - British Oculoplastic Surgery Society, C. J. MacEwen - Scottish Ophthalmologists Club, J. H. Lazarus - Royal College of Physicians, P. Perros - Society for Endocrinology and B. Vaidya - British Thyroid Association
| | - D G Ezra
- a Moorfields Eye Hospital , London , United Kingdom.,g UCL Institute of Ophthalmology Biomedical Research Centre for Ophthalmology , London , United Kingdom
| | | |
Collapse
|
26
|
Quinn AS, Dujardin LR, Knight B, Benzimra J, Quinn AG, Vaidya B. Changing trend in referral to secondary care specialist thyroid eye disease clinic following the Amsterdam declaration. Int Ophthalmol 2017; 38:301-306. [PMID: 28181061 DOI: 10.1007/s10792-017-0463-0] [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: 12/19/2016] [Accepted: 01/31/2017] [Indexed: 10/20/2022]
Abstract
INTRODUCTION Early diagnosis and treatment of thyroid eye disease (TED) improves outcomes. Previous studies have highlighted delays in diagnosis and referral to specialist centres. The Amsterdam declaration (2009) aimed to halve the time from presentation to diagnosis and from diagnosis to referral to a specialist centre in five years. A recent study from the European group on Graves' orbitopathy tertiary centres showed a trend for earlier referral of patients to the centres. It is unknown whether similar improvements are occurring in secondary care hospitals in the UK. AIM To study the trend in referral to a UK secondary care specialist TED clinic since the Amsterdam declaration. METHODS We carried out a prospective audit of patients who attended the specialist TED clinic after the Amsterdam declaration (2010-2015). We compared their clinical characteristics, including duration of symptoms, disease activity and severity, with those of the patients (n = 114) from an earlier audit attending the clinic during 2004-2008. RESULTS During 2010-2015, 126 patients with TED (97 females, median age 55 years, 39 current smokers) attended the clinic. The median time from onset of symptoms to being seen in the clinic was 5 months, reduced from 12 months in 2004-2008 (p < 0.001). As compared to the 2004-2008 cohort, significantly more patients in the current cohort presented with mild disease (72 vs. 52%, p = 0.002). Twenty-seven per cent patients had active TED (clinical activity score ≥3/7) compared to 18% in 2004-2008 (p = 0.1). CONCLUSIONS The trend in referral to secondary care specialist TED clinic is changing in line with the Amsterdam declaration aims.
Collapse
Affiliation(s)
- Annika S Quinn
- West of England Eye Unit, Department of Ophthalmology, Royal Devon and Exeter Hospital NHS Foundation Trust, Exeter, EX2 5DW, UK.
| | - Leticia R Dujardin
- West of England Eye Unit, Department of Ophthalmology, Royal Devon and Exeter Hospital NHS Foundation Trust, Exeter, EX2 5DW, UK
| | - Bridget Knight
- NIHR Exeter Clinical Research Facility, University of Exeter Medical School, University of Exeter, Exeter, UK
| | - James Benzimra
- West of England Eye Unit, Department of Ophthalmology, Royal Devon and Exeter Hospital NHS Foundation Trust, Exeter, EX2 5DW, UK
| | - Anthony G Quinn
- West of England Eye Unit, Department of Ophthalmology, Royal Devon and Exeter Hospital NHS Foundation Trust, Exeter, EX2 5DW, UK
| | - Bijay Vaidya
- Department of Endocrinology, Royal Devon and Exeter Hospital NHS Foundation Trust, Exeter, UK.,University of Exeter Medical School, Exeter, UK
| |
Collapse
|
27
|
Campi I, Vannucchi G, Salvi M. THERAPY OF ENDOCRINE DISEASE: Endocrine dilemma: management of Graves' orbitopathy. Eur J Endocrinol 2016; 175:R117-33. [PMID: 27032693 DOI: 10.1530/eje-15-1164] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/30/2015] [Accepted: 03/31/2016] [Indexed: 12/22/2022]
Abstract
