Teprotumumab Efficacy, Safety and Durability in Longer Duration Thyroid Eye Disease and Retreatment: Optic-X Study

Comparative efficacy and safety of rituximab, tocilizumab, and teprotumumab in Graves' orbitopathy: a systematic review and meta-analysis

Graves' orbitopathy (GO) affects 25-50% of patients with Graves' disease. It progresses through phases, from active inflammation to fibrosis. Thyrotropin-related antibodies (TRAb) and Insulin-like growth factor (IGF-1) contribute to GO's pathogenesis. Conventional treatments like glucocorticoids are often effective, but refractory cases require alternatives like rituximab (RTX), tocilizumab (TCZ), and teprotumumab (TPM). These monoclonal antibodies show promise but carry significant risks. This review aims to assess their efficacy and safety. We retrieved relevant articles up to July 2024 from five databases. Data were extracted from eligible studies by two independent reviewers, including clinical activity scores 7 and 10 (CAS), proptosis, antibody levels, and diplopia. All analyses were conducted using RevMan v5.4. In this review, we included 77 articles. Of these, 58 provided enough data for analysis. TPM, RTX, and TCZ all significantly reduced CAS-7 scores, with TCZ showing the most significant reduction (3.51 points, 95%CI: -4.25, -2.78), followed by TPM (3.1 points, 95%CI: -3.71, -2.49) and RTX. Similarly, for CAS-10, TCZ led with a 5.12-point reduction, significantly outperforming RTX (P = 0.0006). Proptosis decreased significantly with each drug, with TPM leading (2.95 mm), followed by TCZ (1.99 mm) and RTX (0.79 mm). TRAb Levels: TCZ reduced TRAb levels by 8.29 U/L (95%CI: -10.48, -6.09), significantly more than RTX (P = 0.03). Complications varied, with TPM linked to hyperglycemia and ototoxicity, TCZ to hematologic and metabolic issues, and RTX to infusion-related reactions. In conclusion, TCZ and TPM outperform RTX in treating GO, but TPM has higher complications, and RTX, though safer, shows more treatment failures.

Long-term Cardiovascular, Renal, and Safety Outcomes of Teprotumumab versus Systemic Glucocorticoids in Thyroid Eye Disease: A Target Trial Emulation

PURPOSE

The insulin-like growth factor-1 receptor inhibitor teprotumumab is effective for thyroid eye disease (TED), but there is limited evidence on its long-term safety. We studied the long-term cardiovascular, renal, infectious, and safety outcomes of teprotumumab compared to intravenous (IV) glucocorticoids (GCs), oral GCs, and conservative treatment in patients with TED.

DESIGN

Population-based cohort study.

PARTICIPANTS

Patients with TED who initiated teprotumumab, GCs, or conservative treatment between January 1st 2020 to December 1st 2024 from 80 healthcare organizations in the United States.

METHODS

Propensity scores were used to match baseline covariates including demographics, comorbidities, laboratory data, and medications. Cox proportional hazard models were used to calculate hazard ratios.

MAIN OUTCOME MEASURES

Outcomes included all-cause mortality and the risks of new-onset cardiovascular diseases, renal diseases, infectious outcomes, and safety outcomes, including hearing loss, within 5 years after initiating treatment.

RESULTS

Teprotumumab was associated with markedly lower all-cause mortality and reduced risks of acute myocardial infarction, cerebral infarction, peripheral vascular disease, heart failure, atrial fibrillation, acute kidney failure, emergency department visits, hospitalization, urinary tract infection, pneumonia, and severe sepsis, when compared to IV or oral GCs. There was no difference in the risks of diabetes, chronic kidney disease, inflammatory bowel disease, or complications requiring a hearing device, while there was a higher risk of hearing loss after starting teprotumumab compared to IV or oral GCs. All-cause mortality was also markedly reduced in teprotumumab users when compared to patients with conservative treatment.

CONCLUSIONS

The use of teprotumumab compared to IV or oral GCs was associated with reduced risks of death, cardiovascular, renal, and infectious diseases in patients with TED. This suggests that teprotumumab may have fewer adverse outcomes than GCs for treating TED.

Autoimmune neuro-ophthalmic disorders: pathophysiologic mechanisms and targeted biologic therapies

INTRODUCTION

Autoimmune neuro-ophthalmic disorders encompass a diverse array of conditions, including thyroid eye disease (TED), myasthenia gravis (MG), optic neuropathy due to giant cell arteritis (GCA), and optic neuritis related to multiple sclerosis (MS), neuromyelitis optica spectrum disorder (NMOSD) and myelin oligodendrocyte glycoprotein antibody-associated disease (MOGAD). While traditional treatments have shown efficacy in managing symptoms, the rapid emergence of biologic therapies has brought forth new avenues for targeted intervention, revolutionizing treatment approaches for these conditions.

AREAS COVERED

This review highlights the pathophysiologic pathways and FDA-approved biologic therapies utilized in the management of autoimmune neuro-ophthalmic disorders. We explore multiple therapeutic approaches for autoimmune neuro-ophthalmic disorders, including IGF-1 R antagonism, IL-6 inhibition, complement inhibition, FcRn targeting, B-cell depletion and T-cell modulation. Literature from clinical trials, observational studies, and meta-analyses through 2024 was evaluated to assess efficacy, safety, and long-term outcomes.

EXPERT OPINION

Biologic therapies represent a significant advancement in autoimmune neuro-ophthalmic disorders, offering targeted approaches with improved efficacy and safety profiles compared to traditional treatments. Ongoing developments in biomarker identification and delivery systems suggest an increasingly personalized approach to treatment. Future advances will likely focus on optimizing patient selection, reducing costs, improving accessibility, and developing novel therapeutic targets.

Efficacy and Safety of Teprotumumab in Thyroid Eye Disease: A Systematic Review and Meta-Analysis

OBJECTIVE

Teprotumumab was approved by the US Food and Drug Administration (FDA) for treating Graves' orbitopathy in adults on January 21, 2020. This study evaluates its efficacy and safety in treating thyroid eye disease (TED).

METHODS

We reviewed studies on teprotumumab for TED treatment from PubMed, Web of Science, EMBASE, Cochrane library, and Clinical trials. gov up to January 1, 2024. Outcomes included proptosis response, diplopia, Clinical Activity Score (CAS) score, and adverse events (AEs).

RESULTS

Our analysis included 10 studies, 4 randomized controlled trials, and 6 observational studies. The randomized controlled trials involved 210 teprotumumab patients and 193 controls. Teprotumumab significantly improved proptosis response (relative risk [RR] 4.18, 2.72-6.43), diplopia regression (RR 2.29, 1.54-3.41), and CAS score (RR 3.09, 1.98-4.80) compared to placebo. A significant reduction in proptosis was observed (standardized mean difference -8.38, -9.25 - -7.52). The risk of AEs and serious AEs was higher with teprotumumab. The 6 observational studies included 211 patients, showing an 82% proptosis response rate, a -3.31 mm change in proptosis, a 0.58 diplopia improvement rate, and a 0.66 pooled effect size for CAS score. AE incidence was 0.78, and serious AEs were 0.31.

CONCLUSION

Teprotumumab effectively reduces proptosis, improves diplopia, and lowers disease activity in TED, regardless of previous treatments, severity, or dosage, albeit with increased AEs. It has the potential to become a vital first-line treatment for TED, enhancing patient quality of life.

Targeting the Aryl Hydrocarbon Receptor to Attenuate IGF1R Signaling in Thyroid Eye Disease

Background: Thyroid eye disease (TED) is an autoimmune disorder characterized by proptosis, inflammation, and fibrosis. Elevated insulin-like growth factor 1 receptor (IGF1R) signaling in TED orbital fibroblasts (OFs) drives the proliferation and biosynthesis of hyaluronan, which causes enlargement of orbital tissue volume. The aryl hydrocarbon receptor (AHR) is a ligand-activated transcription factor that regulates cellular stress responses, metabolism, and inflammation. Given its important role in regulating cellular responses, we hypothesized that activation of the AHR could limit excessive IGF1R signaling in TED OFs, offering therapeutic potential. Methods: We measured IGF1R and AHR expression levels in TED, non-TED, and non-OF controls. OF activation was analyzed using proliferation, hyaluronan accumulation, and migration assays. RNA sequencing was used to detect transcriptome-wide changes in IGF1-treated TED OFs. After gene set enrichment analysis, select gene expression changes were validated by quantitative polymerase chain reaction. OFs were treated with the AHR ligands 6-formylindolo[3,2-b]carbazole (FICZ) or tapinarof with or without IGF1. Western blotting evaluated signaling pathways impacted by AHR and IGF1R signaling. Results: TED OFs showed elevated IGF1R and AHR expression levels compared to controls. IGF1 significantly increased hyaluronan accumulation, proliferation, and migration in TED OFs compared to non-TED OFs. IGF1R signaling altered the expression of hundreds of genes controlling cell migration, proliferation, and metabolism in TED OFs. These genes included TUBA1B, TUBA1C, CRABP2 (upregulated), and IRS2 and SOD3 (downregulated). AHR activation blocked proliferation, migration, hyaluronan production, and gene expression mediated through IGF1R signaling. The AHR inhibited these pathways by reducing phosphorylation of GSK3β, an important mediator of IGF1R/β-catenin mediated signaling. Conclusions: AHR activation represents a promising therapeutic strategy for mitigating TED progression by inhibiting IGF1R signaling. Through modulation of GSK3β-mediated pathways, AHR activation may target additional pathologically relevant pathways beyond those affected by direct IGF1R inhibitors. This research provides novel insights into TED pathophysiology and offers a potential avenue for developing therapies to improve patient outcomes.

Surgical Timing for Patients With Thyroid Eye Disease Treated With Teprotumumab: A Collaborative Multicenter Study

PURPOSE

To compare regression rates, characteristics, and surgical outcomes of thyroid eye disease patients who underwent orbit, strabismus, or eyelid surgery at various times during or after teprotumumab treatment.

DESIGN

Multicenter, retrospective, observational cohort study.

