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Zhang Z, Feng X, Guo Y, Kang X, Wang D, Zhang J, Zeng Z, Yuan G. Efficacy of rituximab in treating steroid-resistant Graves' orbitopathy in active moderate-to-severe and sight-threatening forms: A retrospective observation from China. Heliyon 2024; 10:e31932. [PMID: 38867959 PMCID: PMC11167350 DOI: 10.1016/j.heliyon.2024.e31932] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/29/2023] [Revised: 05/21/2024] [Accepted: 05/24/2024] [Indexed: 06/14/2024] Open
Abstract
Background and objectives The efficacy of rituximab (RTX) in treating steroid-resistant Graves' orbitopathy (GO) has been limitedly studied in Asians. Moreover, RTX has been considered even less for patients with steroid-resistant dysthyroid optic neuropathy (DON) who failed to undergo orbital decompression surgery for physical or financial reasons, or who responded poorly to the procedure. This study aimed to investigate the efficacy of RTX in treating steroid-resistant active moderate-to-severe and sight-threatening GO in a Chinese population. Methods Data from 28 patients with steroid-resistant GO prescribed a single dose of 500 mg RTX were retrospectively retrieved. Treatment responses and contributing factors were analyzed. Results The median follow-up time was 22 (8-34) weeks. 23 (82.1 %) patients had a positive objective outcome recommended by the European Group on Graves' Orbitopathy (EUGOGO), while 25 (92.6 %) had a decrease in 7-item clinical activity score (CAS) by at least 2. Diplopia, visual dysfunction, and MRI-detected T2 relaxation time of the involved extraocular muscles improved significantly at the last follow-up compared to baseline (81.0 % vs. 47.6 %, 38.9 % vs. 16.7 %, and 87.8 (8.64) vs. 75.8 (10.9) ms, respectively; all p values < 0.05). No significant improvement was seen in terms of proptosis and eye muscle duction. Notably, a higher baseline IgG4 to IgG ratio was a predictor for RTX-induced positive EUGOGO outcomes. After RTX treatment, all 8 patients with DON demonstrated inactivation, and 4 improved in visual acuity by ≥ 1 line. No patient with DON experienced obvious deterioration. Conclusion A single dose of 500 mg RTX seemed to be an effective and tolerable treatment for steroid-resistant GO. However, larger-scale studies with a control group are required for a more solid conclusion. The role of RTX in steroid-resistant DON management where surgery is unavailable or ineffective should be further explored.
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Affiliation(s)
- Ziyin Zhang
- Department of Endocrinology, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, 430030, China
- Branch of National Clinical Research Center for Metabolic Diseases, Wuhan, 430030, China
| | - Xiaohui Feng
- Department of Endocrinology, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, 430030, China
- Branch of National Clinical Research Center for Metabolic Diseases, Wuhan, 430030, China
| | - Yaoyao Guo
- Department of Endocrinology, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, 430030, China
- Branch of National Clinical Research Center for Metabolic Diseases, Wuhan, 430030, China
| | - Xiaonan Kang
- Department of Endocrinology, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, 430030, China
- Branch of National Clinical Research Center for Metabolic Diseases, Wuhan, 430030, China
| | - Dan Wang
- Department of Endocrinology, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, 430030, China
- Branch of National Clinical Research Center for Metabolic Diseases, Wuhan, 430030, China
| | - Jing Zhang
- Department of Radiology, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, 430030, China
| | - Zhixuan Zeng
- Department of Endocrinology, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, 430030, China
- Branch of National Clinical Research Center for Metabolic Diseases, Wuhan, 430030, China
| | - Gang Yuan
- Department of Endocrinology, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, 430030, China
- Branch of National Clinical Research Center for Metabolic Diseases, Wuhan, 430030, China
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Xavier NF, Lucena DT, Cruz AAV. Monoclonal Antibodies for the Treatment of Graves Orbitopathy: Precision Medicine? Ophthalmic Plast Reconstr Surg 2023; 39:307-315. [PMID: 36727923 DOI: 10.1097/iop.0000000000002315] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
PURPOSE To summarize the development, nomenclature, and rationale of the reported use of monoclonal antibodies (Mabs) in Graves Orbitopathy (GO) and to undertake a systematic review of the management of GO with Mabs. METHODS The Pubmed and Embase databases and the Federal Brazilian searching site (Periódicos-CAPES) were screened. The authors searched all the keywords "monoclonal antibodies," "adalimumab," "belimumab," "infliximab," "rituximab," "teprotumumab," and "tocilizumab" combined with the terms "Graves Orbitopathy," "Graves eye disease" and "thyroid eye disease." All the articles published in English, French, and Spanish from 2000 to May 2022 were screened. Only publications with quantitative data on the activity of orbitopathy, proptosis, or both were included. RESULTS Seventy-six articles of the 954 screened records met the inclusion criteria. Seven Mabs were described for treating GO. The three most reported Mabs were Rituximab, Tocilizumab, and Teprotumumab. Only eight randomized clinical trials compared the effect of these three Mabs and Belimumab with the effect of steroids or placebos. Adalimumab, Infliximab, and K1-70 only appeared in a few case series and case reports. Frequent mild-to-moderate and few major side effects occurred with the three most used Mabs. Relapse rates ranged from 7.4% for Tocilizumab to at least 29.4% for Teprotumumab. No randomized clinical trials compared Mabs head-to-head. CONCLUSION Considering the lack of head-to-head comparisons between Mabs, the relapse rate, the possibility of severe collateral effects, and the cost of Mabs, it is not clear which Mab is the safest and most useful to treat GO.
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Affiliation(s)
- Naiara F Xavier
- Department of Ophthalmology, School of Medicine of Ribeirão Preto - University of São Paulo, Brasil
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3
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Pelewicz-Sowa M, Miśkiewicz P. Dysthyroid optic neuropathy: emerging treatment strategies. J Endocrinol Invest 2023:10.1007/s40618-023-02036-0. [PMID: 36802028 DOI: 10.1007/s40618-023-02036-0] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/24/2022] [Accepted: 02/06/2023] [Indexed: 02/21/2023]
Abstract
PURPOSE Dysthyroid optic neuropathy (DON) is a rare sight-threatening complication of Graves' disease. First-line treatment for DON consists of high-dose intravenous methylprednisolone (ivMP), followed by immediate orbital decompression (OD) if the response is poor or absent as recommended by the 2021 European Group on Graves' orbitopathy guidelines. The safety and efficacy of the proposed therapy have been proven. However, consensus regarding possible therapeutic options for patients with contraindications to ivMP/OD or resistant form of disease is missing. This paper aims to provide and summarize all available data regarding possible alternative treatment strategies for DON. METHODS A comprehensive literature search within an electronic database was performed including data published until December 2022. RESULTS Overall, 52 articles describing use of emerging therapeutic strategies for DON were identified. Collected evidence indicates that biologics, including teprotumumab and tocilizumab, may be considered as an important possible treatment option for DON patients. Rituximab should be avoided in DON due to conflicting data and risk of adverse events. Orbital radiotherapy could be beneficial for patients with restricted ocular motility classified as poor surgical candidates. CONCLUSION Only a limited number of studies have been dedicated to the therapy of DON, mostly retrospective with a small sample size. Clear criteria regarding diagnosis and resolution of DON do not exist, which restricts comparison of therapeutic outcomes. Randomized clinical trials and comparison studies with long-term follow-ups are necessary to verify the safety and efficacy of each therapeutic option for DON.
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Affiliation(s)
- M Pelewicz-Sowa
- Department of Internal Medicine and Endocrinology, Medical University of Warsaw, 02-091, Warsaw, Poland
| | - P Miśkiewicz
- Department of Internal Medicine and Endocrinology, Medical University of Warsaw, 02-091, Warsaw, Poland.
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4
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Ali M, Abouzaid M, Clarke L, Lau G, Mitchell A, Napier C, Pearce S. A rare case of severe bilateral Graves' orbitopathy involving an anophthalmic socket. Endocrinol Diabetes Metab Case Rep 2023; 2023:22-0341. [PMID: 36625261 PMCID: PMC9875024 DOI: 10.1530/edm-22-0341] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/02/2022] [Accepted: 12/19/2022] [Indexed: 01/11/2023] Open
Abstract
Summary This is a report of a rare case of Graves' hyperthyroidism associated with severe bilateral Graves' orbitopathy, in a patient with an anophthalmic eye socket. On clinical review her prosthetic eye (left eye) was tilting upwards, along with worsening of Graves' orbitopathy (GO) in the only seeing eye. As she refused IV glucocorticoids, she was offered rituximab which only caused a transient improvement in the clinical activity score of the eye. She had persistent right upper lid retraction of 6 mm, associated with lagophthalmos. To protect her seeing eye from corneal ulceration, the patient received a botulinum toxin injection to the right upper eyelid to induce blepharoptosis as an interim measure prior to right upper eyelid blepharotomy in April 2021. This patient remains biochemically euthyroid on block and replace therapy and her TRAb level is falling over time. Treatment for active GO is ongoing and the patient required a redo blepharotomy for painful corneal exposure in the right eye. Learning points Graves' orbitopathy (GO) does not actually primarily affect the eyeball itself but the orbital contents as well. Patients with severe GO in an only seeing-eyed patient should be referred early to a multidisciplinary Joint Thyroid Eye clinic for expert review and management. Patient outcomes including sight loss are likely to be improved by the extended range of medical and surgical treatment modalities available at specialist clinics treating GO, including the use of immunomodulatory drugs like rituximab or teprotumumab.
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Affiliation(s)
- Mudassir Ali
- Department of Endocrinology, Royal Victoria Infirmary, Newcastle Upon Tyne, UK
| | - Mona Abouzaid
- Department of Endocrinology, Royal Victoria Infirmary, Newcastle Upon Tyne, UK
| | - Lucy Clarke
- Department of Ophthalmology, Royal Victoria Infirmary, Newcastle Upon Tyne, UK
| | - Gordon Lau
- Department of Ophthalmology, Royal Victoria Infirmary, Newcastle Upon Tyne, UK
| | - Anna Mitchell
- Department of Endocrinology, Royal Victoria Infirmary, Newcastle Upon Tyne, UK
| | - Catherine Napier
- Department of Endocrinology, Royal Victoria Infirmary, Newcastle Upon Tyne, UK
| | - Simon Pearce
- Department of Endocrinology, Royal Victoria Infirmary, Newcastle Upon Tyne, UK
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5
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Ly S, Nedosekin D, Wong HK. Review of an Anti-CD20 Monoclonal Antibody for the Treatment of Autoimmune Diseases of the Skin. Am J Clin Dermatol 2023; 24:247-273. [PMID: 36630066 PMCID: PMC9838371 DOI: 10.1007/s40257-022-00751-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/13/2022] [Indexed: 01/12/2023]
Abstract
Biologic therapies targeting B-cells are emerging as an effective strategy to treat a variety of immune-mediated diseases. One of the most studied B-cell-targeted therapies is rituximab, an anti-CD20 monoclonal antibody that exemplifies B-cell depletion therapy and has served as the prototype for other anti-CD20 monoclonal antibodies and the development of biosimilars. While there are multiple studies on the use of rituximab in dermatology, a comprehensive review of rituximab therapy in autoimmune skin conditions is lacking. In this literature review, we summarize indications, treatment efficacy, and safety of rituximab among common autoimmune diseases of the skin: pemphigus vulgaris, cutaneous lupus erythematous, dermatomyositis, systemic sclerosis, thyroid dermopathy, autoimmune pemphigoid diseases, and cutaneous vasculitis diseases. Existing data on rituximab support the approach of rituximab, biosimilars, and newer B-cell-targeting therapies in immune-mediated cutaneous diseases. Overall, rituximab, which targets CD20, provides an effective alternative or concomitant option to traditional immunosuppressants in the management of various autoimmune diseases of the skin. Further studies are necessary to expand the understanding and possible utility of B-cell-targeted therapies among autoimmune skin diseases.