Management of Graves' orbitopathy (GO) must be based on the correct assessment of activity and severity of the disease. Activity is usually assessed with the Clinical Activity Score, whereas severity is classified according to a European Group On Graves' Orbitopathy (EUGOGO) consensus statement as mild, moderate-to-severe, and sight-threatening. Myopathic and chronic congestive forms are uncommon clinical presentations of GO. Restoration and maintenance of stable euthyroidism are recommended in the presence of GO.In moderate-to-severe disease, steroids have been widely employed and have shown to possess an anti-inflammatory activity, but about 20-30% of patients are not responsive and present recurrence. Some novel immunosuppressors have already been employed in clinical studies and have shown interesting results, although the lack of randomized and controlled trials suggests caution for their use in clinical practice. Potential targets for therapy in GO are the thyroid-stimulating hormone and the insulin-like growth factor 1 receptor on the fibroblasts, inflammatory cytokines, B and T cells, and the PIK3/mTORC1 signaling cascades for adipogenesis. A recent open study has shown that tocilizumab, an anti-sIL-6R antibody, inactivates GO. Consistent reports on the efficacy of rituximab have recently been challenged by randomized controlled trials.As the main goal of treatment is the well-being of the patient, the therapeutic strategy should be addressed to better suit the patient needs, more than improving one or more biological parameters. The increasing availability of new therapies will expand the therapeutic options for GO patients and allow the clinician to really personalize the treatment to better suit the patients' personal needs.
Collapse
Affiliation(s)
- Irene Campi
- Graves' Orbitopathy CenterEndocrinology, Fondazione IRCCS Cà Granda, Milan, Italy
| | - Guia Vannucchi
- Graves' Orbitopathy CenterEndocrinology, Fondazione IRCCS Cà Granda, Milan, Italy
| | - Mario Salvi
- Graves' Orbitopathy CenterEndocrinology, Fondazione IRCCS Cà Granda, Milan, Italy
| |
Collapse
|
28
|
Bartalena L, Baldeschi L, Boboridis K, Eckstein A, Kahaly GJ, Marcocci C, Perros P, Salvi M, Wiersinga WM. The 2016 European Thyroid Association/European Group on Graves' Orbitopathy Guidelines for the Management of Graves' Orbitopathy. Eur Thyroid J 2016; 5:9-26. [PMID: 27099835 PMCID: PMC4836120 DOI: 10.1159/000443828] [Citation(s) in RCA: 606] [Impact Index Per Article: 75.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/05/2015] [Accepted: 01/05/2016] [Indexed: 11/19/2022] Open
Abstract
Graves' orbitopathy (GO) is the main extrathyroidal manifestation of Graves' disease, though severe forms are rare. Management of GO is often suboptimal, largely because available treatments do not target pathogenic mechanisms of the disease. Treatment should rely on a thorough assessment of the activity and severity of GO and its impact on the patient's quality of life. Local measures (artificial tears, ointments and dark glasses) and control of risk factors for progression (smoking and thyroid dysfunction) are recommended for all patients. In mild GO, a watchful strategy is usually sufficient, but a 6-month course of selenium supplementation is effective in improving mild manifestations and preventing progression to more severe forms. High-dose glucocorticoids (GCs), preferably via the intravenous route, are the first line of treatment for moderate-to-severe and active GO. The optimal cumulative dose appears to be 4.5-5 g of methylprednisolone, but higher doses (up to 8 g) can be used for more severe forms. Shared decision-making is recommended for selecting second-line treatments, including a second course of intravenous GCs, oral GCs combined with orbital radiotherapy or cyclosporine, rituximab or watchful waiting. Rehabilitative treatment (orbital decompression surgery, squint surgery or eyelid surgery) is needed in the majority of patients when GO has been conservatively managed and inactivated by immunosuppressive treatment.