PARTICIPANTS

Adult patients (age >18) with a minimum of 4 infusions of teprotumumab treatment for thyroid eye disease who had had eye surgery during or after treatment.

METHODS

Two groups were formed based on surgery timing: group 1 (G1) (<180 days since last infusion) and group 2 (G2) (≥180 days since last infusion).

MAIN OUTCOME MEASURES

The primary outcome was postoperative regression rates. Secondary outcomes were postoperative regression characteristics, regression treatment, and orbital decompression proptosis reduction.

RESULTS

This study evaluated 53 patients (81% female) who underwent 78 surgeries. G1 comprised 24 individuals with 34 surgeries, while G2 comprised 29 patients with 44 surgeries. Regression rates did not significantly differ between G1 and G2 (20.8% vs. 14.7%, p = 0.611). Compared with G1 patients, patients in G2 who regressed showed a significant mean increase in Clinical Activity Score (4.2 vs. 6.1, p = 0.027) and a nonsignificant yet measured increase in proptosis when compared with those in G1 (2.9 vs. 4.25, p = 0.298) at the time of regression. Compared with G1 patients, G2 patients who regressed were equally likely to undergo a repeat course of teprotumumab as group 1 ( p = 0.14) but underwent a higher number of additional surgical procedures ( p = 0.057). Thyroid stimulating immunoglobin levels uptrended more often in patients who regressed.

CONCLUSION

Our study suggests that while the rate of regression may not differ significantly, the severity, clinical impact, and need for additional surgery might be more pronounced for patients who have surgery more than 6 months after their last teprotumumab dose.

Efficacy and safety of Tocilizumab for thyroid eye disease: a systemic review and Meta-analysis

PURPOSE

This study aims to investigate efficacy and safety of TCZ in TED.

METHODS

Performing a meta-analysis of included studies. PubMed, Web of Science, Embase, Cochrane Library, and Clinicatrials.gov databases were retrieved to identify all related published literatures as of May 2024. When I2 > 50%, the random effect model was used; otherwise, the fixed model was used.

RESULTS

This meta-analysis included 413 patients with TED. Therapeutic effect of TCZ was evaluated by various metrics, including clinical activity score (CAS), response rate, inactivation rate, proptosis, visual acuity (VA), TRAB/TSI levels, diplopia, eye motility, intraocular pressure (IOP), and relapse rate. The final analysis revealed that TCZ significantly reduced CAS (-4.47, 95%CI [-5.14, -3.79]), with high response rate (0.93, 95%CI [0.88, 0.97]) and inactivation rate (0.90, 95%CI [0.83, 0.96]). Significant improvements were also observed in proptosis (2.05 mm reduction, 95%CI [-2.42, -1.67]) and diplopia (0.56 improvement rate, 95% CI [0.40, 0.72]). Regarding safety, the pooled incidence of adverse events (AEs) was 0.31(95%CI [0.15, 0.48]). Hyperlipidemia was the most prevalent AE, followed by neutropenia and infection. Furthermore, subgroup analysis demonstrated TCZ's superior performance in terms of inactivation rate, antibody decline rate, relapse rate, and safety.

CONCLUSIONS

According to the best available evidence, TCZ appears to be an acceptable alternative for moderate to severe TED patients due to its significant efficacy, well-tolerability, and low relapse rate. Larger sample size and controlled studies are warranted to promote the position of TCZ in TED treatment.

Risk of audiologic side effects with teprotumumab treatment for thyroid eye disease: propensity matched analysis

BACKGROUND/OBJECTIVES

Patients with thyroid eye disease (TED) taking teprotumumab have reported audiologic symptoms as a side effect; however, limited real world data and large sample sizes have been utilized to evaluate this relationship.

METHODS

A retrospective cohort study was created in TriNetX to identify patients with TED utilizing ICD-10, CPT, and Healthcare Common Procedure coding systems. TED patients with and without teprotumumab treatment were analysed with greedy one-to-one propensity matching. Appearance of one or more new ICD-10 codes corresponding to audiologic outcomes of interest (tinnitus, sensorineural hearing loss, hypoacusis, hyperacusis, autophony, Eustachian tube dysfunction) served as the outcome of interest. Patients with a history of hearing impairment were also evaluated for worsening hearing loss after initiation of teprotumumab.

RESULTS

Within the entire TriNetX cohort, 88 out of 441 patients with a diagnosis code for TED treated with teprotumumab had new appearance of an audiologic outcome within TriNetX. After matching, the relative risk for TED patients who were exposed to teprotumumab for new audiologic symptoms was increased with a risk ratio (RR) of 2.85 [95% CI 1.94, 4.20] compared to TED patients not exposed to teprotumumab. Of 51 patients with a history of hearing impairment and TED, 14 had record of new audiologic testing after teprotumumab administration (RR = 1.90 [0.96, 3.78]) compared to unexposed patients.

CONCLUSIONS

This study affirms previous research stating that TED patients receiving teprotumumab are at an increased risk of new audiologic side effects when compared to TED patients not using teprotumumab.

In vivo and in vitro evidence for a protective role of autoantibodies against the insulin-like growth factor-1 receptor (IGF-1R) in Graves' orbitopathy

PURPOSE

The insulin-like growth factor-1 receptor (IGF-1R) plays a role in the pathogenesis of Graves' orbitopathy (GO). A possible protective role of autoantibodies against IGF-1R (IGF-1R-Abs) on GO has been suggested.

METHODS

We conducted a cross-sectional study to investigate IGF-1R-Abs in 147 consecutive Graves' disease (GD) patients, with (n = 92) or without (n = 55) GO (primary outcome), their relationship with GO features and their effect on cell proliferation in primary cultures of orbital fibroblasts.

RESULTS

Serum IGF-1R-Abs levels were higher (29.3 ng/mL, IQR 17.4-36.6) in patients without GO than in those with GO (19.8 ng/mL, IQR 11.2-29.8; Mann Whitney U 1819, P = 0.00509). The prevalence of IGF-1R-Abs levels above the previously established cut-off value of 55 ng/mL did not differ statistically between the two groups, despite a trend towards a greater prevalence in patients without GO (9 vs 3.2%) (Fig. 1b). Within GO patients, serum IGF-1R-Abs did not correlate with proptosis, CAS, eyelid width and visual acuity, whereas there was an inverse correlation with diplopia, being IGF-1R-Abs lower in patients with the most severe degrees (Omega square = 0.0123, P = 0.035). Incubation of orbital fibroblasts from GO patients with IgGs purified from a pool of sera with IGF-1R-Abs > 55 ng/mL decreased cell proliferation in a dose-dependent manner (Omega square = 0.747; P < 0.0001).

CONCLUSIONS

Serum autoantibodies against the IGF-1R are present in a minority of patients with GD and seem to exert a protective role on GO development and features.

Targeted immunotherapies for Graves' thyroidal & orbital diseases

Background

Graves' hyperthyroidism and its associated Graves' orbitopathy are common autoimmune disorders associated with significant adverse health impact. Current standard treatments have limitations regarding efficacy and safety, and most do not specifically target the pathogenic mechanisms. We aim to review the latest development of targeted immunotherapies in these two closely related disorders.

Summary

Targeted immunotherapies of Graves' hyperthyroidism have recently demonstrated clinical efficacy in early phase clinical studies. They include rituximab, an anti-CD20 monoclonal antibody which causes rapid B cell depletion; ATX-GD-59, an antigen specific immunotherapy which restores immune tolerance to thyrotropin receptor; iscalimab, an anti-CD40 monoclonal antibody which blocks the CD40-CD154 co-stimulatory pathway in B-T cell interaction; and K1-70, a thyrotropin receptor blocking monoclonal antibody. Furthermore, there have been major therapeutic advances in the management of Graves' orbitopathy. Mycophenolate has a dual mechanism of action both inhibiting the proliferation of activated B & T cells as well as the mammalian target of rapamycin growth intracellular pathway. Rituximab appears to be effective in active disease of recent onset without impending dysthyroid optic neuropathy. Both tocilizumab (anti-interleukin 6 receptor monoclonal antibody) and sirolimus (mammalian target of rapamycin inhibitor) showed promise in glucocorticoid resistant active disease. Teprotumumab, an anti-insulin-like growth factor-1 receptor monoclonal antibody, demonstrated remarkable all-round efficacy across a wide disease spectrum. Linsitinib, a dual small molecule inhibitor of insulin-like growth factor-1 receptor and insulin receptor, displayed significant proptosis reduction in its phase 2b/3 study. Finally, Batoclimab, an anti-neonatal fragment crystallizable receptor monoclonal antibody, which blocks recycling of pathogenic thyrotropin receptor antibody, showed promising signals for significant proptosis reduction, disease inactivation, overall response, and improvement of quality of life.

Conclusion

Therapeutic advances will continue to optimize our management of Graves' hyperthyroidism and its associated orbitopathy in an effective and safe manner.

Controversies Surrounding IGF-I Receptor Involvement in Thyroid-Associated Ophthalmopathy

Background: Thyroid-associated ophthalmopathy (TAO, aka thyroid eye disease [TED], Graves' orbitopathy) remains poorly understood and inadequately treated since its initial description. It is disfiguring, can threaten vision, and represents an autoimmune process closely associated with thyroid disease. Unambiguous connections linking TAO to the glandular maladies of Graves' disease (GD) remain incompletely clarified. Detecting the thyrotropin receptor (TSHR) in periocular tissues suggests that this cell-surface protein represents a shared autoantigen with the thyroid gland, but we now know that its expression is ubiquitous. Most patients with TAO have relatively high circulating levels of activating anti-TSHR autoantibodies. Emerging more recently is the importance of insulin-like growth factor I receptor (IGF-IR) in the pathogenesis of TAO. The TSHR/IGF-IR signaling complex apparently drives circulating fibrocytes and the unique phenotypes of fibroblasts inhabiting the TAO orbit (GD-OF). Methods: The PubMed database was scanned for articles dating back to the earliest time periods covered. Keywords used for primary searches included thyroid-associated ophthalmopathy, Graves' orbitopathy, TED, orbit, TSH receptor, IGF-I receptor, and autoimmune thyroid disease. Secondary searches used numerous other search terms. Results: GD-OF have been characterized extensively as being particularly responsive to the immunological factors and key effectors in TAO pathogenesis. Both TSHR and IGF-IR are overexpressed by GD-OF and CD34+ fibrocytes and form a signaling complex. They are activated through this TSHR/IGF-IR complex to produce large amounts of hyaluronan and express multiple cytokines. This complex mediates cellular responses to pathogenic IgGs in TAO. CD34+ fibrocytes and CD34+ OF also express relatively high levels of multiple thyroid autoantigens. Identifying IGF-IR as a key component of a receptor complex and its intertwining signaling activities with those of TSHR has led to a targeted medical therapy for TAO. This therapy involves the selective systemic inhibition of IGF-IR. Conclusions: Much has been learned over the preceding decades about the pathogenesis of TAO. Among these is the identification of IGF-IR as a pivotal component underpinning the disease. This has led directly to development of an effective targeted therapy. Important gaps in our understanding persist, and current therapies have limitations. Thus, despite these advancements, considerably more remains to be achieved.