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Affiliation(s)
- Sophia Ly
- grid.241054.60000 0004 4687 1637College of Medicine, University of Arkansas for Medical Sciences, Little Rock, AR USA
| | - Dmitry Nedosekin
- grid.241054.60000 0004 4687 1637College of Medicine, University of Arkansas for Medical Sciences, Little Rock, AR USA
| | - Henry K. Wong
- grid.241054.60000 0004 4687 1637Department of Dermatology, University of Arkansas for Medical Sciences, 4301 W. Markham St., Slot #576, Little Rock, AR 72205 USA
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6
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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: 26] [Impact Index Per Article: 13.0] [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.
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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
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7
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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.
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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
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Supronik J, Szelachowska M, Kretowski A, Siewko K. Rituximab in the treatment of Graves' orbitopathy: latest updates and perspectives. Endocr Connect 2022; 11:e220303. [PMID: 36219838 PMCID: PMC9716394 DOI: 10.1530/ec-22-0303] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/19/2022] [Accepted: 10/11/2022] [Indexed: 11/08/2022]
Abstract
Graves' orbitopathy (GO) is a potentially sight-threatening and disfiguring, extrathyroidal manifestation of Graves' disease. It often impairs patients' quality of life, causing severe social and psychological sequelae. Intravenous glucocorticosteroids is currently the mainstay of therapy, but the efficacy is often underwhelming and recurrence rate is high. For many years, clinicians have been searching for new methods of treatment. Rituximab (RTX) is a chimeric monoclonal antibody targeted against CD20 which is a surface antigen present on B cells. It is frequently used to treat non-Hodgkin's lymphoma, chronic lymphocytic leukemia, rheumatoid arthritis, or various types of vasculitis. Numerous clinical trials employing RTX in the treatment of GO have shown promising results. RTX is currently considered to be a valid second-line treatment option in patients unresponsive to previous interventions or in disease reactivation. This review summarizes the available literature on this topic, including two largest, randomized, controlled studies. Potential benefits, as well as the limitations of RTX therapy, are discussed.
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Affiliation(s)
- Jakub Supronik
- Department of Endocrinology, Diabetology and Internal Medicine, Medical University of Bialystok, Bialystok, Poland
| | - Małgorzata Szelachowska
- Department of Endocrinology, Diabetology and Internal Medicine, Medical University of Bialystok, Bialystok, Poland
| | - Adam Kretowski
- Department of Endocrinology, Diabetology and Internal Medicine, Medical University of Bialystok, Bialystok, Poland
- Clinical Research Centre, Medical University of Bialystok, Bialystok, Poland
| | - Katarzyna Siewko
- Department of Endocrinology, Diabetology and Internal Medicine, Medical University of Bialystok, Bialystok, Poland
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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.
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Affiliation(s)
- Luigi Bartalena
- Department of Medicine and SurgeryUniversity of InsubriaVareseItaly
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10
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Abstract
BACKGROUND Thyroid-associated ophthalmopathy (TAO) is the most frequent extrathyroidal manifestation of Graves' disease, affecting up to 50% of patients. It has a great impact on quality of life. Rituximab (RTX) is a human/murine chimeric monoclonal antibody that targets the CD20 receptor on B-lymphocytes. Preliminary work has shown that blocking this CD20 receptor with RTX may affect the clinical course of TAO by reducing inflammation and the degree of proptosis. OBJECTIVES: This review update, originally published in 2013, assesses the efficacy and safety of using RTX for the treatment of TAO. SEARCH METHODS We searched the Cochrane Central Register of Controlled Trials (CENTRAL; 2022, Issue 2), which contains the Cochrane Eyes and Vision Trials Register, Ovid MEDLINE, Ovid Embase, Latin American and Caribbean Health Science Information database (LILACS), the ISRCTN registry, clinicaltrials.gov and the WHO International Clinical Trials Registry Platform (WHO ICTRP). There were no language restrictions in the electronic search for trials. We last searched the electronic databases on 22 February 2022. SELECTION CRITERIA: We included randomised controlled trials (RCTs) of RTX administered by intravenous infusion using any dosage regimen for the treatment of active TAO in adults, compared to placebo or glucocorticoids treatment. DATA COLLECTION AND ANALYSIS: We used standard methodological procedures expected by Cochrane. Two review authors independently scanned titles and abstracts, and screened full-text reports of potentially relevant studies. The outcomes of interest in this review were: clinical activity score (CAS), NOSPECS severity scale, proptosis (mm), palpebral aperture (mm), extraocular motility (degrees or diplopia rating scale), quality of life and adverse effects. MAIN RESULTS We identified two studies that met the inclusion criteria in this updated review. Across both studies, the mean age of participants was 55 years and 77% were women. RTX compared to intravenous methylprednisolone (IVMP) One study, conducted in Italy, compared RTX (n = 15 after one participant withdrew) with IVMP (n = 16) for active TAO (CAS ≥ 3 out of 7 or 4 out of 10). We judged this study to be at low risk of bias in most domains, but it was stopped early because of disease reactivation in the comparator group (5/16 participants). This study provided low-certainty evidence that RTX may result in CAS improvement at 24 weeks compared to IVMP (15/15 versus 12/16 improved by ≥ 2 points; risk ratio (RR) 1.32, 95% confidence interval (CI) 0.98 to 1.78). Only very low-certainty evidence was available for the other outcomes: NOSPECS improvement by 2 or more classes (3/15 versus 3/16; RR 1.07, 95% CI 0.25 to 4.49); proptosis improvement by 2 mm or more (0/15 versus 1/16; RR 0.35, 95% CI 0.02 to 8.08); palpebral aperture improvement by 3 mm or more (2/15 versus 0/16; RR 5.31, 95% CI 0.28 to 102.38); motility improvement by 1 class or more (3/15 versus 3/16; RR 1.07, 95% CI 0.25 to 4.49); and improvement on the Graves' ophthalmopathy QoL scale by at least 6 points for "functioning" (5/14 versus 8/13; RR 0.58, 95% CI 0.25 to 1.32), and "appearance" (9/14 versus 6/13; RR 1.39, 95% CI 0.69 to 2.82). Adverse events were more common in the RTX group (RR 1.39, 95% CI 0.90 to 2.13; low-certainty evidence). Minor adverse effects (mild infusion reactions) were observed in most people receiving RTX at first infusion. Two participants experienced a major infusion reaction, likely cytokine release syndrome. RTX compared to placebo One study, conducted in the USA, enrolled 25 participants with active TAO (CAS ≥ 4 out of 7), comparing RTX (13 participants) to placebo. We judged this study to be at low risk of bias in most domains, but it was stopped early due to recruitment issues. It provided very low-certainty evidence on the following outcomes at 24 weeks: CAS improvement by 2 or more points (4/13 RTX versus 3/12 placebo; RR 1.23, 95% CI 0.34 to 4.40); NOSPECS improvement by 2 or more classes (2/13 versus 2/12; RR 0.92, 95% CI 0.15 to 5.56); proptosis improvement by 2 mm or more (2/13 versus 4/12; RR 0.46, 95% CI 0.10 to 2.08); palpebral aperture median change (0 mm in RTX group, in both eyes separately, versus -0.5 mm and 0.5 mm in placebo group right and left eye, respectively); motility median diplopia score (3 versus 2.5); SF-12 physical component median score (45.9 versus 40.3) and mental component median score (52.8 versus 46.1). More participants in the RTX group experienced adverse effects (8/13 versus 3/12; RR 2.46, 95% CI 0.84 to 7.18). AUTHORS' CONCLUSIONS: There is currently insufficient evidence to support the use of RTX in people with TAO. Future studies investigating RTX in people with active TAO may need to be multi-centre in order to recruit enough participants to make an adequate judgement on the efficacy and safety of this novel therapy.
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Affiliation(s)
- Swan Kang
- Moorfields Eye Hospital NHS Foundation Trust, London, UK
| | | | - Neda Minakaran
- Department of Ophthalmology, Moorfields Eye Hospital NHS Foundation Trust, London, UK
| | - Daniel G Ezra
- Moorfields and UCL Institute of Ophthalmology BMRC, Moorfields Eye Hospital NHS Foundation Trust, London, UK
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Cheetham TD, Cole M, Abinun M, Allahabadia A, Barratt T, Davies JH, Dimitri P, Drake A, Mohamed Z, Murray RD, Steele CA, Zammitt N, Carnell S, Prichard J, Watson G, Hambleton S, Matthews JNS, Pearce SHS. Adjuvant Rituximab-Exploratory Trial in Young People With Graves Disease. J Clin Endocrinol Metab 2022; 107:743-754. [PMID: 34687316 PMCID: PMC8851941 DOI: 10.1210/clinem/dgab763] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/18/2021] [Indexed: 11/19/2022]
Abstract
CONTEXT Remission rates in young people with Graves hyperthyroidism are less than 25% after 2 years of thionamide antithyroid drug (ATD). OBJECTIVE We explored whether rituximab (RTX), a B-lymphocyte-depleting agent, would increase remission rates when administered with a short course of ATD. METHODS This was an open-label, multicenter, single-arm, phase 2 trial in young people (ages, 12-20 years) with Graves hyperthyroidism. An A'Hern design was used to distinguish an encouraging remission rate (40%) from an unacceptable rate (20%). Participants presenting with Graves hyperthyroidism received 500 mg RTX and 12 months of ATD titrated according to thyroid function. ATDs were stopped after 12 months and primary outcome assessed at 24 months. Participants had relapsed at 24 months if thyrotropin was suppressed and free 3,5,3'-triiodothyronine was raised; they had received ATD between months 12 and 24; or they had thyroid surgery/radioiodine. RESULTS A total of 27 participants were recruited and completed the trial with no serious side effects linked to treatment. Daily carbimazole dose at 12 months was less than 5 mg in 21 of 27 participants. Thirteen of 27 participants were in remission at 24 months (48%, 90% one-sided CI, 35%-100%); this exceeded the critical value (9) for the A'Hern design and provided evidence of a promising remission rate. B-lymphocyte count at 28 weeks, expressed as a percentage of baseline, was related to likelihood of remission. CONCLUSION Adjuvant RTX, administered with a 12-month course of ATD, may increase the likelihood of remission in young people with Graves hyperthyroidism. A randomized trial of adjuvant RTX in young people with Graves hyperthyroidism is warranted.