Collapse
Affiliation(s)
- Luigi Bartalena
- Department of Clinical and Experimental Medicine, University of Insubria, Endocrine Unit, Ospedale di Circolo, Varese, Italy
- *Prof. Luigi Bartalena, Department of Clinical and Experimental Medicine, University of Insubria, Endocrine Unit, Ospedale di Circolo, Viale Borri 57, IT-21100 Varese (Italy), E-Mail
| | - Lelio Baldeschi
- Department of Ophthalmology, Hospital Saint Luc, Catholic University of Louvain, Brussels, Belgium
| | - Kostas Boboridis
- Ophthalmology Department, Aristotle University of Thessaloniki, Thessaloniki, Greece
| | - Anja Eckstein
- Zentrum für Augenheilkunde, Universitätsklinikum Essen, Essen, Germany
| | - George J. Kahaly
- Department of Medicine I, Johannes Gutenberg University (JGU) Medical Center, Mainz, Germany
| | - Claudio Marcocci
- Department of Clinical and Experimental Medicine, University of Pisa, Pisa, Italy
| | - Petros Perros
- Department of Endocrinology, Newcastle upon Tyne Hospitals NHS Foundation Trust, Newcastle upon Tyne, UK
| | - Mario Salvi
- Graves' Orbitopathy Center, Endocrinology, Fondazione Ca' Granda IRCCS, University of Milan, Milan, Italy
| | - Wilmar M. Wiersinga
- Department of Endocrinology and Metabolism, Academic Medical Center, University of Amsterdam, Amsterdam, The Netherlands
| | | |
Collapse
|
29
|
Bartalena L, Fatourechi V. Extrathyroidal manifestations of Graves' disease: a 2014 update. J Endocrinol Invest 2014; 37:691-700. [PMID: 24913238 DOI: 10.1007/s40618-014-0097-2] [Citation(s) in RCA: 153] [Impact Index Per Article: 15.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/03/2014] [Accepted: 05/20/2014] [Indexed: 01/17/2023]
Abstract
INTRODUCTION Graves' orbitopathy (GO), thyroid dermopathy (also called pretibial myxedema) and acropachy are the extrathyroidal manifestations of Graves' disease. They occur in 25, 1.5, and 0.3 % of Graves' patients, respectively. Thus, GO is the main and most common extrathyroidal manifestation. Dermopathy is usually present if the patient is also affected with GO. The very rare acropachy occurs only in patients who also have dermopathy. GO and dermopathy have an autoimmune origin and are probably triggered by autoimmunity to the TSH receptor and, likely, the IGF-1 receptor. Both GO and dermopathy may be mild to severe. MANAGEMENT Mild GO usually does not require any treatment except for local measures and preventive actions (especially refraining from smoking). Currently, moderate-to-severe and active GO is best treated by systemic glucocorticoids, but response to treatment is not optimal in many instances, and retreatments and use of other modalities (glucocorticoids, orbital radiotherapy, cyclosporine) and, in the end, rehabilitative surgery are often needed. Dermopathy is usually managed by local glucocorticoid treatment. No specific treatment is available for acropachy. PERSPECTIVES Novel treatments are presently being investigated for GO, and particular attention is paid to the use of rituximab. It is unknown whether novel treatments for GO might be useful for the other extrathyroidal manifestations. Future novel therapies shown to be beneficial for GO in randomized studies may be empirically used for dermopathy and acropachy.
Collapse
Affiliation(s)
- Luigi Bartalena
- Department of Clinical and Experimental Medicine, University of Insubria, Endocrine Unit, Ospedale di Circolo, Viale Borri, 57, 21100, Varese, Italy.
| | - Vahab Fatourechi
- Department of Endocrinology and Metabolism, Mayo Clinic, Rochester, MN, USA.
| |
Collapse
|
30
|
Bartalena L. Graves' orbitopathy: imperfect treatments for a rare disease. Eur Thyroid J 2013; 2:259-69. [PMID: 24783057 PMCID: PMC3923600 DOI: 10.1159/000356042] [Citation(s) in RCA: 43] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/06/2013] [Accepted: 09/25/2013] [Indexed: 12/13/2022] Open
Abstract
Graves' orbitopathy (GO) is the most frequent and invalidating extrathyroidal expression of Graves' disease. Its incidence and prevalence are, however, low. About three quarters of Graves' patients have no GO at diagnosis, and moderate-to-severe and severe forms represent no more that 5-6% of cases. Progression to severe forms occurs rarely, but it may be caused by risk factors, the most important being smoking and poor control of thyroid dysfunction. Lot of progress has been recently achieved in the understanding of GO pathogenesis, while the disease remains a therapeutic challenge and dilemma. Common treatments for moderate-to-severe and active forms of GO (glucocorticoids and orbital radiotherapy) frequently provide incomplete responses and may be followed by relapse or progression of GO. After the disease has been inactivated by medical treatment, many patients need rehabilitative surgery for residual manifestations (orbital decompression for exophthalmos, squint surgery for extraocular muscle dysfunction, eyelid surgery for eyelid malposition). Novel pharmacological treatments are on the horizon and might target pathogenetic mechanisms of the disease better than glucocorticoids. Clinical evidence concerning their efficacy and safety is presently lacking.
