Update on Graves Disease

Advances in Treatment of Mild, Moderate and Severe Thyroid Eye Disease

Diego Strianese


Curr Opin Ophthalmol. 2017;28(5):505-513. 

In This Article

Moderate-to-severe Disease

Patients with evidence of inflammatory signs and objective and subjective evidence of disease progression necessitate treatment. We suggest a close follow up of those patients, with repeated visits every 3–4 weeks, in order to carefully evaluate disease progression. The mainstay treatment remains the use of steroid, which should be administered i.v. at the recommended dose of 500 mg of methylprendisolone per week, for 4–6 weeks.[15] If steroids must be withdrawn for side-effects or failure after 2–3 administrations, the patient can be started on an alternative immunosuppressive antimetabolite such as methotrexate, which can have a duration of 2 years to prevent relapse, or mycophenolate.[24,25,26] On the basis of existing data, RTX should not replace steroid as the treatment of choice in active, moderate-to-severe Graves' ophthalmopathy. It can be tried in severe corticosteroid-resistant cases, although the chance of a favorable response appears lower with longer disease duration.[27]

Recent evidence suggests that the use of biologic agents such as etanercept, adalimumab, tocilizumab and teprotumumab may be effective in reduction of the inflammatory signs with the possible advantage of preventing relapse of the disease.[30–32,33] All these medications may be used after an entire course of i.v. steroid with disease relapse. Alternatively, RT (20 Gy dose) seems to be effective even more when used with steroid.[17,18,19] We recommend a low dose of steroid when the RT is delivered to minimize the inflammatory effect of the RT in the early stage.