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Affiliation(s)
- Tim D Cheetham
- Translational and Clinical Research Institute, Faculty of Medical Sciences, Newcastle University, International Centre for Life, Newcastle upon Tyne, NE1 3BZ, UK
- Department of Paediatric Endocrinology, Great North Children’s Hospital, Newcastle upon Tyne Hospitals NHS Foundation Trust, NE1 4LP, UK
- Correspondence: Tim D. Cheetham, MD, Newcastle University, c/o Department of Paediatric Endocrinology, Office Block 1, Level 3, Royal Victoria Infirmary, Newcastle upon Tyne, NE1 4LP, UK.
| | - Michael Cole
- Population Health Sciences Institute, Newcastle University, Newcastle upon Tyne, NE2 4AX, UK
| | - Mario Abinun
- Immunity & Inflammation Theme, Translational and Clinical Research Institute, Faculty of Medical Sciences, Newcastle University, Newcastle upon Tyne, NE2 4HH, UK
- Department of Paediatric Immunology, Great North Children’s Hospital, Newcastle upon Tyne Hospitals NHS Foundation Trust, Newcastle upon Tyne, NE1 4LP, UK
| | - Amit Allahabadia
- Academic Directorate of Diabetes and Endocrinology, Royal Hallamshire Hospital, Sheffield, S10 2JF, UK
| | - Tim Barratt
- University of Birmingham, Diabetes Unit, Birmingham Children’s Hospital, Birmingham, B4 6NH, UK
- Birmingham Children’s Hospital, Birmingham, B46NH, UK
| | - Justin H Davies
- Department of Paediatric Endocrinology, Faculty of Medicine, University of Southampton, University Hospital Southampton NHS Foundation Trust, Southampton, SO16 6YD, UK
| | - Paul Dimitri
- The Department of Paediatric Endocrinology, Sheffield Children’s NHS Trust, Western Bank, Sheffield, S10 2TH, UK
| | - Amanda Drake
- Centre for Cardiovascular Science, Queen’s Medical Research Institute, Edinburgh, EH16 4TJ, UK
| | | | - Robert D Murray
- Leeds Centre for Diabetes and Endocrinology, Leeds Teaching Hospitals NHS Trust, Leeds, LS97TF, UK
| | - Caroline A Steele
- Children and Adolescent services, Leeds Teaching Hospitals NHS Trust, UK
| | - Nicola Zammitt
- Edinburgh Centre for Endocrinology & Diabetes, Royal Infirmary of Edinburgh, Edinburgh, EH16 4SA, UK
| | - Sonya Carnell
- Newcastle Clinical Trials Unit, Newcastle University, Newcastle upon Tyne, NE2 4AE, UK
| | - Jonathan Prichard
- Newcastle Clinical Trials Unit, Newcastle University, Newcastle upon Tyne, NE2 4AE, UK
| | - Gillian Watson
- Newcastle Clinical Trials Unit, Newcastle University, Newcastle upon Tyne, NE2 4AE, UK
| | - Sophie Hambleton
- Immunity & Inflammation Theme, Translational and Clinical Research Institute, Faculty of Medical Sciences, Newcastle University, Newcastle upon Tyne, NE2 4HH, UK
- Department of Paediatric Immunology, Great North Children’s Hospital, Newcastle upon Tyne Hospitals NHS Foundation Trust, Newcastle upon Tyne, NE1 4LP, UK
| | - John N S Matthews
- Population Health Sciences Institute, Newcastle University, Newcastle upon Tyne, NE2 4AX, UK
- School of Mathematics, Statistics & Physics, Newcastle University, Newcastle upon Tyne, NE1 7RU, UK
| | - Simon H S Pearce
- Translational and Clinical Research Institute, Faculty of Medical Sciences, Newcastle University, International Centre for Life, Newcastle upon Tyne, NE1 3BZ, UK
- Department of Endocrinology, Royal Victoria Infirmary, Newcastle upon Tyne, NE1 4LP, UK
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12
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Wang Y, Hu H, Chen L, Zhang H, Yang T, Xu X, Chen H. Observation study of using a small dose of rituximab treatment for thyroid-associated ophthalmopathy in seven Chinese patients: One pilot study. Front Endocrinol (Lausanne) 2022; 13:1079852. [PMID: 36743915 PMCID: PMC9889535 DOI: 10.3389/fendo.2022.1079852] [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: 10/26/2022] [Accepted: 12/29/2022] [Indexed: 01/20/2023] Open
Abstract
OBJECTIVE To report the efficacy, long-term safety, and tolerability of using a small dose (125 mg/m2 weekly for 4 weeks) of rituximab to treat Chinese patients with thyroid-associated ophthalmopathy (TAO). METHODS Seven patients with active moderate-to-severe TAO were prospectively recruited in this study. A small dose of rituximab (125mg/m2 body surface area) was given weekly with a duration of four weeks. Thyroid function, thyrotropin receptor antibody (TRAb), B cell and T cell subsets, ophthalmological examination, magnetic resonance imaging derived parameters, and adverse reactions were recorded at each visit. RESULTS Seven patients were followed for an average of 224 weeks. B-cell depletion was observed in all patients following rituximab infusion. The clinical activity score (CAS) decreased from 4.86 ± 0.69 to 3.00 ± 0.82 at 5 weeks after treatment (P = 0.033) and remained significantly lower than baseline values at the end of follow-up (P = 0.001). Compared to baseline values, significant decreases in exophthalmos of the right eye, the thickness of extraocular muscles with maximum signal intensity, and the highest signal intensity ratio (SIR) of extraocular muscle to ipsilateral temporal muscle values were observed at the last follow-up (all P < 0.05). Disease progressions or recurrences were not observed during follow-up. Only mild fatigue was observed after the first infusion as a side effect (n = 1). CONCLUSION Small dose of rituximab may be a promising option with adequate safety, tolerability, and long-term efficacy for patients with active moderate-to-severe TAO.
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Affiliation(s)
- Yueyue Wang
- Department of Endocrinology, The First Affiliated Hospital of Nanjing Medical University, Nanjing, China
| | - Hao Hu
- Department of Radiology, The First Affiliated Hospital of Nanjing Medical University, Nanjing, China
| | - Lu Chen
- Department of Radiology, The First Affiliated Hospital of Nanjing Medical University, Nanjing, China
| | - Haitao Zhang
- Department of Endocrinology, The First Affiliated Hospital of Nanjing Medical University, Nanjing, China
| | - Tao Yang
- Department of Endocrinology, The First Affiliated Hospital of Nanjing Medical University, Nanjing, China
| | - Xiaoquan Xu
- Department of Radiology, The First Affiliated Hospital of Nanjing Medical University, Nanjing, China
- *Correspondence: Xiaoquan Xu, ; Huanhuan Chen,
| | - Huanhuan Chen
- Department of Endocrinology, The First Affiliated Hospital of Nanjing Medical University, Nanjing, China
- *Correspondence: Xiaoquan Xu, ; Huanhuan Chen,
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13
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Mateen S, Pontious J. Thyroid Dermopathy Treatment of the Foot in the Setting of Graves Hyperthyroidism. J Foot Ankle Surg 2021; 60:834-838. [PMID: 33509724 DOI: 10.1053/j.jfas.2020.12.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/06/2020] [Revised: 11/17/2020] [Accepted: 12/10/2020] [Indexed: 02/03/2023]
Abstract
Graves' hyperthyroidism is one of the most common autoimmune diseases, caused by autoantibodies acting against the thyrotropin receptor. Extra-thyroid manifestations include ophthalmopathy, acropachy, and dermopathy, which accounts for 4% to 13% of clinical presentations. This is a case study of a 55-year-old female who presented with recurrent soft tissue mass formation over the dorsal right foot. The patient underwent a soft tissue mass excisional biopsy and the pathology report revealed a soft tissue mass secondary to thyroid dermopathy. Given her history of soft tissue recurrence and previous diagnosis, the patient underwent both excisional biopsy and radiation treatment with success. After 1 year of follow-up, the patient had completely healed without complication. This case demonstrates a multidisciplinary approach for clinical diagnosis and treatment.
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Affiliation(s)
- Sara Mateen
- Resident, Temple University Hospital Podiatric Surgical Residency Program, Philadelphia, PA.
| | - Jane Pontious
- Clinical Professor, Department of Surgery, Temple University School of Podiatric Medicine, Philadelphia, PA
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14
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Chen J, Chen G, Sun H. Intravenous rituximab therapy for active Graves' ophthalmopathy: a meta-analysis. Hormones (Athens) 2021; 20:279-286. [PMID: 33783712 DOI: 10.1007/s42000-021-00282-6] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/22/2020] [Accepted: 03/14/2021] [Indexed: 01/03/2023]
Abstract
AIM The successful treatment of Graves' ophthalmopathy (GO) remains a challenge, while the efficacy of rituximab (RTX) is at present controversial. The aim of this meta-analysis was to investigate the potential impact of intravenous RTX therapy in patients with GO. METHODS We performed a search in the PubMed, Embase, and Web of Science databases for relevant studies published before July 2020. The primary outcome was the change of clinical activity score (CAS), and secondary outcomes were the change of proptosis and TSH receptor antibodies (TRAb). A meta-analysis was conducted to calculate the standard mean difference (SMD) for these outcomes by using fixed- or random-effect models. RESULTS Analysis of outcomes in 152 patients collected from 12 published articles was conducted. Compared to baseline value, CAS was significantly decreased at 1, 6, 12, and >12 months after RTX treatment. For proptosis, the results revealed no significant decrease at 1-3, 6, and ≥12 months. Moreover, the pooled analysis employed in this meta-analysis showed no significant difference of TRAb at 1 month, but significant declines were observed at 6 and ≥12 months. CONCLUSION Our results strongly suggest that intravenous RTX treatment has an acute and long-lasting beneficial effect on decreasing both CAS and TRAb. The study also indicates that the effect of RTX on proptosis is limited. There is evidently a need to investigate the mechanism behind RTX ineffectiveness on proptosis and explore other therapeutic regimens for the reduction of proptosis.
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Affiliation(s)
- Jing Chen
- The Shengli Clinical Medical College, Fujian Medical University, Fuzhou, 350001, Fujian, China
- Department of Ophthalmology, Fujian Provincial Hospital, Fuzhou, 350001, Fujian, China
| | - Gang Chen
- The Shengli Clinical Medical College, Fujian Medical University, Fuzhou, 350001, Fujian, China.
- Department of Endocrinology, Fujian Provincial Hospital, Fuzhou, 350001, Fujian, China.
- Fujian Provincial Key Laboratory of Medical Analysis, Fujian Academy of Medical Sciences, Fuzhou, 350001, Fujian, China.
| | - Huilan Sun
- The Shengli Clinical Medical College, Fujian Medical University, Fuzhou, 350001, Fujian, China.
- Department of Ophthalmology, Fujian Provincial Hospital, Fuzhou, 350001, Fujian, China.
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15
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Vannucchi G, Campi I, Covelli D, Currò N, Lazzaroni E, Palomba A, Soranna D, Zambon A, Fugazzola L, Muller I, Guastella C, Salvi M. Efficacy Profile and Safety of Very Low-Dose Rituximab in Patients with Graves' Orbitopathy. Thyroid 2021; 31:821-828. [PMID: 33234032 DOI: 10.1089/thy.2020.0269] [Citation(s) in RCA: 22] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/12/2022]
Abstract
Background: Rituximab (RTX), a chimeric human-murine anti-CD20 monoclonal antibody, has been used for treatment of active moderate-severe Graves' orbitopathy (GO) since 2004 as second-line therapy in patients unresponsive to intravenous steroids. We conducted an open-label prospective study (EUDRACT 2012-001980-53) in which patients were treated with a single infusion of only 100 mg RTX to analyze the efficacy and safety of this low dose. Methods: Seventeen patients, of whom nine had disease that was unresponsive to intravenous methylprednisolone and eight with newly diagnosed GO, were enrolled. Disease activity was assessed with the clinical activity score (CAS) and severity with a composite ophthalmic score. Long-term surgical treatment and quality of life were also assessed, as well as treatment-related adverse events. Results: Mean baseline CAS was 4.56 ± 0.96 and decreased to 1.25 ± 1.14 at 24 weeks (p = 0.001). Disease inactivation occurred within 24 weeks in >90% of patients and was unrelated to disease duration. Severity improved in about 60% of patients, with no relapses. All patients showed peripheral depletion of CD20+ and CD19+ cells at the end of RTX infusion (60 minutes). Two patients required surgical orbital decompression because of optic neuropathy (ON). Among adverse events observed, there was one patient who developed a cytokine release syndrome. Conclusions: A dose of 100 mg RTX is effective in patients with active moderate-severe GO. Low doses are better tolerated, expose patients to immune suppression for a shorter period of time, and are extremely cost effective, compared with higher doses. This dose, consistently with all other immunosuppressants, does not prevent the progression of GO to dysthyroid ON.