Collapse
Affiliation(s)
- Luigi Bartalena
- Department of Clinical and Experimental Medicine, University of Insubria, Varese, Italy
| |
Collapse
|
31
|
Benzimra JD, Quinn AG, Kersey T, McGrane D, Goss L, Vaidya B. Management of patients in a combined thyroid eye clinic in secondary care. Int Ophthalmol 2013; 34:1-6. [PMID: 23549634 DOI: 10.1007/s10792-013-9768-9] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/17/2012] [Accepted: 03/24/2013] [Indexed: 12/01/2022]
Abstract
The European Group on Graves' Orbitopathy (EUGOGO) recommends the use of specialised multidisciplinary clinics for the management of thyroid eye disease (TED). In the UK, many patients with TED are managed outside of specialised clinics. We describe the organisation of a combined TED clinic in a secondary care setting and present the result of a prospective audit of the patient characteristics and outcomes during the first four years of a combined TED clinic. Of a total of 132 patients referred to the TED clinic, 114 (86 %) had TED (90 females, median age 56 years; range 17-90 years). At presentation, 77 (67 %) were current or ex-smokers and 99 (87 %) were biochemically euthyroid. Median duration of eye symptoms was 12 months. Fifty-two percent, 45 and 3 had mild, moderate-to-severe and sight-threatening TED, respectively. Only 18 % of patients had a clinical activity score (CAS) of ≥3. Sixty-nine patients (61 %) required follow-up appointments in the TED clinic. In those who required follow-up, 43 % (n = 30) received either immunosuppressive or surgical treatment. CAS improved from first to final visit, with 29 % (n = 20) having a CAS of ≥3 at the first visit and 1 % (n = 1) at the final visit (p = 0.0001). There was also a decrease in prevalence of smoking and thyroid dysfunction at the final visit. A multidisciplinary specialised TED clinic offers an optimal setting for managing patients with TED; however, patients are often referred late to a specialist TED clinic.
Collapse
Affiliation(s)
- J D Benzimra
- West of England Eye Unit, Royal Devon and Exeter Hospital, Exeter, UK,
| | | | | | | | | | | |
Collapse
|
32
|
Bartalena L, Krassas GE, Wiersinga W, Marcocci C, Salvi M, Daumerie C, Bournaud C, Stahl M, Sassi L, Veronesi G, Azzolini C, Boboridis KG, Mourits MP, Soeters MR, Baldeschi L, Nardi M, Currò N, Boschi A, Bernard M, von Arx G. Efficacy and safety of three different cumulative doses of intravenous methylprednisolone for moderate to severe and active Graves' orbitopathy. J Clin Endocrinol Metab 2012; 97:4454-63. [PMID: 23038682 DOI: 10.1210/jc.2012-2389] [Citation(s) in RCA: 218] [Impact Index Per Article: 18.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
BACKGROUND Optimal doses of i.v. glucocorticoids for Graves' orbitopathy (GO) are undefined. METHODS We carried out a multicenter, randomized, double-blind trial to determine efficacy and safety of three doses of i.v. methylprednisolone in 159 patients with moderate to severe and active GO. Patients were randomized to receive a cumulative dose of 2.25, 4.98, or 7.47 g in 12 weekly infusions. Efficacy was evaluated objectively at 12 wk by blinded ophthalmologists and subjectively by blinded patients (using a GO specific quality of life questionnaire). Adverse events were recorded at each visit. RESULTS Overall ophthalmic improvement was more common using 7.47 g (52%) than 4.98 g (35%; P = 0.03) or 2.25 g (28%; P = 0.01). Compared with lower doses, the high-dose regimen led to the most improvement in objective measurement of ocular motility and in the Clinical Activity Score. The Clinical Activity Score decreased in all groups and to the least extent with 2.25 g. Quality of life improved most in the 7.47-g group, although not reaching statistical significance. No significant differences occurred in exophthalmos, palpebral aperture, soft tissue changes, and subjective diplopia score. Dysthyroid optic neuropathy developed in several patients in all groups. Because of this, differences