Assessment of Hearing Dysfunction in Patients With Graves' Disease and Thyroid Eye Disease Without or With Teprotumumab

CONTEXT

Thyroid eye disease (TED) negatively affects quality of life. TED occurs predominantly in Graves' disease (GD). Teprotumumab improves TED but concern for hearing adverse events (AEs) has emerged. Hearing dysfunction is reported in thyroid autoimmune disease but the background prevalence in GD/TED without teprotumumab remains uncertain.

OBJECTIVE

This work aimed to quantify ear-related diagnostic codes/hearing AEs in GD, TED, and patients receiving teprotumumab by examining medical claims and clinical trials.

METHODS

Deidentified claims for ear/labyrinth-related International Classification of Disorders, Tenth Revision codes (KOMODO) were examined in GD patients without TED, and TED patients without/with teprotumumab treatment. Hearing AE incidence/severity was evaluated in teprotumumab clinical trials. Graves' Ophthalmopathy Quality of Life questionnaire (GO-QOL) scores were compared in teprotumumab TED trial patients without/with hearing AEs.

RESULTS

GD (469 720), TED (38 566) and teprotumumab-treated (967) patients were identified in the claims database. Ear-related codes (including those not specific for hearing) occurred in 24% GD, 33% TED, and 32% teprotumumab-treated patients. "Sensorineural hearing loss bilateral" was most frequent: 7% (32 961/469 720) GD, 11.1% (4279/38 566) TED, and 10.8% (104/967) teprotumumab patients. Before teprotumumab use, 17.1% (165) patients had ear-related codes, while 10.1% (98) had new ear-related codes post treatment.Eight teprotumumab oncology trials revealed 8.1% (51/633) had ear/labyrinth disorders with 2.1% (13) considered study-drug-related and 3.8% (24) hearing impairment/tinnitus-related AEs with 1.3% (8) considered study-drug-related. Similar rates occurred in TED trials.GO-QOL improved in teprotumumab-treated patients without/with hearing AEs. Incidence/severity was consistent across patients with chronic and acute TED.

CONCLUSION

These analyses indicate similar prevalence of hearing claims in patients with GD/TED alone as following teprotumumab treatment. Future analyses of incremental hearing risk from teprotumumab should use a priori study designs accounting for background hearing dysfunction in patients with GD/TED.

Novel perspectives on the pharmacological treatment of thyroid-associated ophthalmopathy

Thyroid-associated ophthalmopathy (TAO), an autoimmune disease closely related to thyroid dysfunction, remains a challenging ophthalmic condition among adults. Its clinical manifestations are complex and diverse, and disease progression can lead to exophthalmos, diplopia, exposure keratitis, corneal ulceration, and compressive optic neuropathy, resulting in irreversible vision damage or even blindness. Traditional treatment methods for TAO, including glucocorticoids, immunosuppressants, and radiation therapy, often have limitations and side effects, making this disease problematic in ophthalmology. As a result, the development of novel targeted drugs has become a research hotspot for addressing the pathogenesis of TAO. A range of novel targeted drugs, such as teprotumumab and tocilizumab, have been successfully developed and demonstrated remarkable efficacy in relieving inflammation and managing this disease. In addition, some drug candidates and molecular targets identified in the TAO in vitro model have shown promising prospects. This article briefly reviews the potential new strategies for future clinical treatment and the progress of new drug therapies for TAO.

Observational Characterization of the Retreatment Course of Patients With Thyroid Eye Disease

BACKGROUND

To characterize the retreatment course of patients with thyroid eye disease (TED), who had reactivation after initial therapy with teprotumumab.

METHODS

This was a single-center longitudinal cohort study of patients who received an initial course of teprotumumab for active TED and were followed for at least 6 months. Reactivation was defined as the increase of proptosis of 2 mm or more or an increase in Clinical Activity Score (CAS) of two points or more, as adapted from the Optic-X study. Data collection included patient age, sex, smoking status, history of thyroidectomy or radioactive iodine, proptosis measurements, clinical activity score (CAS) before initial infusion of teprotumumab, time interval to reactivation, diplopia assessment by the Bahn-Gorman scale, CAS at the time of reactivation, and CAS and proptosis measurements after completion of retreatment and retreatment modalities, including clinical monitoring, corticosteroids, teprotumumab, and/or surgery. Among the reactivated cohort, the treatment response of patients who received a second course of teprotumumab was compared with patients who were treated with intravenous (IV) steroids.

RESULTS

Twenty-six percent (11/42) of patients experienced reactivation of TED with an average time to reactivation of 9 (SD:5) months (range: 2-20 months), average CAS at reactivation of 4 (SD:1) (range: 3-7), and average increase in proptosis of 3 (SD:1) mm (range: 2-6 mm). Of the 11 patients who reactivated, 4 received a second course of teprotumumab, while 6 received IV steroids. One patient elected to monitor. The patients who received a second course of teprotumumab had a mean (SD) posttreatment CAS score of 0 reduction in proptosis of 4 (2) mm (range: 3-6). The patients who received IV steroids had a mean (SD) posttreatment CAS of 2 (1) (range: 1-4) and a reduction in proptosis of 0 (1) mm (range: [-1] to [2]). Univariate analyses to look at predictors of reactivation found no correlation between factors such as age, sex, duration of TED, smoking status, presence of diplopia, previous treatment with radioactive iodine, history of periorbital surgery, and/or thyroidectomy after initial completion of teprotumumab between the 2 cohorts. We found a significant correlation between the CAS scores before initial treatment (P = 0.036) and thyroid hormone dysregulation (P = 0.006) in those who experienced reactivation.

CONCLUSIONS

Patients with TED may experience reactivation of the disease after initial therapy with teprotumumab. Reactivated disease responds to repeat therapy with teprotumumab with higher previous CAS and thyroid hormonal dysregulation being the variables that were significantly associated with reactivation. These data underscore the importance of long-term monitoring and exploring underlying triggers for disease reactivation. Understanding these factors could help predict which patients may require retreatment or chronic dosing with teprotumumab. Further studies are essential to advance our understanding of the immunomodulatory effects of teprotumumab, duration of its therapeutic benefit, and potential retreatment strategies to improve long-term patient outcomes.

Effects of Teprotumumab on Eyelid Retraction in Thyroid Eye Disease

PURPOSE

This study evaluates the efficacy of teprotumumab in reducing eyelid retraction in thyroid eye disease (TED) patients.

METHODS

This retrospective study included patients with active or chronic moderate-to-severe TED who completed at least 4 cycles of teprotumumab. Patients with upper and/or lower eyelid retraction, defined as margin-to-reflex distance (MRD) 1 and/or MRD2 of more than 5 mm, in one or OU were included. The main outcome measure was a change in MRD1 and MRD2 after treatment. Changes in MRD1 and MRD2 were each analyzed for correlation (r) with changes in exophthalmolmetry. Student t test was performed for each comparison, and p values <0.05 were considered significant.

RESULTS

The study included 91 patients, predominantly female (87%), with an average age of 52.02 ± 14.6 years. The mean baseline proptosis measurement was 21.8 ± 2.9 OD and 21.7 ± 3.3 OS. The average MRD1 was 5.5 ± 1.5 OD and 5.4 ± 1.7 OS, and the average MRD2 was 6.1 ± 1.1 OD and 6.2 ± 1.1 OS. The follow-up duration post-treatment was 37.5 ± 31.7 weeks. At first follow-up post-treatment, the mean change in proptosis, MRD1, and MRD2 were -2.6 ± 2.0 OD, -2.5 ± 2.1 OS, -0.8.5 ± 1.4 OD, -0.8 ± 1.0 OS, and -0.7 ± 0.9 OD, -0.8 ± 1.0 OS, respectively. Correlation analysis showed that proptosis reduction was positively correlated with MRD1 and MRD2 reduction at the first post-treatment follow-up (MRD1: r = 0.23, p value < 0.01; MRD2: r = 0.17, p = 0.03].

CONCLUSION

Teprotumumab treatment improves upper and lower eyelid retraction. The improvement in MRD correlated positively with proptosis reduction, indicating the influence of globe position on eyelid position.

Postmarketing Safety Concerns of Teprotumumab: A Real-World Pharmacovigilance Assessment

CONTEXT

Teprotumumab, which targets the insulin-like growth factor-1 receptor, is the only drug approved by the US Food and Drug Administration (FDA) for the treatment of thyroid eye disease (TED).

OBJECTIVE

This study aimed to identify potential safety signals of teprotumumab by analyzing postmarketing safety data from the FDA Adverse Event Reporting System (FAERS) database in 2023.

METHODS

The case/noncase approach was used to estimate the reporting odds ratio (ROR) and information component (IC) with relevant 95% CI for adverse events (AEs) that numbered 3 or more.