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Affiliation(s)
- Guia Vannucchi
- Endocrine and Metabolic Department, Istituto Auxologico Italiano IRCCS, Milano, Italy
| | - Irene Campi
- Endocrine and Metabolic Department, Istituto Auxologico Italiano IRCCS, Milano, Italy
| | - Danila Covelli
- Department of Clinical Sciences and Community Health, Graves' Orbitopathy Center, Endocrinology, Milan, Italy
| | - Nicola Currò
- Department of Ophthalmology, Fondazione IRCCS Cà Granda, Milan, Italy
| | - Elisa Lazzaroni
- Department of Clinical Sciences and Community Health, Graves' Orbitopathy Center, Endocrinology, Milan, Italy
| | - Andrea Palomba
- Division of Biostatistics, Epidemiology and Public Health, Department of Statistics and Quantitative Methods, University of Milano-Bicocca, Milan, Italy
| | | | - Antonella Zambon
- Division of Biostatistics, Epidemiology and Public Health, Department of Statistics and Quantitative Methods, University of Milano-Bicocca, Milan, Italy
| | - Laura Fugazzola
- Endocrine and Metabolic Department, Istituto Auxologico Italiano IRCCS, Milano, Italy
| | - Ilaria Muller
- Department of Clinical Sciences and Community Health, Graves' Orbitopathy Center, Endocrinology, Milan, Italy
| | - Claudio Guastella
- Department of Otolaryngology, Fondazione IRCCS Cà Granda, Milan, Italy
| | - Mario Salvi
- Department of Clinical Sciences and Community Health, Graves' Orbitopathy Center, Endocrinology, Milan, Italy
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16
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Jain AP, Jaru-Ampornpan P, Douglas RS. Thyroid eye disease: Redefining its management-A review. Clin Exp Ophthalmol 2021; 49:203-211. [PMID: 33484076 DOI: 10.1111/ceo.13899] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/05/2020] [Revised: 12/03/2020] [Accepted: 12/18/2020] [Indexed: 12/27/2022]
Abstract
Thyroid eye disease (TED) is a debilitating, vision threatening disease that dramatically alters patients' quality of life. Until recently, the management of TED is a long arduous course with supportive therapy, followed by an extensive surgical treatment plan to reverse the disease endpoints. Teprotumumab offers an early, safe therapeutic intervention to help reverse disease end points such as diplopia and proptosis and improve quality of life.
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Affiliation(s)
- Amy P Jain
- Ophthalmology, Cedars-Sinai Medical Center, Los Angeles, California, USA
| | | | - Raymond S Douglas
- Ophthalmology, Cedars-Sinai Medical Center, Los Angeles, California, USA
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17
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Campi I, Vannucchi G, Muller I, Lazzaroni E, Currò N, Dainese M, Montacchini B, Covelli D, Guastella C, Pignataro L, Fugazzola L, Arosio M, Salvi M. Therapy With Different Dose Regimens of Rituximab in Patients With Active Moderate-To-Severe Graves' Orbitopathy. Front Endocrinol (Lausanne) 2021; 12:790246. [PMID: 35145479 PMCID: PMC8822584 DOI: 10.3389/fendo.2021.790246] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/06/2021] [Accepted: 12/22/2021] [Indexed: 12/31/2022] Open
Abstract
BACKGROUND Immunosuppressive therapy of Graves' orbitopathy (GO) is indicated during the active phase of disease. Intravenous steroids (IVGC) are effective in about 70% of patients, although unresponsiveness or relapse are observed. In previous studies, rituximab (RTX) has been shown to be effective in inactivating moderate-to-severe GO when used early in the disease, but its optimal dosage has never been studied in randomized clinical trials. Aim of this study was to compare the efficacy and safety of different doses of RTX, based on a post-hoc analysis of two open label studies and one prospective trial randomized to IVGC. METHODS of 40 patients (35 women, 5 men), with active moderate-to-severe GO treated with RTX, 14 received a single dose of 100 mg (Group 1), 15 a single dose of 500 mg (Group 2) and 11 two 1000 mg doses, administered one week apart (Group 3). Thyroid function, TSH-receptor antibodies (TRAb) and peripheral CD19+ cells were measured. Primary endpoint was disease inactivation, measured as a decrease of the Clinical Activity Score (CAS) of at least two points. Secondary endpoints were improvement of proptosis, diplopia, quality of life and safety. RESULTS Baseline CAS decreased significantly in all groups (P<0.0001), independently of GO duration or whether patients had newly occurring or relapsing GO after IVGC. Proptosis did not significantly change. There was an inverse correlation between the Gorman score for diplopia and RTX dose (P<0.01). The appearance score of the GO-QoL improved in Group 1 (P=0.015), and the visual function score, in Group 2 (P=0.04). A reduction of serum TRAb was observed in Group 1 (P=0.002) and Group 2 (P<0.0002), but not in Group 3. CD19+ cell decreased in all groups (P<0.01), independently of the dose. CONCLUSIONS We studied the optimal dosage of RTX in the treatment of active moderate-to-severe GO. In this analysis, we considered the efficacy of RTX in inactivating GO, in changing its natural course, its effect on disease severity and on the patients' quality of life. Based on our clinical findings, and balancing the cost of therapy, a single 500 mg dose regimen is suggested in the majority of patients.
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Affiliation(s)
- Irene Campi
- Department of Endocrine and Metabolic Diseases, Istituto Auxologico Italiano IRCCS, Milan, Italy
| | - Guia Vannucchi
- Department of Endocrine and Metabolic Diseases, Istituto Auxologico Italiano IRCCS, Milan, Italy
| | - Ilaria Muller
- Graves’ Orbitopathy Center, Endocrinology, Fondazione IRCCS Cà Granda, Ospedale Maggiore Policlinico Milan, Milan, Italy
- Department of Clinical Sciences and Community Health, University of Milan, Milan, Italy
- Division of Infection and Immunity, School of Medicine, Cardiff University, Cardiff, United Kingdom
| | - Elisa Lazzaroni
- Graves’ Orbitopathy Center, Endocrinology, Fondazione IRCCS Cà Granda, Ospedale Maggiore Policlinico Milan, Milan, Italy
| | - Nicola Currò
- Ophthalmology, Fondazione IRCCS Cà Granda, Ospedale Maggiore Policlinico Milan, Milan, Italy
| | - Martina Dainese
- Graves’ Orbitopathy Center, Endocrinology, Fondazione IRCCS Cà Granda, Ospedale Maggiore Policlinico Milan, Milan, Italy
| | - Benedetta Montacchini
- Graves’ Orbitopathy Center, Endocrinology, Fondazione IRCCS Cà Granda, Ospedale Maggiore Policlinico Milan, Milan, Italy
| | - Danila Covelli
- Graves’ Orbitopathy Center, Endocrinology, Fondazione IRCCS Cà Granda, Ospedale Maggiore Policlinico Milan, Milan, Italy
| | - Claudio Guastella
- Otolaryngology, University of Milan and Fondazione IRCCS Cà Granda, Milan, Italy
| | - Lorenzo Pignataro
- Otolaryngology, University of Milan and Fondazione IRCCS Cà Granda, Milan, Italy
| | - Laura Fugazzola
- Department of Endocrine and Metabolic Diseases, Istituto Auxologico Italiano IRCCS, Milan, Italy
- Department of Pathophysiology and Transplantation, University of Milan, Milan, Italy
| | - Maura Arosio
- Graves’ Orbitopathy Center, Endocrinology, Fondazione IRCCS Cà Granda, Ospedale Maggiore Policlinico Milan, Milan, Italy
- Department of Clinical Sciences and Community Health, University of Milan, Milan, Italy
| | - Mario Salvi
- Graves’ Orbitopathy Center, Endocrinology, Fondazione IRCCS Cà Granda, Ospedale Maggiore Policlinico Milan, Milan, Italy
- *Correspondence: Mario Salvi,
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18
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Lane LC, Cheetham TD, Perros P, Pearce SHS. New Therapeutic Horizons for Graves' Hyperthyroidism. Endocr Rev 2020; 41:5897403. [PMID: 32845332 PMCID: PMC7567404 DOI: 10.1210/endrev/bnaa022] [Citation(s) in RCA: 38] [Impact Index Per Article: 9.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/17/2020] [Accepted: 08/20/2020] [Indexed: 11/19/2022]
Abstract
Graves' hyperthyroidism is characterized by the presence of autoantibodies that stimulate the thyroid-stimulating hormone receptor (TSHR), resulting in uncontrolled secretion of excessive thyroid hormone. Conventional treatments, including antithyroid medication, radioiodine, or surgery have remained largely unchanged for the past 70 years and either lack efficacy for many patients, or result in lifelong thyroid hormone replacement therapy, in the case of the latter 2 options. The demand for new therapeutic options, combined with greater insight into basic immunobiology, has led to the emergence of novel approaches to treat Graves' hyperthyroidism. The current therapies under investigation include biologics, small molecules, and peptide immunomodulation. There is a growing focus on TSHR-specific treatment modalities, which carry the advantage of eliciting a specific, targeted approach, with the aim of avoiding disruption of the functioning immune system. These therapies present a new opportunity to supersede the inadequate treatments currently available for some Graves' patients, offering hope of successful restoration of euthyroidism without the need for ongoing therapy. Several of these therapeutic options have the potential to translate into clinical practice in the near future. This review provides a comprehensive summary of the recent advances and various stages of development of the novel therapeutic approaches to treat Graves' hyperthyroidism.