among the three groups were no longer apparent at the exploratory 24-wk visit. Major adverse events were slightly more frequent using the highest dose but occurred also using the lowest dose. Among patients whose GO improved at 12 wk, 33% in the 7.47-group, 21% in the 4.98-group, and 40% in the 2.25-group had relapsing orbitopathy after glucocorticoid withdrawal at the exploratory 24-wk visit. CONCLUSIONS The 7.47-g dose provides short-term advantages over lower doses. However, this benefit is transient and associated with slightly greater toxicity. The use of a cumulative dose of 7.47 g of methylprednisolone provides short-term advantage over lower doses. This may suggest that an intermediate-dose regimen be used in most cases and the high-dose regimen be reserved to most severe cases of GO.
Collapse
Affiliation(s)
- L Bartalena
- Department of Clinical and Experimental Medicine, University of Insubria, Endocrine Unit, Ospedale di Circolo, 21100 Varese, Italy.
| | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | |
Collapse
|
33
|
Yang M, Perros P. Management plan and delivery of care in Graves' ophthalmopathy patients. Best Pract Res Clin Endocrinol Metab 2012; 26:303-11. [PMID: 22632367 DOI: 10.1016/j.beem.2012.03.011] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
Most patients with Graves' orbitopathy have mild disease that requires no or minimal intervention. For the minority of patients with moderate or severe disease, multiple medical and surgical treatments may be required at different stages. It is crucial that such patients are monitored closely and treatments applied with care in the right sequence. Medical treatments should be used as early as possible and only during the active phase of the disease. Rehabilitative surgery is indicated in the inactive phase of the disease and should follow the sequence: surgical decompression followed by eye muscle surgery, followed by lid surgery. Delivery of care in a coordinated fashion that makes use of best available expertise is important and best implemented through a Combined Thyroid Eye clinic.
Collapse
Affiliation(s)
- Morgan Yang
- Singapore National Eye Centre, 11 Third Hospital Avenue, Singapore 168751, Singapore.
| | | |
Collapse
|
34
|
Abstract
AIMS The purpose of this study was to obtain data on orbital decompression procedures performed in England, classed by hospital and locality, to evaluate regional variation in care. METHODS Data on orbital decompression taking place in England over a 2-year period between 2007 and 2009 were derived from CHKS Ltd and analysed by the hospital and primary care trust. RESULTS AND CONCLUSIONS In all, 44% of these operations took place in hospitals with an annual workload of 10 or fewer procedures. Analysis of the same data by primary care trust suggests an almost 30-fold variance in the rates of decompression performed per unit population. Expertise available to patients with Graves' orbitopathy and rates of referral for specialist care in England appears to vary significantly by geographic location. These data, along with other outcome measures, will provide a baseline by which progress can be judged.
Collapse
|
35
|
Abstract
Thyroid eye disease (TED) is a chronic debilitating condition causing physical discomfort, facial disfigurement and impaired visual function. The physical consequences of TED could have a negative and lasting impact on patients' employment, hobbies and psychosocial function. In this review, we assess the evidence of the impact of TED on patients' quality of life (QOL) and also explore the effects of suboptimal quality of care on QOL of patients with this disease. It is hoped that recent initiatives, including the Amsterdam declaration, to raise the quality of care for patients with TED will help to improve their QOL.
Collapse
Affiliation(s)
- Stephanie Estcourt
- Department of Endocrinology Ophthalmology, Royal Devon and Exeter Hospital, Exeter EX2 5DW, UK
| | | | | |
Collapse
|
36
|
|