RESULTS

A total of 2158 cases were included in the analysis. Main safety signals identified were ear and labyrinth disorders, reproductive system and breast disorders, metabolism and nutrition disorders, and gastrointestinal disorders. Specifically, autophony (ROR [95% CI] = 4188.34 [1403.29-12500.8]), eyelid retraction (ROR [95% CI] = 2094.17 [850.69-5155.29]), permanent deafness (ROR [95% CI] = 1552.35 [789.07-3053.98]), bilateral deafness (ROR [95% CI] = 73.12 [41.14-129.97]), inflammatory bowel disease (ROR [95% CI] = 23.26 [13.46-40.19]), hyperglycemic hyperosmolar nonketotic syndrome (ROR [95% CI] = 17.75 [5.70-55.28]), and amenorrhea (ROR [95% CI] = 47.98 [36.22-63.54]) showed significant safety signals with teprotumumab.

CONCLUSION

This study identified ear and labyrinth disorders, and reproductive system and breast disorders, as specific safety signals of teprotumumab. Clinicians and pharmacists should be vigilant regarding these AEs. However, available data are currently insufficient, and further pharmacovigilance and surveillance are needed to fully understand this issue.

Stability of Ocular Alignment After Teprotumumab Therapy in a Cohort of Patients With Thyroid Eye Disease and Baseline Diplopia

BACKGROUND

Teprotumumab is a monoclonal antibody that is effective in treating patients with thyroid eye disease (TED) and has been shown to produce subjective improvements in diplopia in this group. The aims of this study were to evaluate the rate and timing of recurrence/worsening of diplopia after teprotumumab treatment in a cohort of patients with TED presenting with diplopia at baseline.

METHODS

A retrospective chart review of 15 patients with diplopia secondary to TED, treated with teprotumumab, was conducted in a single-center academic institution. The primary outcome was the rate of recurrence/worsening of diplopia after completing teprotumumab. Secondary outcomes include the time to recurrence/worsening of diplopia and clinical activity scores (CAS) to correlate with changes in ocular alignment.

RESULTS

Fifteen patients met the inclusion criteria for this study, and 7 of these had recurrence of diplopia (46.7%). Two patients had worsening of CAS to ≥4, 6 had worsening of CAS to 3, and the other 7 had CAS ≤2 during the follow-up period. The mean follow-up period was 20.4 months (SD 7.2) after completing teprotumumab. The mean time to diplopia recurrence/worsening was 8.8 months (range 6.7-12.2, SD 1.8).

CONCLUSIONS

Patients with TED and baseline diplopia have a substantial rate of recurrence/worsening of diplopia after teprotumumab therapy, suggesting that they may not have stable ocular alignment immediately after treatment. Strabismus surgeons may need to weigh the significant risk of disease relapse when planning optimum timing for surgical correction.

Hyperlipidemia and apolipoprotein E are associated with intraocular pressure of thyroid-associated ophthalmopathy in a Chinese population: a cross-sectional study

Objective

This study aimed to explore the clinical characteristics of thyroid-associated ophthalmopathy (TAO) with hyperlipidemia and to identify the key lipid indicator.

Methods

Patients with TAO were recruited to this study and divided into two groups based on the presence of hyperlipidemia. TAO patients with hyperlipidemia were further classified based on the type of hyperlipidemia. Basic and clinical information of the patients were collected, and comparisons between groups were carried out. Correlation analyses, regression analyses, and stratified analysis were performed to assess the correlations and relationship of the serum lipids with the ophthalmic indicators.

Results

A total of 273 patients with TAO were recruited, including 158 patients with hyperlipidemia and 115 patients without hyperlipidemia. Patients with hyperlipidemia, especially those with mixed hyperlipidemia, exhibited high intraocular pressure (IOP). Spearman's correlation analysis and partial correlation analysis showed that apolipoprotein E (ApoE) was positively related to IOP levels after controlling for confounding factors, including age, gender, BMI, smoking history, triiodothyronine (T3), and thyrotropin (thyroid-stimulating hormone, TSH). Moreover, multiple linear regression obtained a regression equation including ApoE, gender, age, and BMI and showed that elevated ApoE levels were associated with elevated IOP [β = 0.072, 95% confidence interval (CI) = 0.037-0.155, p = 0.030]. Stratified analysis highlighted the impact of ApoE on IOP in younger patients (≤48 years), female patients, patients with normal BMI (<24 kg/m2), and patients with a shorter course of ophthalmopathy (≤6 months).

Conclusion

Overall, higher IOP levels were observed in patients with hyperlipidemia, especially those with mixed hyperlipidemia. Notably, a higher ApoE was identified as an independent risk factor for higher IOP. This finding confirmed the close relationship between TAO and lipid metabolism and provides a new insight into the pathogenesis research and the long-term management of TAO.

Advances of IGF-1R inhibitors in Graves' ophthalmopathy

Graves' ophthalmopathy is the most common extra-thyroidal organ manifestation of Graves' disease. The mainstay of clinical treatment is glucocorticoids; however, side effects and relapse are common problems, and current treatment options cannot alter the disease progression. IGF-1R is an important component of the signaling pathway in Graves' ophthalmopathy, and downstream signaling of IGF-1 and IGF-1R plays a role in many immune-related diseases, possibly leading to disease occurrence through changes in immune phenotype and protein synthesis. Teprotumumab is a human monoclonal antibody targeting the insulin-like growth factor-I receptor (IGF-1R). Clinical trials have shown that teprotumumab reduces proptosis better than placebo, and may be beneficial for patients with worsening disease after steroid cessation. In this review, we discuss the role and prospects of IGF-1R inhibitors in thyroid-associated ophthalmopathy.

Graves disease: latest understanding of pathogenesis and treatment options

Graves disease is the most common cause of hyperthyroidism in iodine-sufficient areas. The main responsible mechanism is related to autoantibodies that bind and activate the thyrotropin receptor (TSHR). Although Graves hyperthyroidism is relatively common, no causal treatment options are available. Established treatment modalities are antithyroid drugs, which reduce thyroid hormone synthesis, radioactive iodine and surgery. However, emerging drugs that target the main autoantigen (monoclonal antibodies, small molecules, peptides) or block the immune pathway have been recently tested in clinical trials. Graves disease can involve the thyroid exclusively or it can be associated with extrathyroidal manifestations, among which Graves orbitopathy is the most common. The presence of Graves orbitopathy can change the management of the disease. An established treatment for moderate-to-severe Graves orbitopathy is intravenous glucocorticoids. However, recent advances in understanding the pathogenesis of Graves orbitopathy have allowed the development of new target-based therapies by blocking pro-inflammatory cytokine receptors, lymphocytic infiltration or the insulin-like growth factor 1 receptor (IGF1R), with several clinical trials providing promising results. This article reviews the new discoveries in the pathogenesis of Graves hyperthyroidism and Graves orbitopathy that offer several important tools in disease management.

Effects of Teprotumumab and Role of Human Leukocyte Antigens Markers in Patients With Thyroid Eye Disease

OBJECTIVE

To evaluate the effects of teprotumumab on ophthalmologic and biochemical findings and assess potential genetic markers for response to treatment.

METHODS

This is a retrospective study. Participants were 18-76 year old. All subjects were treated with teprotumumab. The primary outcome was the change in proptosis before and after teprotumumab treatment. Secondary outcomes include change in other ophthalmic measures and thyroid laboratory tests. Human leukocyte antigens (HLA) markers were analyzed for response to teprotumumab.

RESULTS

Twenty-six patients were included in the final analysis. There was a significant decrease in thyroid stimulating immunoglobulin and thyrotropin receptor antibody levels and significant increases in glycated hemoglobin A1c, fasting glucose, and total T3 levels. There was also significant reduction in proptosis, clinical activity score, retinal nerve fiber layer thickness, ganglion cell analysis, and intraocular pressure. HLA haplotypes were distinct between responders and nonresponders, with HLA-DRB3 02:02:01G, HLA-DRB4 neg, and HLA-DQB1 02:01:01G demonstrating better response to teprotumumab and HLA-A 23:01:01G strongly correlating to nonresponse.

CONCLUSIONS

Patients with both acute and chronic thyroid eye disease treated with teprotumumab had a significant reduction in thyroid stimulating immunoglobulin and thyrotropin receptor antibody levels and improvement in proptosis, clinical activity score, retinal nerve fiber layer and ganglion cell analysis thickness, and intraocular pressure. HLA may predict responders vs nonresponders. Further studies with longer duration and larger population comparing teprotumumab with steroids or other immunomodulatory agents (tocilizumab, rituximab, etc) may be helpful.

A Comprehensive Review of Thyroid Eye Disease Pathogenesis: From Immune Dysregulations to Novel Diagnostic and Therapeutic Approaches

Thyroid eye disease is a complex inflammatory disorder of the orbit that has gained tremendous interest over the past years, and numerous scientific efforts have been deployed to elucidate its pathophysiology for novel drug development. Our manuscript will delve into the molecular dysregulations involved in the pathogenesis of thyroid eye disease that led to its clinical manifestations. Abnormalities within the apoptotic pathway, inflammatory cascade, and autoimmune regulatory systems will be covered. We will further discuss the challenges involved in its diagnosis and management and provide a summary of the current diagnostic tools (i.e., molecular biomarkers, diagnostic scores) from the perspective of clinicians. Finally, our comprehensive literature review will provide a thorough summary of most recent preclinical and clinical studies around the topic of thyroid eye disease, with an emphasis on the manuscripts published within the last five years. We believe our manuscript will bring novelty within the field by bridging the fundamental sciences with the clinical aspect of this disease. This review will be a great tool for clinicians in better understanding the pathogenesis of thyroid eye disease while providing an outlook on future perspectives (i.e., liquid biopsies, artificial intelligence).

Impact of Teprotumumab on Clinical Practice in Thyroid Eye Disease

BACKGROUND

Following its Food and Drug Administration approval in January 2020, we examined the impact of teprotumumab on thyroid eye disease (TED) clinical practices.

METHODS

Across 3 referral centers from January 1, 2018, to December 30, 2022, we retrospectively analyzed demographics, clinical features, treatment choices, and insurance status of patients with active, moderate to severe TED.