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Affiliation(s)
- Laura C Lane
- Translational and Clinical Research Institute, Newcastle University, Newcastle-upon-Tyne, UK.,Endocrine unit, Royal Victoria Infirmary, Newcastle-upon-Tyne Hospitals NHS Foundation Trust, Newcastle-upon-Tyne, UK.,Department of Paediatric Endocrinology, The Great North Children's Hospital, Newcastle-upon-Tyne, UK
| | - Tim D Cheetham
- Translational and Clinical Research Institute, Newcastle University, Newcastle-upon-Tyne, UK.,Department of Paediatric Endocrinology, The Great North Children's Hospital, Newcastle-upon-Tyne, UK
| | - Petros Perros
- Endocrine unit, Royal Victoria Infirmary, Newcastle-upon-Tyne Hospitals NHS Foundation Trust, Newcastle-upon-Tyne, UK
| | - Simon H S Pearce
- Translational and Clinical Research Institute, Newcastle University, Newcastle-upon-Tyne, UK.,Endocrine unit, Royal Victoria Infirmary, Newcastle-upon-Tyne Hospitals NHS Foundation Trust, Newcastle-upon-Tyne, UK
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19
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Davies TF, Andersen S, Latif R, Nagayama Y, Barbesino G, Brito M, Eckstein AK, Stagnaro-Green A, Kahaly GJ. Graves' disease. Nat Rev Dis Primers 2020; 6:52. [PMID: 32616746 DOI: 10.1038/s41572-020-0184-y] [Citation(s) in RCA: 158] [Impact Index Per Article: 39.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 05/19/2020] [Indexed: 02/08/2023]
Abstract
Graves' disease (GD) is an autoimmune disease that primarily affects the thyroid gland. It is the most common cause of hyperthyroidism and occurs at all ages but especially in women of reproductive age. Graves' hyperthyroidism is caused by autoantibodies to the thyroid-stimulating hormone receptor (TSHR) that act as agonists and induce excessive thyroid hormone secretion, releasing the thyroid gland from pituitary control. TSHR autoantibodies also underlie Graves' orbitopathy (GO) and pretibial myxoedema. Additionally, the pathophysiology of GO (and likely pretibial myxoedema) involves the synergism of insulin-like growth factor 1 receptor (IGF1R) with TSHR autoantibodies, causing retro-orbital tissue expansion and inflammation. Although the aetiology of GD remains unknown, evidence indicates a strong genetic component combined with random potential environmental insults in an immunologically susceptible individual. The treatment of GD has not changed substantially for many years and remains a choice between antithyroid drugs, radioiodine or surgery. However, antithyroid drug use can cause drug-induced embryopathy in pregnancy, radioiodine therapy can exacerbate GO and surgery can result in hypoparathyroidism or laryngeal nerve damage. Therefore, future studies should focus on improved drug management, and a number of important advances are on the horizon.
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Affiliation(s)
- Terry F Davies
- Thyroid Research Laboratory, Icahn School of Medicine at Mount Sinai, New York, NY, USA. .,James J. Peters VA Medical Center, New York, NY, USA. .,Mount Sinai Thyroid Center, Mount Sinai Downtown at Union Sq, New York, NY, USA.
| | - Stig Andersen
- Department of Geriatric and Internal Medicine and Arctic Health Research Center, Aalborg University Hospital, Aalborg, Denmark
| | - Rauf Latif
- Thyroid Research Laboratory, Icahn School of Medicine at Mount Sinai, New York, NY, USA.,James J. Peters VA Medical Center, New York, NY, USA
| | - Yuji Nagayama
- Department of Molecular Medicine, Atomic Bomb Disease Institute, Nagasaki University, Nagasaki, Japan
| | - Giuseppe Barbesino
- Thyroid Unit, Division of Endocrinology, Massachusetts General Hospital, Boston, MA, USA
| | - Maria Brito
- Mount Sinai Thyroid Center, Mount Sinai Downtown at Union Sq, New York, NY, USA
| | - Anja K Eckstein
- Department of Ophthalmology, University Duisburg Essen, Essen, Germany
| | - Alex Stagnaro-Green
- Departments of Medicine, Obstetrics and Gynecology and Medical Education, University of Illinois College of Medicine at Rockford, Rockford, IL, USA
| | - George J Kahaly
- Department of Medicine I, Johannes Gutenberg University Medical Centre, Mainz, Germany
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20
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Khong JJ, McNab A. Medical treatment in thyroid eye disease in 2020. Br J Ophthalmol 2020; 105:299-305. [PMID: 32447327 DOI: 10.1136/bjophthalmol-2020-316051] [Citation(s) in RCA: 17] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/11/2020] [Revised: 04/28/2020] [Accepted: 05/03/2020] [Indexed: 02/06/2023]
Abstract
Thyroid eye disease (TED) affects 25% of patients with Graves' hyperthyroidism, where 1 in 20 patients has active, moderate-to-severe disease that will require medical treatment for reducing TED activity and severity. Intravenous corticosteroid has been the mainstay of treatment for active moderate-to-severe TED. With improved understanding of the pathophysiology of TED, immunotherapy targeting different molecular pathways including T cells, B cells, cytokines and cell surface receptors have been investigated in randomised clinical trials. This review provides an overview of the current advances in medical treatment including teprotumumab, tocilizumab, rituximab and mycophenolate and the indications for their use in the management of active, moderate-to-severe TED.
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Affiliation(s)
- Jwu Jin Khong
- Department of Surgery, University of Melbourne, Centre for Eye Research Australia Ltd, East Melbourne, Victoria, Australia .,Orbital Plastics and Lacrimal Unit, Royal Victorian Eye and Ear Hospital, East Melbourne, Victoria, Australia.,Department of Ophthalmology, Austin Health, Heidelberg, VIC, Australia
| | - Alan McNab
- Department of Surgery, University of Melbourne, Centre for Eye Research Australia Ltd, East Melbourne, Victoria, Australia.,Orbital Plastics and Lacrimal Unit, Royal Victorian Eye and Ear Hospital, East Melbourne, Victoria, Australia
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21
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Efficacy of rituximab in patients with Graves' orbitopathy: a retrospective multicenter nationwide study. Graefes Arch Clin Exp Ophthalmol 2020; 258:2013-2021. [PMID: 32405700 DOI: 10.1007/s00417-020-04651-6] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/06/2018] [Revised: 03/08/2020] [Accepted: 03/19/2020] [Indexed: 12/27/2022] Open
Abstract
PURPOSE The clinical utility of rituximab (RTX) in Graves' orbitopathy (GO) treatment remains controversial since the discrepant results from 2 prospective randomized studies (Stan M et al. J Clin Endocrinol Metab 2015; Salvi M et al. J Clin Endocrinol Metab 2015). The aim of this study was to assess in real life the characteristics and the clinical outcomes of patients with GO treated with RTX in cases of corticosteroid resistance or corticosteroid dependence. METHODS Multicenter French retrospective study including patients with moderate-to-severe GO requiring second-line treatment with RTX. Patients were classified according to three main baseline characteristics: clinical inflammation (CAS ≥ 3), oculomotor limitation, and visual dysfunction. Patients were considered as responders if, at 24 weeks (week 24), at least 1 of these 3 parameters improved with no worsening elsewhere. RESULTS Forty patients were included (65% smokers, 38% dysthyroidism). Thirty-two patients were treated with RTX alone (one patient excluded owing to side effects): 64.5% had favorable responses at week 24 and significant reduction in baseline CAS (3.29 ± 1.6) at 12 weeks (1.93 ± 1.1; P < 0.001) and at week 24 (1.59 ± 1.1; P < 0.001); reduction in anti-TSH receptor antibodies at week 24 (P < 0.01); and significant improvement of visual acuity (P = 0.04) and ocular hypertonia (P = 0.04) at week 12, but no improvement in oculomotor dysfunction. Eight patients needed emergency treatment with concomitant RTX and orbital decompression, with favorable outcome for 5 patients. Predictive factors for a poor response to RTX were low baseline CAS, smoker, and baseline ocular hypertonia. All patients reported good tolerance except one serious side effect (a cytokine release syndrome). CONCLUSIONS The efficiency results of RTX in reducing CAS in this cohort are just between those of Stan and Salvi. This could be explained by our delay before treatment initiation, quicker than Stan but longer than Salvi. RTX appears to be effective as a second-line treatment for the inflammatory component of GO, especially if the disease is highly active and recent.
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22
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Zhang B, Li Y, Xu W, Peng B, Yuan G. Use of Rituximab After Orbital Decompression Surgery in Two Grave's Ophthalmopathy Patients Progressing to Optic Neuropathy. Front Endocrinol (Lausanne) 2020; 11:583565. [PMID: 33193097 PMCID: PMC7649761 DOI: 10.3389/fendo.2020.583565] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/22/2020] [Accepted: 10/05/2020] [Indexed: 11/16/2022] Open
Abstract
BACKGROUND While orbital decompression can alleviate optic nerve compression and prevent further vision loss in dysthyroid optic neuropathy (DON), it cannot relieve inflammatory symptoms. Very high doses of intravenous glucocorticoids (GCs) are the first-line therapy for DON; however, the effective rate is only 40% and might be much lower in patients who fail high-dose GC pulse therapy and progressed to DON. The results of two case series studies indicated that rituximab treatment had a much better curative effect compared to very high doses of intravenous GCs, but some patients required urgent orbital decompression after rituximab injection because rituximab might lead to the release of cytokines, aggravated intraorbital edema, and further vision loss. METHODS We retrospectively studied the therapeutic process of two Grave's ophthalmopathy (GO) patients complicated with DON who failed high-dose GC pulse therapy and underwent orbital decompression. Both patients received single-dose (500 mg) rituximab treatment. RESULTS During more than 2 years of follow-up, rituximab treatment exhibited significant improvement in inflammatory symptoms, as manifested by a substantial decrease in Clinical Activity Score (CAS); meanwhile, the vision of both patients improved significantly and their diplopia was relieved. CONCLUSIONS The results of this study were consistent with those of two previous case series studies indicating the significant and lasting effect of rituximab treatment on DON, especially for patients with GC resistance or recurrence after GC therapy. Orbital decompression before rituximab treatment might reduce the incidence of rapid vision loss and urgent orbital decompression surgery caused by aggravated orbital edema after rituximab injection; however, the necessity for preventive decompression surgery requires further study.
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Affiliation(s)
- Benping Zhang
- Department of Endocrinology, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Yaling Li
- Department of Critical Care Medicine, Wuhan No.1 Hospital, Wuhan, China
| | - Weijie Xu
- Department of Endocrinology, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Bei Peng
- Department of Endocrinology, Taikang Tongji (Wuhan) Hospital, Wuhan, China
| | - Gang Yuan
- Department of Endocrinology, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
- *Correspondence: Gang Yuan,
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23
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Rituximab in Ocular Adnexal Lymphoma and Orbital Inflammatory Disease. Clin Ophthalmol 2020; 60:63-75. [DOI: 10.1097/iio.0000000000000301] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
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24
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Abstract
PURPOSE OF REVIEW Thyroid eye disease is a complex autoimmune disorder which causes substantial morbidity. It can result in orbital disfigurement, double vision, and visual loss. Consequently, it has a substantial negative effect on quality of life, mental health, and socioeconomic status. Most signs and symptoms of thyroid eye disease (TED) can be explained by the expansion of the orbital contents. Steroids are the mainstay of treatment in TED. However, recurrence may occur once steroids are withdrawn. Furthermore, in most cases, normal orbital anatomy is not restored, and skilled rehabilitative surgery is required to reduce disfigurement, double vision, and to preserve vision. Therefore, novel, causal, and more efficacious treatment strategies are warranted. RECENT FINDINGS In the last decade, the pathophysiology of TED has also been revised with the identification of new potential therapeutic targets. Recent clinical trials have shown that considerable benefit may be derived from the addition of antiproliferative agents (e.g., mycophenolate sodium) in preventing deterioration after steroid cessation. In addition, targeted biologic therapies have shown promise, including teprotumumab (anti-IGFR) which appears to substantially reduce proptosis, rituximab (anti-CD20) which reduces inflammation and tocilizumab (anti-IL-6) which potentially benefits both of these parameters. SUMMARY This short review summarizes the recent research developments in this area.