RESULTS

Of 74 patients recommended for medical therapy, 53% received collaborative recommendations from endocrinologists and ophthalmologists in a TED clinic. Prior to teprotumumab availability, 19 patients were recommended medical therapy, and all received medical therapy (100%), which consists of corticosteroids (14, 73.7%) or tocilizumab (5, 26.3%). After teprotumumab became available, out of 55 patients that were recommended medical therapy, only 41 (74.6%) received medical therapy, mostly teprotumumab (33, 60%), followed by corticosteroids (5, 9.1%) or tocilizumab (3, 5.4%), while 14 (25.4%) did not receive medical therapy. Discordance between physicians' recommendations and therapy received or lack thereof was explained by patients' refusal (9, 64.3%), mostly due to side effect concerns (8, 88.9%), and insurance denial (5, 35.7%). Teprotumumab use was mostly associated with otic changes (10, 30.3%), weight loss (9, 27.3%), and hyperglycemia (6, 18.2%), but 2 (6.1%) patients developed serious infections. Corticosteroids were associated with insomnia (4, 21.1%), and 1 patient in the tocilizumab group had an infusion reaction requiring hospitalization.

CONCLUSION

Teprotumumab introduction increased TED therapy evaluations, yet not all received recommended treatment due to safety concerns or accessibility issues. Enhancing collaborative care, medication accessibility, and adverse effect management is crucial.

Teprotumumab's Impact on Proptosis in Long-duration Thyroid Eye Disease: A Systematic Review and Meta-analysis

Background: Long-duration thyroid eye disease (TED) may present with persistent proptosis despite the absence of inflammatory symptoms, and treatment options have been limited to surgical intervention. Recently, teprotumumab, a monoclonal antibody, has garnered interest as a non-surgical option to reduce proptosis in such cases. This systematic review investigates the impact of teprotumumab on reducing proptosis in long-duration TED. Methods: A search was conducted across major online databases, and data were aggregated from observational studies, clinical trials and case series. Nine studies met the inclusion criteria. Cumulative and weighted effect measures were synthesized. The biases and limitations of each study were assessed. Results: Existing evidence shows teprotumumab to be highly efficacious in reducing proptosis in chronic TED; however, there are significant limitations in the quality of existing evidence. The cumulative meta-analysis reveals a mean proptosis reduction of 3.05 ± 0.54 mm across 182 orbits from nine studies, and the weighted meta-analysis shows a mean reduction of 2.69 ± 0.53 mm across 172 orbits from eight studies. Discussion: While existing clinical studies are open to bias and intrinsically limited, the meta-analysis dilutes the risk of bias by weighting more precise evidence, providing the highest quality evidence to date. Further research is essential to understand teprotumumab's long-term efficacy and comparative advantages over surgical options. These findings have significant implications for treating persistent proptosis in patients with long-duration TED, potentially offering a non-surgical alternative where options were previously limited.

Teprotumumab for the Treatment of Thyroid Eye Disease: Why Should We Keep Our Eyes "Wide Open"?-A Clinical and Pharmacovigilance Point of View

Objectives: Thyroid eye disease (TED) treatment has been recently revolutionized with the approval of teprotumumab, a targeted insulin growth factor 1 receptor (IGF1R) inhibitor. To date, teprotumumab is the only FDA-approved drug for treating TED. In this article, we would like to temper the current enthusiasm around IGF1R inhibitors. Methods: critical review of the literature by independent academic practitioners. Results: several questions should be raised. First, "how an orphan drug has become a blockbuster with annual sales exceeding $1 billion?" Teprotumumab infusions are expensive, costing about USD 45,000 for one infusion and USD 360,000 for eight infusions in a 75 kg patient. Teprotumumab approval was based on two randomized clinical trials investigating active (clinical activity score ≥ 4) TED patients. Despite this, teprotumumab was approved by the FDA for "the treatment of TED" without distinguishing between active and inactive forms. The second question is as follows: "how can a new drug, compared only to a placebo, become the new standard without being compared to historically established gold standard medical or surgical treatments?" Teprotumumab has never been compared to other medical treatments in active TED nor to surgery in chronic TED. Up to 75% of patients may experience proptosis regression after treatment discontinuation. Finally, ototoxicity has emerged as a potentially devastating side effect requiring frequent monitoring. Investigation into the long-term side effects, especially in women of childbearing age, is also warranted. Conclusions: Teprotumumab is undoubtedly a major treatment option in TED. However, before prescribing a drug, practitioners should assess its benefit/risk ratio based on the following: (i) evidence-based medicine; (ii) their empirical experience; (iii) the cost/benefit analysis; (iv) the long-term outcomes and safety profile.

The effect of teprotumumab infusion on ocular alignment in patients with symptomatic thyroid eye disease

BACKGROUND

Thyroid eye disease (TED) can result in proptosis and ocular misalignment, leading to eye pain, diplopia, and vision loss. Teprotumumab, a humanized antibody against insulin-like growth factor 1 receptor, was approved in 2020 for the treatment of TED. The purpose of this study was to describe the effect of a full course of teprotumumab on ocular misalignment.

METHODS

The medical records of patients who underwent treatment with teprotumumab for active moderate-to-severe TED at a single institution from April 2020 to September 2023 were reviewed retroactively. Sensorimotor examination was performed at each visit using simultaneous prism-cover testing. Demographic information and previous history of radioactive iodine, steroids, strabismus surgery, and smoking were extracted from the record for analysis.

RESULTS

A total of 19 patients were treated during the study period, of whom 11 had strabismus and diplopia. The initial absolute horizontal misalignment in these 11 was 6.0Δ ± 1.5Δ, vertical misalignment was 7.7Δ ± 2.4Δ, and total misalignment was 11.5Δ ± 2.0Δ. On completion of treatment, these measurements decreased by 2.0Δ ± 1.5Δ, 2.2Δ ± 1.0Δ, and 3.2Δ ± 1.6Δ, respectively (P = 0.10, 0.02, and 0.04, resp.). Eight patients (73%) had a decrease in their strabismus, and 5 (46%) reported complete resolution of their diplopia at the final visit. No factors were predictive of which patients would have resolution of their misalignment. Of the remaining 3 patients who had no improvement in ocular alignment, 2 (66%) underwent strabismus surgery. Of the 8 patients with improvement of strabismus, only a single patient (13%) underwent strabismus surgery for persistent diplopia.

CONCLUSIONS

In our study cohort, a full course of teprotumumab coincided with complete resolution of diplopia in 46% of patients and a decrease in strabismus in 73% of patients.

Thyroid Eye Disease: Advancements in Orbital and Ocular Pathology Management

Thyroid Eye Disease (TED) is a debilitating autoimmune condition often associated with thyroid dysfunction, leading to significant ocular and orbital morbidity. This review explores recent advancements in the management of TED, focusing on both medical and surgical innovations. The introduction of Teprotumumab, the first FDA-approved drug specifically for TED, marks a pivotal development in medical therapy. Teprotumumab targets the insulin-like growth factor-1 receptor (IGF-1R), effectively reducing inflammation and tissue remodeling. Clinical trials demonstrate its efficacy in reducing proptosis and improving quality of life, making it a cornerstone in the treatment of active, moderate-to-severe TED. Surgical management remains critical for patients with chronic TED or those unresponsive to medical therapy. Advancements in orbital decompression surgery, including image-guided and minimally invasive techniques, offer improved outcomes and reduced complications. Innovations in eyelid and strabismus surgery enhance functional and cosmetic results, further improving patient satisfaction. The management of TED necessitates a multidisciplinary approach involving endocrinologists, ophthalmologists, oculoplastic surgeons, radiologists, and other specialists. This collaborative strategy ensures comprehensive care, addressing the diverse aspects of TED from thyroid dysfunction to ocular health and psychological well-being. Future directions in TED treatment include emerging pharmacological therapies targeting different aspects of the disease's pathophysiology and advanced surgical techniques aimed at enhancing precision and safety. This review underscores the importance of a personalized, multidisciplinary approach in managing TED, highlighting current advancements, and exploring potential future innovations to improve patient outcomes and quality of life.

Glycemic Trends in Patients with Thyroid Eye Disease Treated with Teprotumumab in 3 Clinical Trials

PURPOSE

Assess incidence, severity, and glucose excursion outcomes in thyroid eye disease (TED) patients receiving the insulin-like growth factor-1 receptor inhibitor teprotumumab from 3 clinical trials.

DESIGN

Analysis of pooled glycemic data over time.

PARTICIPANTS

Eighty-four teprotumumab- and 86 placebo-treated active TED patients from the phase 2 and phase 3 (OPTIC) controlled clinical trials and 51 teprotumumab-treated patients from the OPTIC extension (OPTIC-X) trial.

METHODS

Eight intravenous infusions were given over 21 weeks. Phase 2 serum glucose was measured at weeks 1, 4, 15, and 21, with fasting measurements at weeks 1 and 4. Serum glucose was measured at each study visit in OPTIC and OPTIC-X, with fasting measurements at weeks 1 and 4 (in patients without diabetes) or all visits (in patients with diabetes). In all studies, hemoglobin A1c (HbA1c) was measured at baseline, 12, and 24 weeks plus weeks 36 and 48 in OPTIC-X.

MAIN OUTCOME MEASURES

Serum glucose and HbA1c.

RESULTS

In the phase 2 and 3 studies, 9 hyperglycemic episodes occurred in 8 teprotumumab patients; mean HbA1c level increased 0.22% from baseline to week 24 (to 5.8%; range, 5.0%-7.9%) versus 0.04% in patients receiving the placebo (to 5.6%; range, 4.6%-8.1%). At study end, 78% (59/76) of teprotumumab patients and 87% (67/77) of patients receiving placebo had normoglycemic findings. Normoglycemia was maintained in 84% (57/68) of patients receiving teprotumumab and 93% (64/69) of patients receiving placebo. Among baseline prediabetic patients, 43% (3/7) remained prediabetic in both groups, and 29% (2/7) of teprotumumab patients and 14% (1/7) of patients receiving placebo had diabetic findings at week 24. OPTIC-X patients trended toward increased fasting glucose and HbA1c whether initially treated or retreated with teprotumumab. Fasting glucose commonly rose after 2 or 3 infusions and stabilized thereafter. Most hyperglycemic incidents occurred in patients with baseline prediabetes/diabetes but were controlled with medication. No evidence was found for progression or increased incidence of hyperglycemia with subsequent doses.

CONCLUSIONS

Serious glycemic excursions are uncommon in patients with normoglycemia before teprotumumab therapy. Patients with controlled diabetes or impaired glucose tolerance can be treated safely if baseline screening, regular monitoring of glycemic control, and timely treatment of hyperglycemia are practiced.

FINANCIAL DISCLOSURE(S)

Proprietary or commercial disclosure may be found in the Footnotes and Disclosures at the end of this article.

Teprotumumab for Thyroid Eye Disease-related Strabismus

PURPOSE

To assess and quantify teprotumumab's effect on thyroid eye disease-related strabismus by change in measured horizontal and vertical deviations and change in extraocular motility.

METHODS

We reviewed a series of patients with thyroid eye disease-related strabismus treated with teprotumumab. Exclusion criteria included age under 18 years, strabismus of alternate etiology, or thyroid eye disease-related reconstructive surgery during the treatment course. Primary outcomes were absolute (prism diopters) and relative (%) differences in horizontal and vertical deviations in primary position at distance, as well as change in ductions of the more affected eye. Secondary outcomes included incidence and timing of strabismus surgery postteprotumumab.

RESULTS

Thirty-one patients were included, with mean age 63 years and thyroid eye disease duration 10 months. After teprotumumab, there was 6 prism diopters (39%) mean reduction in vertical deviation ( p < 0.001), without significant change in mean horizontal deviation ( p = 0.75). Supraduction, abduction, adduction, and infraduction significantly improved in the more restricted eye ( p < 0.01, p < 0.01, p = 0.04, and p = 0.01, respectively). Thirty-five percent of patients underwent strabismus surgery posttreatment, at an average 10 months after last infusion.

CONCLUSIONS

Teprotumumab produced a statistically significant reduction in vertical but not horizontal strabismus angles in primary position at distance. Extraocular motility in all 4 ductions also improved. A substantial minority of patients still required strabismus surgery following teprotumumab.

Long-Term Efficacy of Teprotumumab in Thyroid Eye Disease: Follow-Up Outcomes in Three Clinical Trials

Introduction: Thyroid eye disease (TED) is an autoimmune process characterized by extraocular muscle and orbital fat remodeling/expansion resulting in swelling, pain, redness, proptosis, and diplopia. Teprotumumab, an insulin-like growth factor-I receptor inhibitor, demonstrated improvements in TED signs and symptoms in three adequately powered clinical trials of 24 weeks duration. Here we analyze the long-term maintenance of responses with teprotumumab from these trials. Methods: A total of 112 patients who received 7 or 8 infusions of teprotumumab in the Phase 2, Phase 3 (OPTIC study), and OPTIC Extension (OPTIC-X) studies were included in this analysis. Responses, including clinical activity score (CAS ≥2-point improvement), the European Group of Graves' Orbitopathy ophthalmic composite outcome, diplopia (≥1 Gorman grade improvement), proptosis (≥2 mm improvement), Overall (improvement in proptosis + CAS), and disease inactivation (CAS ≤1), were assessed and pooled from study baseline to week 24 (formal study) and up to week 72 (formal follow-up). Graves' Ophthalmopathy quality-of-life (GO-QoL) scores were also assessed. Outcomes included the percentages of observed patient responses from the study baseline. Additional alternative treatments for TED were assessed as a surrogate of persistent benefit from week 24 through week 120 (extended follow-up). Studies differed in the timing of follow-up visits, and data from some visits were unavailable. Results: At week 72, 52/57 (91.2%), 51/57 (89.5%), 35/48 (72.9%), 38/56 (67.9%), and 37/56 (66.1%) of patients were responders for CAS, composite outcome, diplopia, proptosis, and Overall response, respectively. The mean reduction in proptosis was 2.68 mm (SD 1.92, n = 56), mean GO-QoL improvement was 15.22 (SE 2.82, n = 56), and disease inactivation (CAS ≤1) was detected in 40/57 (70.2%). Over 99 weeks following teprotumumab therapy, 19/106 (17.9%) patients reported additional TED therapy during formal and extended follow-up. Conclusion: The long-term response to teprotumumab as observed 51 weeks after therapy was similar to week 24 results in the controlled clinical trials. Inflammatory and ophthalmic composite outcome improvements were seen in 90% of patients with nearly 70% reporting improvement in diplopia and proptosis. Further, 82% of patients in this analysis did not report additional TED treatment (including surgery) over 99 weeks following the final teprotumumab dose.

Reactivation After Teprotumumab Treatment for Active Thyroid Eye Disease

PURPOSE

To determine the recurrence and reactivation rates after teprotumumab therapy for active thyroid eye disease.

DESIGN

Retrospective consecutive case series.

METHODS

This was a study of all patients followed for active thyroid eye disease at the Cole Eye Institute, Cleveland Clinic, treated with teprotumumab between May 2020 and May 2021. Patients with less than 6 months follow-up after completion of infusions were excluded. The primary outcome measure was reactivation, defined as a regression in proptosis (increase of ≥2 mm in either eye and to within ≤2 mm of pre-treatment level and Clinical Activity Score [CAS] worsening of 2 points or greater). Secondary outcome was diplopia response.

RESULTS

A total of 21 patients were included in the study. The average long-term improvement in proptosis in the eye with more proptosis after teprotumumab was 1.57mm (range, -3 to 4 mm). Of the 17 initial responders, there were 8 reactivations (47%) and 2 isolated proptosis regressions (12%); Overall, 7 of 21 patients (33%) responded throughout the study period. Average time to regression was 12.25 months (range, 2-22.5 months). There was no statistically significant change in diplopia at final visit in any subgroup (P = 0.68 to >.99).

CONCLUSIONS

At most, 33% of patients demonstrate continued response 2 years after teprotumumab treatment. The proptosis and CAS regression occurs in the setting of disease reactivation in 80% of regressions. Teprotumumab treatment appears to offer minimal long-term improvement in diplopia.

The changing landscape of thyroid eye disease: current clinical advances and future outlook

AIMS

This review aims to provide an overview of the current understanding of TED and its pathophysiology. To describe the evidence base for current consensus treatment recommendations and newer biological therapies available as well as to present future therapeutic research.

METHODS

We reviewed and assessed the peer-reviewed literature placing particular emphasis on recent studies evaluating the pathophysiology of TED, landmark trials forming the basis of current management and recent clinical trials informing future therapeutics. Searched were made in MEDLINE Ovid, Embase Ovid, US National Institutes of Health Ongoing Trials Register and EU Clinical Trials Register. Keywords included: "Thyroid Eye Disease", "Graves Orbitopathy", "Thyroid Orbitopathy" and "Graves' Ophthalmopathy".

RESULTS AND CONCLUSIONS

The pathophysiology of TED involves a complex array of cellular and humoral based autoimmune dysfunction. Previous therapies have been broad-based acting as a blunt instrument on this mechanism with varying efficacy but often accompanied with a significant side effect profile. The recent development of targeted therapy, spearheaded by Teprotumumab has led to an array of treatments focusing on specific components of the molecular pathway optimising their impact whilst possibly minimising their side effect profile. Future challenges involve identifying the most effective target for each patient rather than any single agent being a panacea. Long-term safety profiles will require clarification as unintended immunological consequence downstream may become manifest as seen in other diseases. Finally, future novel therapeutics will entail significant expenditure and may lead to a divergence of available treatment modalities between healthcare systems due to funding disparities.

Outcomes of Strabismus Surgery Following Teprotumumab Therapy

PURPOSE

To investigate the results of patients undergoing surgical treatment for strabismic diplopia in thyroid eye disease (TED) following teprotumumab.

DESIGN

Multicenter, retrospective, case series.

METHODS

We report 28 patients who underwent extraocular muscle surgery for strabismic diplopia after treatment with teprotumumab at 7 different academic centers. Elapsed time from last teprotumumab dose to the date of surgery, previous orbital decompression, primary preoperative horizontal and vertical deviation, surgical procedure, and 2-month postoperative results were collected from the patient records.

RESULTS

Sixteen (57%) patients were diplopia-free after 1 surgery. Three (11%) chose prism spectacles to correct residual diplopia, 2 (7%) used compensatory head posture to resolve diplopia, and 1 (4%) had intermittent diplopia and was functionally improved (choosing no prisms or further surgery). These were considered treatment successes. Three (11%) patients required reoperation, and all were diplopia-free after their second procedure.

CONCLUSIONS

Most patients requiring surgery for strabismic diplopia following teprotumumab achieve good outcomes with success rates comparable to series published before the availability of teprotumumab.

[Interdisciplinary Management of Orbital Diseases]

Diagnosis and therapy of orbital diseases is an interdisciplinary challenge, in which i.e. otorhinolaryngologists, ophthalmologists, radiologists, radiation therapists, maxillo-facial surgeons, endocrinologists, and pediatricians are involved. This review article describes frequent diseases which both, otolaryngologists and ophthalmologists are concerned with in interdisciplinary settings. In particular the inflammatory diseases of the orbit including orbital complications, autoimmunological diseases of the orbit including Grave´s orbitopathy, and primary and secondary tumors of the orbit are discussed. Beside describing the clinical characteristics and diagnostic steps the article focusses on the interdisciplinary therapy. The review is completed by the presentation of most important surgical approaches to the orbit, their indications and possible complications. The authors tried to highlight the relevant facts despite the shortness of the text.

Predictive model for the progression of inactive thyroid eye disease: a retrospective study

PURPOSE

This study aimed to develop a model for predicting the progression of inactive thyroid eye disease (TED).

METHODS

We retrospectively analyzed 107 patients with inactive TED, who did not receive any TED treatment during the follow-up period of 3-6 months. A multivariable regression analysis was employed to examine the clinical risk factors influencing the progress of TED and a predictive model based on risk factors was established.