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Affiliation(s)
- George J Kahaly
- Department of Medicine I, Johannes Gutenberg University Medical Center, Mainz, Germany
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25
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Insull EA, Sipkova Z, David J, Turner HE, Norris JH. Early low-dose rituximab for active thyroid eye disease: An effective and well-tolerated treatment. Clin Endocrinol (Oxf) 2019; 91:179-186. [PMID: 30864162 DOI: 10.1111/cen.13970] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/05/2018] [Revised: 03/01/2019] [Accepted: 03/10/2019] [Indexed: 01/16/2023]
Abstract
BACKGROUND Thyroid eye disease (TED) is an autoimmune inflammatory disease that can be disfiguring and potentially sight threatening. Suppression of inflammation in active disease can reduce the risk of visual loss and limit long-term sequelae. Current management involves inflammation suppression using glucocorticoids. The aim of this study was to evaluate the efficacy of early disease intervention with targeted immunomodulatory therapy to alter disease course. This paper reports the efficacy of low-dose rituximab in reducing clinical activity in TED in a small population. METHODS A retrospective audit of consecutive patients with active TED managed primarily with a 100 mg rituximab infusion. Further glucocorticoid or steroid-sparing agents were prescribed if clinically indicated. Clinical activity score, VISA overall severity score and Oxford Quality of Life score were recorded at each visit as well as TSH receptor antibody levels (TRAb), B cell subsets and adverse reactions. RESULTS Twelve patients had mean follow-up of 6.3 months. Clinical activity scores significantly decreased (mean score 5.08 to 1.58; P < 0.001), VISA overall severity scores reduced by 50% from 12 to 6, P < 0.001 and the mean cumulative dose of IV methylprednisolone was 2.3 g. 100 mg rituximab induced significant CD19+ B cell depletion (n = 8, P < 0.001). There was no significant reduction in serum TRAb (n = 8, P = 0.06). A transient infusion-related rash was the only adverse effect, n = 4. QoL scores did not differ markedly before and after treatment. CONCLUSION Low-dose rituximab is an efficacious, well-tolerated and safe treatment for active TED; reducing disease activity and allowing reduced administration of systemic steroid.
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Affiliation(s)
| | - Zuzana Sipkova
- Oxford Eye Hospital, John Radcliffe Hospital, Oxford, UK
| | - Joel David
- Rheumatology Department, John Radcliffe Hospital, Oxford, UK
| | - Helen E Turner
- Department of Endocrinology, Oxford Centre for Diabetes, Endocrinology and Metabolism, Churchill Hospital, Oxford, UK
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26
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Eid L, Coste-Verdier V, Longueville E, Ribeiro E, Nicolescu-Catargi B, Korobelnik JF. The effects of Rituximab on Graves'orbitopathy: A retrospective study of 14 patients. Eur J Ophthalmol 2019; 30:1008-1013. [PMID: 31025590 DOI: 10.1177/1120672119845224] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
PURPOSE Management of Graves' ophthalmopathy remains challenging. Over the last decade, previous studies have shown promising results for Rituximab in the treatment of Graves' ophthalmopathy. We present the response of 14 individuals with active moderate-to-severe Graves' ophthalmopathy to Rituximab, representing one of the largest retrospective case series reported to date. METHODS Rituximab was administered intravenously, 1000 mg twice at a 2-week interval. The primary end point was a clinical activity score reduction (improvement by ⩾ 2 points or disease inactivation: clinical activity score < 3) at 24 weeks. Secondary end points included clinical activity score improved by ⩾ 2 points or inactivation of Graves' ophthalmopathy at 12 weeks, improvement in each item of the clinical activity score, in proptosis, in severity disease by the total eye score and in diplopia according to the Gorman score. RESULTS A limited improvement in clinical activity score was observed (median improvement at 24 weeks by 1 point, p = 0.002, (5/14 patients, 35.7%). Disease inactivation occurred in 50% of patients (7/14 patients). At 12 weeks, clinical activity score improved by ⩾ 2 points in 2/14 patients (14.3%) and inactivation of Graves' ophthalmopathy occurred in four patients (28.6%). Improvement in proptosis and total eye score was observed in 3/9 patients (33%) and in 4/14 patients (28.6%) at 24 weeks, respectively. Only one patient experienced moderate adverse event. CONCLUSION Rituximab is a well-tolerated treatment with a good safety profile, but offered limited and partial improvement for active moderate-to-severe Graves' ophthalmopathy with a long duration of disease.
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Affiliation(s)
- Laura Eid
- Ophthalmology Department, Bordeaux University Hospital, Bordeaux, France
| | | | - Eric Longueville
- Ophthalmology Department, Bordeaux University Hospital, Bordeaux, France
| | - Emmanuel Ribeiro
- Internal Medicine Department, Bordeaux University Hospital, Bordeaux, France
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27
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Cole M, Hynes AM, Howel D, Hall L, Abinun M, Allahabadia A, Barrett T, Boelaert K, Drake AJ, Dimitri P, Kirk J, Zammitt N, Pearce S, Cheetham T. Adjuvant rituximab, a potential treatment for the young patient with Graves' hyperthyroidism (RiGD): study protocol for a single-arm, single-stage, phase II trial. BMJ Open 2019; 9:e024705. [PMID: 30670519 PMCID: PMC6347892 DOI: 10.1136/bmjopen-2018-024705] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/09/2018] [Revised: 09/25/2018] [Accepted: 11/22/2018] [Indexed: 12/11/2022] Open
Abstract
INTRODUCTION Graves' disease (Graves' hyperthyroidism) is a challenging condition for the young person and their family. The excess thyroid hormone generated by autoimmune stimulation of the thyroid stimulating hormone receptor on the thyroid gland can have a profound impact on well-being. Managing the young person with Graves' hyperthyroidism is more difficult than in older people because the side effects of conventional treatment are more significant in this age group and because the disease tends not to resolve spontaneously in the short to medium term. New immunomodulatory agents are available and the anti-B cell monoclonal antibody rituximab is of particular interest because it targets cells that manufacture the antibodies that stimulate the thyroid gland in Graves'. METHODS AND ANALYSIS The trial aims to establish whether the combination of a single dose of rituximab (500 mg) and a 12-month course of antithyroid drug (usually carbimazole) can result in a meaningful increase in the proportion of patients in remission at 2 years, the primary endpoint. A single-stage, phase II A'Hern design is used. 27 patients aged 12-20 years with newly presenting Graves' hyperthyroidism will be recruited. Markers of immune function, including lymphocyte numbers and antibody levels (total and specific), will be collected regularly throughout the trial. DISCUSSION The trial will determine whether the immunomodulatory medication, rituximab, will facilitate remission above and beyond that observed with antithyroid drug alone. A meaningful increase in the expected proportion of young patients entering remission when managed according to the trial protocol will justify consideration of a phase III trial.Ethics and dissemination The trial has received a favourable ethical opinion (North East - Tyne and Wear South Research Ethics Committee, reference 16/NE/0253, EudraCT number 2016-000209-35). The results of this trial will be distributed at international endocrine meetings, in the peer-reviewed literature and via patient support groups. TRIAL REGISTRATION NUMBER ISRCTN20381716.
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Affiliation(s)
- Michael Cole
- Institute of Health and Society, Newcastle University, Newcastle upon Tyne, UK
| | - Ann Marie Hynes
- Newcastle Clinical Trials Unit, Newcastle University, Newcastle upon Tyne, UK
| | - Denise Howel
- Institute of Health and Society, Newcastle University, Newcastle upon Tyne, UK
| | - Lesley Hall
- Newcastle Clinical Trials Unit, Newcastle University, Newcastle upon Tyne, UK
| | - Mario Abinun
- Institute of Cellular Medicine, Newcastle University, Great North Children’s Hospital, Newcastle upon Tyne, UK
| | - Amit Allahabadia
- Academic Directorate of Diabetes and Endocrinology, Royal Hallamshire Hospital, Sheffield, UK
| | - Timothy Barrett
- C/O Diabetes Unit, Birmingham Children’s Hospital, Birmingham, UK
| | - Kristien Boelaert
- Institute of Metabolism and Systems Research, College of Medical and Dental Sciences, Institute of Biomedical Research, University of Birmingham, Birmingham, UK
| | - Amanda J Drake
- Centre for Cardiovascular Science, Queen’s Medical Research Institute, Edinburgh, UK
| | - Paul Dimitri
- The Academic Unit of Child Health, Sheffield Children’s NHS Trust Western Bank, Sheffield, UK
| | - Jeremy Kirk
- Department of Endocrine, Birmingham Children’s Hospital, Birmingham, UK
| | - Nicola Zammitt
- Edinburgh Centre for Endocrinology and Diabetes, Royal Infirmary of Edinburgh, Edinburgh, UK
| | - Simon Pearce
- Institute of Genetic Medicine, Newcastle University, Newcastle upon Tyne, UK
| | - Tim Cheetham
- Department of Paediatric Endocrinology, Institute of Genetic Medicine, Newcastle University, Great North Children’s Hospital, Newcastle upon Tyne, UK
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28
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B cells in Graves' Orbitopathy: more than just a source of antibodies? Eye (Lond) 2018; 33:230-234. [PMID: 30514895 DOI: 10.1038/s41433-018-0285-y] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/18/2018] [Accepted: 10/25/2018] [Indexed: 12/12/2022] Open
Abstract
B cells have multiple actions on different phases of an immune reaction, mainly resulting in B and T cell-interaction (help), production of cytokines, regulation of dendritic cells and downregulation of regulatory B cells. The effectiveness of B cell depletion therapy is probably due to blockade of the antigen-presenting function of B cells, occurring very early in the setting of autoimmune reactions. B cells undergo a maturation process from stem cells during which the CD 20 antigen, which is the target of rituximab (RTX), is expressed from the stage of pre-B cells to mature and memory B cells, but not on plasma cells. During the maturation process, the cytokine B cell stimulating factor (BAFF) induces maturation of B cells and expansion of clones to produce plasma cells and eventually antibodies. The effect of RTX in GO is rather rapid, with significant improvement of the disease already 4-6 weeks after the first RTX infusion. Based on the evidence of significant lymphocytic infiltration in the orbits of patients with active GO, it is reasonable to postulate that RTX may cause depletion of B cells and block their antigen-presenting cell mechanism. Since it has been reported that serum BAFF concentrations are elevated in hyperthyroid GD patients and that BAFF is expressed on the thyrocytes of patients with either autoimmune disease or nodular goiter, the hypothesis that belimumab, an anti-BAFF monoclonal antibody, may be effective in patients with active GO his currently being tested in a randomized controlled trial.
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29
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Kraus CN, Sodha P, Vaidyanathan P, Kirkorian AY. Thyroid dermopathy and acropachy in pediatric patients. Pediatr Dermatol 2018; 35:e371-e374. [PMID: 30187962 DOI: 10.1111/pde.13670] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
The extrathyroid manifestations of Graves disease (GD) include thyroid orbitopathy, dermopathy, and acropachy. Thyroid dermopathy (TD), also known as pretibial myxedema, classically presents as nonpitting edema or plaquelike lesions on the pretibial region, while thyroid acropachy (TA) is seen in cases of severe TD, characterized by soft tissue swelling and clubbing of fingers and toes, as well as a periosteal reaction of the bones of the hands and feet. Both TD and TA are rare manifestations of thyroid disease and uncommonly reported in pediatric patients. Our aim was to increase awareness of dermatological manifestations associated with pediatric GD and review the literature of pediatric thyroid dermopathy as well as report a case of acropachy in a child.
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Affiliation(s)
- Christina N Kraus
- Department of Dermatology, University of California, Irvine, California
| | - Pooja Sodha
- Department of Dermatology, Duke University, Durham, North Carolina
| | - Priya Vaidyanathan
- Division of Endocrinology, Children's National Health System, Washington, District of Columbia.,George Washington University School of Medicine & Health Sciences, Washington, District of Columbia
| | - A Yasmine Kirkorian
- George Washington University School of Medicine & Health Sciences, Washington, District of Columbia.,Division of Dermatology, Children's National Health System, Washington, District of Columbia
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30
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Adamidou F, Anagnostis P, Boboridis K, Manani C, Georgiou T, Veneti S, Kita M. Enduring remission of active and sight-threatening Graves' orbitopathy with rituximab: report of two cases. Endocr J 2018; 65:963-967. [PMID: 29937466 DOI: 10.1507/endocrj.ej18-0074] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
Intravenous (i.v.) glucocorticosteroids (GCs) constitute the first-line treatment for active and moderate-to-severe Graves' orbitopathy (GO). In cases of persistent disease, rituximab, a monoclonal anti-CD20 antibody, may be used, although studies have yielded conflicting results. In case 1, a 50-year-old female heavy smoker presented with severe bilateral disfiguring eyelid edema of four months, bilateral exophthalmos and a clinical activity score (CAS) of 5/7. Laboratory investigation showed thyrotoxicosis and high thyroid-stimulating immunoglobulin (TSI) levels [32 IU/L (normal <1.75]. After minor improvement by i.v. methylprednisolone and standard retrobulbar radiotherapy (20 Gy), her visual acuity progressively declined to "hand motion". Rituximab was administered (two pulses of 500 mg, two weeks apart), with significant response. At 3 1/2 years of follow-up, CAS is 0/7 and CD20+ lymphocytes remain at the lower normal range. In case 2, a 78-year-old non-smoker male was referred for management of severe active GO, one month after total thyroidectomy for Graves' thyrotoxicosis (TSI: 6.74 IU/L). Over the preceding two-three months, severe GO manifested with chemosis, constant diplopia, loss of color vision and acuity of 1/10 bilaterally (CAS: 7/7). Following partial response to i.v. methylprednisolone and concomitant radiotherapy, rituximab (two pulses of 500 mg each, two weeks apart), was administered. Vision partially recovered and GO remains in remission one year later, even after 131I (100 mCi) administration for papillary thyroid carcinoma (TSI: 0.9 IU/L and CD20+ count at the lower normal range). In conclusion, rituximab may be an effective second-line therapy in GO patients, providing long-lasting remission.
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Affiliation(s)
- Fotini Adamidou
- Department of Endocrinology and Diabetes, Hippokration Hospital of Thessaloniki, Thessaloniki, Greece
| | - Panagiotis Anagnostis
- Department of Endocrinology and Diabetes, Hippokration Hospital of Thessaloniki, Thessaloniki, Greece
| | - Kostas Boboridis
- 1st University Department of Ophthalmology, Aristotle University of Thessaloniki, Thessaloniki, Greece
| | - Christina Manani
- Department of Endocrinology and Diabetes, Hippokration Hospital of Thessaloniki, Thessaloniki, Greece
| | - Thomas Georgiou
- Department of Endocrinology and Diabetes, Hippokration Hospital of Thessaloniki, Thessaloniki, Greece
| | - Stavroula Veneti
- Department of Endocrinology and Diabetes, Hippokration Hospital of Thessaloniki, Thessaloniki, Greece
| | - Marina Kita
- Department of Endocrinology and Diabetes, Hippokration Hospital of Thessaloniki, Thessaloniki, Greece
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31
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Corvilain B, Hamy A, Brunaud L, Borson-Chazot F, Orgiazzi J, Bensalem Hachmi L, Semrouni M, Rodien P, Lussey-Lepoutre C. Treatment of adult Graves' disease. ANNALES D'ENDOCRINOLOGIE 2018; 79:618-635. [PMID: 30193753 DOI: 10.1016/j.ando.2018.08.003] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 10/28/2022]
Abstract
Treatment strategy in Graves' disease firstly requires recovery of euthyroid status by antithyroid therapy. Treatment modalities, precautions, advantages and side-effects are to be discussed with the patient. No particular treatment modality has demonstrated superiority. Pregnancy or pregnancy project affects choice of treatment and monitoring. Graves' orbitopathy is liable to be aggravated by iodine-131 treatment and requires pre-treatment assessment. Iodine-131 treatment aims at achieving hypothyroidism. Thyroid surgery for Graves' disease should preferably be performed by an expert team. In case of recurrence of hyperthyroidism, the various treatment options should be discussed with the patient. Empiric treatment of thyroid dermopathy uses local corticosteroids in occlusive dressing.
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Affiliation(s)
- Bernard Corvilain
- Department of Endocrinology, Erasme University Hospital, université Libre de Bruxelles, Brussels, Belgium
| | - Antoine Hamy
- Service de chirurgie viscérale et endocrine, CHU d'Angers, 49000 Angers, France
| | - Laurent Brunaud
- Service de chirurgie, unité de chirurgie endocrinienne, thyroïdienne et métabolique, unité multidisciplinaire de chirurgie de l'obésité, université de Lorraine, CHU Nancy, hôpital Brabois adultes, 11, allée du Morvan, 54511 Vandœuvre-les-Nancy, France
| | - Françoise Borson-Chazot
- HESPER EA 7425, hospices civils de Lyon, fédération d'endocrinologie, université Claude-Bernard Lyon 1, 69008 Lyon, France
| | - Jacques Orgiazzi
- CERMEP-imagerie du vivant, université Claude-Bernard Lyon 1, Lyon, France
| | - Leila Bensalem Hachmi
- Service d'endocrinologie à l'Institut national de nutrition de Tunis, faculté de médecine de Tunis, Tunisia
| | | | - Patrice Rodien
- Service EDN, centre de référence des maladies rares de la thyroïde et des récepteurs hormonaux, CHU d'Angers, 49000 Angers, France.
| | - Charlotte Lussey-Lepoutre
- Service de médecine nucléaire, Inserm U970, Sorbonne université, groupe hospitalier Pitié-Salpétrière, 75013 Paris, France
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Abstract
PURPOSE Dysthyroid optic neuropathy (DON) is a serious complication of Graves orbitopathy that can result in irreversible and profound visual loss. Controversy exists regarding the pathogenesis and management of the disease. The authors provide an overview of the current understanding of DON and present a therapeutic guideline. METHODS A review of the literature. RESULTS The mechanism of DON appears to be multifactorial: direct compression of the optic nerve by enlarged extraocular muscles, stretching of the optic nerve by proptosis, orbital pressure, vascular insufficiency, and inflammation. Some or all of these factors may be involved in an individual patient. There has only been one controlled trial comparing high-dose intravenous methylprednisolone to bony orbital decompression for DON. Both 2-wall and 3-wall decompression techniques successfully improve visual functions of patients with DON. There are few case reports/case series that suggest biologic agents may improve visual function in DON. CONCLUSIONS DON is a serious complication of Graves orbitopathy, the diagnosis and management of which is complex and requires a multidisciplinary approach. There is little evidence regarding the optimum management strategy. Based on the current literature, the first line of treatment is intravenous methylprednisolone, with the exact timing and indication of bony orbital decompression still to be determined. In addition, there may be a role for the use of biologic agents that will require a systematic program to determine efficacy.
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33
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Treatment of Concurrent Thrombotic Thrombocytopenic Purpura and Graves' Disease: A Report on Two Cases. Case Rep Endocrinol 2018; 2018:5747969. [PMID: 30159177 PMCID: PMC6106962 DOI: 10.1155/2018/5747969] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/20/2018] [Accepted: 08/01/2018] [Indexed: 11/22/2022] Open
Abstract
Graves' disease (GD) and thrombotic thrombocytopenic purpura (TTP) are autoimmune diseases caused by autoantibodies against the TSH receptor (TRAb) and the enzyme ADAMTS13. We here report on two patients with concurrent GD and TTP, who achieved sustained remission of both conditions with the TTP treatment regimen and thiamazole. Both patients suffered from relapsing TTP and were diagnosed with GD concomitantly at the time of relapse. They were treated with steroids, plasma exchange, rituximab, and thiamazole. This therapy induced complete remission of TTP. TRAb levels also decreased rapidly and both patients developed subclinical hypothyroidism three and five weeks later. Our observations suggest that TTP and GD may be concomitant and that GD possibly triggers a relapse of TTP. The combination of thyrostatic treatment and immunosuppression with PE, rituximab, and steroids is able to induce rapid and prolonged remission of GD.
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34
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Wang C, Ning Q, Jin K, Xie J, Ye J. Does rituximab improve clinical outcomes of patients with thyroid-associated ophthalmopathy? A systematic review and meta-analysis. BMC Ophthalmol 2018; 18:46. [PMID: 29452583 PMCID: PMC5816536 DOI: 10.1186/s12886-018-0679-4] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/05/2017] [Accepted: 01/12/2018] [Indexed: 11/24/2022] Open
Abstract
BACKGROUND The current therapies of thyroid-associated ophthalmopathy (TAO) were still a challenging matter. In this study, we aimed to contrast the impact of before- after rituximab (RTX) therapy in the patients with TAO. METHODS We searched the PubMed, EMBASE, and SCOPUS databases for articles published up to July 3, 2017. Fixed- or random-effects meta-analysis was used to provide pooled estimates of standard mean difference (SMD) both the primary outcome from clinical activity score (CAS), and secondary outcomes from thyrotropin receptor antibody (TRAb), proptosis, thyroid stimulating hormone (TSH), and interleukin-6 (IL-6) levels. In addition, the quality and each study was assessed using either the Newcastle Ottawa Scale (NOS) or the Cochrane Risk of Bias tool, and reliability of the meta-analytic result using the Grading of Recommendations Assessment, Development and Evaluation (GRADE). RESULTS Of the 839 articles initially searched, 11 studies were finally eligible for inclusion. Subgroup analysis results showed that comparing with initial value, there was a decline in CAS at 1,3,6,12 month after RTX treatment, decreased TRAbs level at 6,12 month, proptosis improvement at least 1 month, unchanged IL-6 level at 6 month, decreased TSH level at 3 month but unchanged at 12 month. All included studies were classified as good quality. CONCLUSIONS The pooled data suggested that the preliminary effects of RTX treatment on TAO might be promising. However, more large-sample and high-quality studies targeting RTX use during this disease and long-term surveillance of prognosis are urgently needed.
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Affiliation(s)
- Changjun Wang
- Department of Ophthalmology, the Second Affiliated Hospital of Zhejiang University, College of Medicine, Hangzhou, 310009, China
| | - Qingyao Ning
- Department of Ophthalmology, the Second Affiliated Hospital of Zhejiang University, College of Medicine, Hangzhou, 310009, China
| | - Kai Jin
- Department of Ophthalmology, the Second Affiliated Hospital of Zhejiang University, College of Medicine, Hangzhou, 310009, China
| | - Jiajun Xie
- Department of Ophthalmology, the Second Affiliated Hospital of Zhejiang University, College of Medicine, Hangzhou, 310009, China
| | - Juan Ye
- Department of Ophthalmology, the Second Affiliated Hospital of Zhejiang University, College of Medicine, Hangzhou, 310009, China.