RESULTS

Seventeen (15.9%) patients had progressed at the last observation. Male (p = 0.024), having smoking history (p = 0.009), compound indicator combined the duration of TED and immunosuppressive treatment history before 3 months (p = 0.026) and more severe diplopia (p = 0.015) were found to be the potential risk factors for progression. Among the subset of patients who exhibited progression, there was a notable escalation in the severity of proptosis (p = 0.021), margin reflex distance-1 (p = 0.031), and clinical activity score (p = 0.011). The multivariable stepwise regression analysis identified positive smoking history as well as untreated and having a duration of TED > 12 months as independent risk factors of TED progression. A predictive model including these risk factors was built, with the AUC (Area Under Curve) score of 0.783.

CONCLUSIONS

The predictors of TED progression include smoking history and composite indicators of duration time and treatment history. Our model may provide recommendations for immunosuppressive therapy and prognostic predictions for inactive TED patients preparing for surgery.

Teprotumumab for the Treatment of Recalcitrant Thyroid Eye Disease

PURPOSE

Teprotumumab, an insulin-like growth factor 1 receptor monoclonal antibody, is FDA-approved to treat thyroid eye disease (TED). The initial clinical trials excluded patients with previous orbital irradiation, surgery, glucocorticoid use (cumulative dose >1 gm), or prior biologic treatment. Information on the use of teprotumumab for patients who failed prior therapy is limited. Our purpose is to characterize the efficacy of teprotumumab for the treatment of recalcitrant TED.

METHODS

This is a multicenter retrospective study of all patients treated with teprotumumab for moderate-to-severe TED after failing conventional therapy with corticosteroids, orbital radiation, surgical decompression, biologics, or other steroid-sparing medications. Treatment failure was defined as an incomplete response to or reactivation after previous treatment. Only patients who received at least 4 infusions of teprotumumab were included in the analysis. Primary outcome measures comprised proptosis response (≥2 mm reduction in the study eye without a similar increase in the other eye), clinical activity score (CAS) response (≥2-point reduction in CAS), and diplopia response (≥1 point improvement in Gorman diplopia score in patients with baseline diplopia) following treatment. Adverse events and risk factors for recalcitrant disease were also evaluated.

RESULTS

Sixty-six patients were included in this study, 46 females and 20 males. Average age was 59.3 years (range 29-93). The mean duration of disease from TED diagnosis to first infusion was 57.8 months. The proptosis, CAS, and diplopia responses in this recalcitrant patient population were 85.9%, 93.8%, and 69.1%, respectively. Patients experienced a mean reduction in proptosis of 3.1 ± 2.4 mm and a mean improvement in CAS of 3.8 ± 1.6. Patients who underwent prior decompression surgery experienced a statistically significant decrease in diplopia response (46.7% vs. 77.5%, p = 0.014) and proptosis response (75.0% vs. 90.9%, p = 0.045) when compared with nondecompression patients. Additionally, there were no significant differences in proptosis, CAS, and diplopia responses between patients with acute (defined as disease duration <1 year) versus chronic (disease duration ≥1 year) TED. While most adverse events were mild to moderate, 4 patients reported serious adverse events related to persistent hearing loss.

CONCLUSIONS

Patients with recalcitrant TED demonstrated a significant improvement after teprotumumab in each of the primary study outcomes. The degree of proptosis reduction, diplopia response, and CAS improvement in the recalcitrant group were similar to those of treatment-naïve patients from the pivotal clinical trials. Patients with a prior history of orbital decompression, however, demonstrated poor improvement in diplopia and less reduction in proptosis than surgery naïve patients. These results indicate that teprotumumab is a treatment option for the treatment of patients with TED recalcitrant to prior medical therapies.

A comparison of proptosis reduction with teprotumumab versus surgical decompression based on fat-to-muscle ratio in thyroid eye disease

PURPOSE

To explore if orbital fat-to-muscle ratio (FMR) is predictive of whether surgical decompression or teprotumumab leads to greater proptosis reduction in thyroid eye disease (TED).

METHODS

A single-center retrospective cohort study comparing surgical decompression with teprotumumab according to FMR. All TED patients completing an 8-dose course of teprotumumab between January 2020 and September 2022 and all patients undergoing bony orbital decompression from January 2017 to December 2019 were included. Subjects were excluded if they were <18 years, received both surgical decompression and teprotumumab, or lacked orbital imaging. The primary exposure variable was teprotumumab or surgical decompression. The secondary exposure variable was baseline FMR. The primary outcome measure was change in proptosis (mm).

RESULTS

Thirty-eight patients, mean age 53.5 years (±11.4), were included in the teprotumumab group and 160 patients, mean age 48 years (±11.1), in the surgical group. Average proptosis reduction after teprotumumab and surgical decompression was 3 mm (±1.44) and 5 mm (±1.75), respectively. The FMR was stratified at the median of 1.80. In subjects with FMR < 1.80, teprotumumab showed equivalent proptosis reduction compared to surgical decompression, -0.33 mm (SE 1.32) p = .802. In subjects with FMR ≥ 1.80, surgical decompression led to significantly more proptosis reduction than teprotumumab, 3.01 mm (SE 0.54), p < .001.

CONCLUSIONS

Baseline FMR can be used to counsel patients as to proptosis reduction with teprotumumab versus surgery. Subjects with low FMR obtain comparable proptosis reduction with teprotumumab or surgery, whereas high FMR is associated with more significant proptosis reduction following surgery over teprotumumab.

Data mining and analysis of adverse event signals associated with teprotumumab using the Food and Drug Administration adverse event reporting system database

BACKGROUND

Teprotumumab was approved by the US Food and Drug Administration (FDA) for the treatment of thyroid eye disease in 2020. However, its adverse events (AEs) have not been investigated in real-world settings.

AIM

This study aimed to detect and evaluate AEs associated with teprotumumab in the real-world setting by conducting a pharmacovigilance analysis of the FDA Adverse Event Reporting System (FAERS) database.

METHOD

Reporting odds ratio (ROR) was used to detect risk signals from the data from January 2020 to March 2023 in the FAERS database.

RESULTS

A total of 3,707,269 cases were retrieved, of which 1542 were related to teprotumumab. The FAERS analysis identified 99 teprotumumab-related AE signals in 14 System Organ Classes (SOCs). The most frequent AEs were muscle spasms (n = 287), fatigue (n = 174), blood glucose increase (n = 121), alopecia (n = 120), nausea (n = 118), hyperacusis (n = 117), and headache (n = 117). The AEs with strongest signal strengths were autophony (ROR = 14,475.49), deafness permanent (ROR = 1853.35), gingival recession (ROR = 190.74), deafness neurosensory (ROR = 129.89), nail growth abnormal (ROR = 103.67), onychoclasis (ROR = 73.58), ear discomfort (ROR = 72.88), and deafness bilateral (ROR = 62.46). Eleven positive AE signals were found at the standardized MedDRA queries (SMQs) level, of which the top five SMQs were hyperglycemia/new-onset diabetes mellitus, hearing impairment, gastrointestinal nonspecific symptoms and therapeutic procedures, noninfectious diarrhea, and hypertension. Age significantly increased the risk of hearing impairment.

CONCLUSION

This study identified potential new and unexpected AE signals of teprotumumab. Our findings emphasize the importance of pharmacovigilance analysis in the real world to identify and manage AEs effectively, ultimately improving patient safety during teprotumumab treatment.

Objective Diplopia Outcomes for Patients Treated With Teprotumumab for Thyroid Eye Disease

BACKGROUND

Thyroid eye disease (TED) is a condition caused by inflammatory damage to the periocular tissue that often leads to double vision. Teprotumumab is an insulin-like growth factor 1 receptor antibody that was FDA approved for the management of TED in 2020, although much is yet to be elucidated regarding its effects on diplopia outcomes among patients with TED. Diplopia is a significant and life-altering effect of TED. Previous studies have reported the effect of teprotumumab on double vision subjectively using the Gorman diplopia score. However, there is a gap in the literature addressing the effect of teprotumumab treatment on objective ocular alignment measures. The purpose of our study was to address this gap.

METHODS

We performed a retrospective review of patients who were diagnosed with TED, presented with diplopia, and treated with teprotumumab in a single-center academic ophthalmology practice. The primary outcome was change in ocular alignment in primary gaze position at 6 months (completion of teprotumumab treatment). Secondary outcomes included change in ocular alignment in other gaze positions, proptosis, eyelid position, and clinical activity score (CAS) at 6 months compared with baseline. To determine what factors may predict ocular alignment response to teprotumumab, we analyzed baseline characteristics among 3 groups, divided based on whether ocular alignment was worsened, stable, or improved at 6 months.

RESULTS

Seventeen patients met inclusion criteria, 3 (18%) worsened, 10 (59%) were stable, and 4 (24%) improved. CAS ( P = 0.02) was significantly different among the groups and was higher in those who worsened and those who improved compared with those who remained stable. Right gaze horizontal prism deviation ( P = 0.01) and left gaze horizontal prism deviation ( P = 0.03) were significantly different among the groups, with a greater degree of left gaze horizontal prism deviation in the worse group than the stable group ( P = 0.04).

CONCLUSIONS

Our study demonstrated that most patients remained stable after teprotumumab treatment regarding ocular alignment in primary gaze and the number of patients who improved was slightly higher than the number of patients who worsened after teprotumumab treatment. There are some baseline measures, such as CAS and right and left gaze horizontal prism deviation that can help better predict how a patient will respond to teprotumumab treatment. Our results can better inform physicians of how to counsel patients with TED when considering teprotumumab therapy.

Proptosis Regression After Teprotumumab Treatment for Thyroid Eye Disease

PURPOSE

This study analyzed the degree and timing of proptosis regression after teprotumumab therapy.

METHODS

A retrospective study of all patients who completed 8 teprotumumab infusions at 1 institution from January 1, 2020 to December 31, 2022. Change in proptosis was assessed in millimeters and percentages compared with immediate post-treatment and pretreatment proptosis.

RESULTS

Of 119 patients with post-treatment data (mean follow-up 10.56 months, range: 3.05-25.08), 208 (87.39%) eyes of 110 patients had initial proptosis improvement. Of the 78 patients with multiple follow-up visits, 102 (65.38%) eyes of 59 patients had proptosis regression averaging 12.78% (range: 1.85-58.82%) compared with immediately post-treatment or 2.43 mm (0.5-10.0 mm). Eight (7.84%) eyes had initial documentation of regression more than 1 year after treatment, 40 (39.22%) between 6 months and 1 year, and 54 (52.94%) eyes within 6 months with 25 (46.30%) of these continuing to worsen at subsequent follow-up. Forty (25.64%) eyes of 24 patients had more proptosis at most recent follow-up than before teprotumumab, with an average regression of 1.53 mm (0.5-4.0 mm) or 7.74% (1.85-20.69%) of pretreatment proptosis. In comparison, 99 (63.46%) eyes of 54 patients maintained improvement, with reduction averaging 3.13 mm (0.5-11.0 mm) or 13.19% (1.92-41.67%) of pretreatment proptosis ( p < 0.001).

CONCLUSIONS

Two-thirds of eyes had regression despite initial teprotumumab response, typically within 1 year of treatment, with ongoing worsening over time. Most patients maintained some proptosis reduction compared with before treatment despite regression, although 25% were worse than pretreatment. The occurrence of regression was independent of the pretreatment duration of clinical thyroid eye disease. Overall, compared with preteprotumumab, there was a greater amount of improvement than regression at most recent follow-up.

Disease Modulation Versus Modification: A Call for Revised Outcome Metrics in the Treatment of Thyroid Eye Disease

PURPOSE

This perspective introduces the concepts of disease-modulating and -modifying therapy for thyroid eye disease and offers novel metrics for therapeutic outcomes.

METHODS

A focused literature review was performed.

RESULTS

Modulators are treatments that suppress disease symptoms whereas modifiers alter the natural history of a disease. Though many drugs are capable of exhibiting both effects, consideration of a drug's primary effect is useful when considering therapeutic options. For thyroid eye disease, corticosteroids and teprotumumab are effective at modulating many signs and symptoms of the disease, particularly those related to soft tissue inflammation. Orbital radiotherapy and rituximab have demonstrated effectiveness at durably modifying the natural history of thyroid eye disease.

CONCLUSIONS

Outcome metrics should reflect the unique therapeutic objectives associated with disease modulation and modification. This conceptual framework should guide treatment of thyroid eye disease.

A case of rapidly declining glycemic control and diabetic ketoacidosis in a newly diagnosed diabetes patient after starting teprotumumab for thyroid eye disease

PURPOSE

Teprotumumab for thyroid eye disease has a known hyperglycemic adverse effect through its impact on the insulin-like growth factor-1 receptor. While most cases are mild and easily managed by adjusting diabetes medications, it appears some patients have a more dramatic response. The purpose of this case report is to highlight an example of rapidly declining glycemic control and diabetic ketoacidosis (DKA) in a patient with newly diagnosed diabetes after starting teprotumumab for thyroid eye disease.

METHODS

This was a single-patient case report assessing a severe episode of hyperglycemia leading to new-onset diabetes. The case report was approved by Atrium Health Wake Forest Baptist's IRB committee. The patient was closely monitored by a pharmacist-led pharmacotherapy clinic after initial diagnosis and periodically since then to adjust therapy and assess glucose and hemoglobin A1c (HbA1c) trends.

RESULTS

After the acute episode of DKA was managed inpatient, the patient was discharged with insulin outpatient, but this was ultimately weaned off, and the patient's glucose and HbA1c are stable on metformin alone. This patient decided to not continue teprotumumab due to extensive side effects including but not limited to severe hyperglycemia.

CONCLUSION

While additional research is needed as to the cause of severe hyperglycemia in select patients, providers should consider proactively monitoring glucose throughout treatment with teprotumumab by ensuring that patients have baseline labs and labs at every visit and access to a glucometer with education for its use.

Current Therapeutic Approaches for Graves' Orbitopathy - are Targeted Therapies the Future?

Graves' orbitopathy is an autoimmune disease of the orbit that most frequently occurs with Graves' hyperthyroidism. The occurrence of autoantibodies directed against the TSH receptor (TRAb) is of central importance for the diagnosis and pathogenesis. These autoantibodies are mostly stimulating, and induce uncontrolled hyperthyroidism and tissue remodelling in the orbit and more or less pronounced inflammation. Consequently, patients suffer to a variable extent from periocular swelling, exophthalmos, and fibrosis of the eye muscles and thus restrictive motility impairment with double vision. In recent decades, therapeutic approaches have mainly comprised immunosuppressive treatments and antithyroid drug therapy for hyperthyroidism to inhibit thyroid hormone production. With the recognition that TRAb also activates an important growth factor receptor, IGF1R (insulin-like growth factor 1 receptor), biological agents have been developed. Teprotumumab (an inhibitory IGF1R antibody) has already been approved in the USA and the therapeutic effects are enormous, especially with regard to the reduction of exophthalmos. Side effects are to be considered, especially hyperglycaemia and hearing loss. It is not yet clear whether the autoimmune reaction (development of the TRAb/attraction of immunocompetent cells) is also influenced by anti-IGF1R inhibiting agents. Recurrences after therapy show that the inhibition of antibody development must be included in the therapeutic concept, especially in severe cases.

Long-Term Follow-Up of a Case of Severe Hyperglycemia Requiring Hospitalization after Third Dose of Teprotumumab: A Case Report

Introduction

In 2020, teprotumumab became the first FDA-approved treatment for thyroid eye disease (TED). In clinical trials, hyperglycemia had been described as mild and controlled with medication. We present a case that occurred in 2020 of a 67-year-old male with TED and pre-existing glucose intolerance, who was hospitalized with severe hyperglycemia (1,059 mg/dL) after three doses of teprotumumab.

Case Presentation

This patient's HbA1c was in the pre-diabetic range (6.3%) 6 months prior to initiating teprotumumab. After three doses, the patient was hospitalized with hyperosmolar hyperglycemic nonketotic syndrome and an HbA1c of 11.7%. He was diagnosed with type 2 diabetes mellitus and treated with insulin aspart mixed 70/30. He remained on this regimen for 14 months with an A1c of 6.0%. He then self-discontinued the insulin, with an A1c 4 months later measuring 5.5%. The patient's latest HbA1c approximately two and a half years after hospitalization was 6.1% on no medications.

Conclusion

It appears that teprotumumab was a trigger for this transient case of diabetes, and detecting those that have underlying glucose intolerance ahead of time is important. We recommend blood glucose levels for patients with pre-diabetes prior to and ideally in the first few days after each infusion, to help determine patients at a greater risk for adverse hyperglycemic outcomes. A glucometer may be valuable for patients to self-monitor while on teprotumumab. If fasting blood glucose is ≥126 mg/dL or non-fasting glucose is >200 mg/dL, patients should be referred for further diabetes assessment and possible treatment initiation.

A Mini-review on New Developments in Nanocarriers and Polymers for Ophthalmic Drug Delivery Strategies

The eye is an important and vital organ of the human body consisting of two segments - anterior and posterior segments and these segments are associated with many diseases. This review elaborates upon the various eye-related diseases with their medications and carriers used to deliver them. Delivery strategies include drugs encapsulated into liposomes, polymeric micelles of drugs, solid lipid nanoparticles, nanostructured lipid carriers, nano emulsions, and Nanosuspension used to improve penetrating properties, bioavailability, and residence time of the drugs as examples available in the literature. With regard to this, different forms of ocular drug delivery are classified and elaborated. Additionally, the possibility of addressing the physical and chemical complexities of ocular diseases and how they could be overcome with environmentally stable nanoformulations are briefly discussed. Enhanced drug delivery efficiency with various novel pharmaceuticals along with enhanced uptake by different routes/modes of drug administration. Current advancements in drug carrier systems, i.e., nanocarriers, have shown promise for improving the retention time, drug permeation and prolonging the duration of release of the drug in the ocular site. Bio-degradable polymers investigated for the preparation of nanocarriers for the entrapment of drugs and to enhance the efficacy through improved adherence of tissue in the eye, sustained release measures, enhanced bioavailability, lower toxicity, and targeted delivery is applicable. This review covers the introduction of various nanocarriers and polymers for ocular drug delivery with the purpose of enhancing the absorption, retention and bioavailability of medications in the eye.

Teprotumumab in thyroid eye disease

Thyroid eye disease (TED) is an inflammatory condition involving the periocular and orbital soft tissues, affecting most commonly patients with hyperthyroid disorders. Traditional treatments used for the active phase of the disease range from conservative lubrication for mild symptoms to systemic immunomodulating drugs for moderate-to-severe symptoms. Teprotumumab (Tepezza) is a monoclonal antibody with an inhibitory effect on insulin-like growth factor 1 and is the first Food and Drug Administration (FDA) approved targeted medical therapy for reducing the inflammatory signs and symptoms associated with TED. Two large multicenter, randomized, double-masked, placebo-controlled trials have confirmed the efficacy and safety of teprotumumab in patients with active, moderate-to-severe TED. Recent reports and publications have also demonstrated the efficacy of teprotumumab in a wider range of patients. In this review, we summarize the clinical features and pathophysiology of TED, disease course, and traditional management methods. We further detail the development of teprotumumab, the founding studies that brought it to its FDA approval, adverse events profile, and ongoing as well as future investigations.

Immunological Processes in the Orbit and Indications for Current and Potential Drug Targets

Thyroid eye disease (TED) is an extrathyroidal manifestation of Graves' disease (GD). Similar to GD, TED is caused by an autoimmune response. TED is an autoimmune inflammatory disorder of the orbit and periorbital tissues, characterized by upper eyelid retraction, swelling, redness, conjunctivitis, and bulging eyes. The pathophysiology of TED is complex, with the infiltration of activated T lymphocytes and activation of orbital fibroblasts (OFs) and autoantibodies against the common autoantigen of thyroid and orbital tissues. Better understanding of the multifactorial pathogenesis of TED contributes to the development of more effective therapies. In this review, we present current and potential drug targets. The ideal treatment should slow progression of the disease with as little interference with patient immunity as possible. In the future, TED treatment will target the immune mechanism involved in the disease and will be based on a strategy of restoring tolerance to autoantigens.