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Gan EH, Pearce SH. MANAGEMENT OF ENDOCRINE DISEASE: Regenerative therapies in autoimmune Addison's disease. Eur J Endocrinol 2017; 176:R123-R135. [PMID: 27810905 DOI: 10.1530/eje-16-0581] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/09/2016] [Revised: 09/19/2016] [Accepted: 11/03/2016] [Indexed: 12/15/2022]
Abstract
The treatment for autoimmune Addison's disease (AAD) has remained virtually unchanged in the last 60 years. Most patients have symptoms that are relatively well controlled with exogenous steroid replacement, but there may be persistent symptoms, recurrent adrenal crisis and poor quality of life, despite good compliance with optimal current treatments. Treatment with conventional exogenous steroid therapy is also associated with premature mortality, increased cardiovascular risk and complications related to excessive steroid replacement. Hence, novel therapeutic approaches have emerged in the last decade attempting to improve the long-term outcome and quality of life of patients with AAD. This review discusses the recent developments in treatment innovations for AAD, including the novel exogenous steroid formulations with the intention of mimicking the physiological biorhythm of cortisol secretion. Our group has also carried out a few studies attempting to restore endogenous glucocorticoid production via immunomodulatory and regenerative medicine approaches. The recent advances in the understanding of adrenocortical stem cell biology, and adrenal plasticity will also be discussed to help comprehend the science behind the therapeutic approaches adopted.
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Affiliation(s)
- Earn H Gan
- Institute of Genetic MedicineInternational Centre for Life, Centre Parkway, Newcastle upon Tyne, UK
| | - Simon H Pearce
- Institute of Genetic MedicineInternational Centre for Life, Centre Parkway, Newcastle upon Tyne, UK
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Stan MN, Salvi M. MANAGEMENT OF ENDOCRINE DISEASE: Rituximab therapy for Graves' orbitopathy - lessons from randomized control trials. Eur J Endocrinol 2017; 176:R101-R109. [PMID: 27760790 DOI: 10.1530/eje-16-0552] [Citation(s) in RCA: 66] [Impact Index Per Article: 9.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/27/2016] [Revised: 09/26/2016] [Accepted: 10/19/2016] [Indexed: 11/08/2022]
Abstract
Rituximab (RTX) use in open-label series has been associated with very encouraging responses in patients with active and moderate-to-severe Graves' orbitopathy (GO). Recently, randomized controlled trials of RTX have been performed in such patients to answer the question of clinical efficacy and the safety profile of this agent. That data, reported separately, focused on Clinical Activity Score (CAS) and indicated in one trial a strong benefit of RTX in comparison with IV glucocorticoids, whereas the other trial noted the absence of a benefit by comparison with placebo. The outcome was reanalyzed post hoc here, using EUGOGO criteria, and the results were not significantly different. The authors comment further on the differences between the two trials regarding populations treated, methodology, analysis of outcomes and the adverse effect profile of RTX. The populations treated appear different with younger patients, lower TRAb and shorter duration of disease prevalent in the Italian trial, all elements favoring a better response. Smoking, usually diminishing a response, was also more prevalent in some patients. The combined outcome proposed by EUGOGO revealed similar results with CAS regarding RTX efficacy; yet, it might be a more comprehensive outcome. The adverse events of concern relate mainly to the risk of DON, which seems to be increased by the use of RTX in a certain subset of patients. Based on available data, a multicenter trial using the EUGOGO-proposed outcomes might be the next best step to define the role of RTX in GO therapy.
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Affiliation(s)
- Marius N Stan
- Mayo ClinicDivision of Endocrinology, Rochester, Minnesota, USA
| | - Mario Salvi
- Department of Clinical SciencesGraves' Orbitopathy Center, Endocrinology, Fondazione Cà Granda IRCCS and University of Milan, Milan, Italy
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Précausta F, Arsène S, Renoult-Pierre P, Laure B, Crinière L, Pisella PJ. Treatment by rituximab on six Grave's ophthalmopathies resistant to corticosteroids. ANNALES D'ENDOCRINOLOGIE 2017; 78:20-26. [DOI: 10.1016/j.ando.2016.12.002] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/25/2016] [Revised: 11/05/2016] [Accepted: 12/14/2016] [Indexed: 01/07/2023]
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Affiliation(s)
- Terry J Smith
- From the Department of Ophthalmology and Visual Sciences, Kellogg Eye Center, and the Department of Internal Medicine, University of Michigan Medical School - both in Ann Arbor (T.J.S.); and the Departments of Endocrinology and Metabolism (L.H.) and Ophthalmology (T.J.S.), Odense University Hospital, University of Southern Denmark, Odense
| | - Laszlo Hegedüs
- From the Department of Ophthalmology and Visual Sciences, Kellogg Eye Center, and the Department of Internal Medicine, University of Michigan Medical School - both in Ann Arbor (T.J.S.); and the Departments of Endocrinology and Metabolism (L.H.) and Ophthalmology (T.J.S.), Odense University Hospital, University of Southern Denmark, Odense
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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.
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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
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Cheetham T, Bliss R. Treatment options in the young patient with Graves' disease. Clin Endocrinol (Oxf) 2016; 85:161-4. [PMID: 26252256 DOI: 10.1111/cen.12871] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/05/2015] [Revised: 07/10/2015] [Accepted: 07/31/2015] [Indexed: 12/21/2022]
Abstract
The treatment options in the young patient with Graves' disease are the same as in adults, namely antithyroid drug (ATD), surgery (partial or total thyroidectomy) and radioiodine. However, the emphasis and expectation is different in the young person, reflecting a range of considerations including age, pubertal status, disease natural history, likely impact of ATD on disease course and the implications of radiation exposure. New therapeutic strategies that could increase the likelihood of long-term remission are being explored.
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Affiliation(s)
- Tim Cheetham
- Department of Paediatric Endocrinology, c/o Old Children's Out Patients, Royal Victoria Infirmary, Newcastle-upon-Tyne, UK
- Institute of Genetic Medicine, Newcastle University, Newcastle-upon-Tyne, UK
| | - Richard Bliss
- Department of Surgery, Royal Victoria Infirmary, Newcastle-upon-Tyne, UK
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Liu X, Guo H, Liu J, Shi B. Clinical efficacy of combined rituximab treatment in a woman with severe Graves' ophthalmopathy. Exp Ther Med 2016; 12:1093-1096. [PMID: 27446325 DOI: 10.3892/etm.2016.3367] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/03/2015] [Accepted: 04/11/2016] [Indexed: 11/06/2022] Open
Abstract
The present study reports the case of a female Chinese patient with Graves' disease (GD) and severe Graves' ophthalmopathy (GO) in its active phase, who was treated with propylthiouracil and oral prednisolone for 2 months at a local hospital. However, a lack of improvement in symptoms meant that the patient was transferred to the First Affiliated Hospital of Xi'an Jiaotong University (Xi'an, China), whereupon the patient received high-dose intravenous methylprednisolone pulse therapy, although with limited efficacy. Subsequently, rituximab (RTX; anti-CD20 monoclonal antibody) combined with orbital irradiation treatment was initiated. The patient responded positively to the combined treatment; the clinical symptoms and enlargement of the extraocular muscles were ameliorated, and there were marked decreases in the clinical activity and NOSPECS grading scores. Furthermore, the serum levels of anti-thyrotropin receptor antibodies (TRAb) were markedly decreased at 2 months following RTX therapy. The patient was maintained in a euthyroid state by treatment with methimazole during and following RTX therapy. It was concluded that RTX treatment may attenuate severe GO by depleting lymphocytes, and may promote the recovery of GD by reducing the serum levels of TRAb.
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Affiliation(s)
- Xiaomei Liu
- Department of Endocrinology, First Affiliated Hospital of Xi'an Jiaotong University, Xi'an, Shaanxi 710061, P.R. China; Department of Endocrinology, Nanjing First Hospital, Nanjing Medical University, Nanjing, Jiangsu 210006, P.R. China
| | - Hui Guo
- Department of Endocrinology, First Affiliated Hospital of Xi'an Jiaotong University, Xi'an, Shaanxi 710061, P.R. China
| | - Juan Liu
- Department of Endocrinology, First Affiliated Hospital of Xi'an Jiaotong University, Xi'an, Shaanxi 710061, P.R. China
| | - Bingyin Shi
- Department of Endocrinology, First Affiliated Hospital of Xi'an Jiaotong University, Xi'an, Shaanxi 710061, P.R. China
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Ruchała M, Sawicka-Gutaj N. Advances in the pharmacological treatment of Graves' orbitopathy. Expert Rev Clin Pharmacol 2016; 9:981-9. [PMID: 26966785 DOI: 10.1586/17512433.2016.1165606] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
Graves' orbitopathy has a deteriorating effect on patients' appearance and vision, thus significantly decreases their quality of life. A multidisciplinary team of endocrinologists, ophthalmologists, head and neck surgeons, nuclear medicine physicians, radiologists, and psychologists should constitute a standard health care team for those patients. It is vital that the therapy is based on an individual approach, with patients being well informed and involved in the decision-making process. Generally, traditional therapies include immunosuppression with steroids, orbital irradiation and surgical decompression. Novel treatment modalities include: biological agents, somatostatin analogs, antioxidants, methotrexate. Better insight into pathogenesis of Graves' orbitopathy is the only chance for targeted therapy development.
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Affiliation(s)
- Marek Ruchała
- a Department of Endocrinology, Metabolism and Internal Medicine , Poznan University of Medical Sciences , Poznań , Poland
| | - Nadia Sawicka-Gutaj
- a Department of Endocrinology, Metabolism and Internal Medicine , Poznan University of Medical Sciences , Poznań , Poland
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Fallahi P, Ferrari SM, Elia G, Nasini F, Colaci M, Giuggioli D, Vita R, Benvenga S, Ferri C, Antonelli A. Novel Therapies for Thyroid Autoimmune Diseases. Expert Rev Clin Pharmacol 2016; 9:853-61. [PMID: 26900630 DOI: 10.1586/17512433.2016.1157468] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/26/2023]
Abstract
C-X-C chemokine receptor (CXCR)3 and its interferon(IFN)γ-dependent chemokines (CXCL10, CXCL9, CXCL11) are implicated in the immune-pathogenesis of autoimmune thyroiditis (AT), Graves disease (GD) and Graves Ophthalmopathy (GO). In tissue, recruited Th1 lymphocytes produce IFNγ, enhancing the tissue secretion of IFNγ-inducible chemokines, initiating and perpetuating the autoimmune process. Patients with AT (with hypothyroidism), and with GO and GD, particularly in the active phase, have high IFNγ-inducible chemokines. Peroxisome proliferator-activated receptor (PPAR)γ or -α agonists and methimazole exert an immune-modulation on CXCR3 chemokines in AT, GD and GO. Other studies are ongoing to evaluate new molecules acting as antagonists of CXCR3, or blocking CXCL10, in Hashimoto thyroiditis (HT), GD and GO. Recently, novel molecules targeting the various agents involved in the pathogenesis of GO, such as rituximab, have been proposed as an alternative to corticosteroids. However, randomized and controlled studies are needed to generalize these interesting results.
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Affiliation(s)
- Poupak Fallahi
- a Department of Clinical and Experimental Medicine , University of Pisa , Pisa , Italy
| | | | - Giusy Elia
- a Department of Clinical and Experimental Medicine , University of Pisa , Pisa , Italy
| | - Francesco Nasini
- b Department of Surgical, Medical, Molecular Pathology and of Emergency , University of Pisa , Pisa , Italy
| | - Michele Colaci
- c Department of Medical, Surgical, Maternal, Pediatric and Adult Sciences , University of Modena & Reggio Emilia , Modena , Italy
| | - Dilia Giuggioli
- c Department of Medical, Surgical, Maternal, Pediatric and Adult Sciences , University of Modena & Reggio Emilia , Modena , Italy
| | - Roberto Vita
- d Department of Clinical and Experimental Medicine, Section of Endocrinology , University of Messina , Messina , Italy
| | - Salvatore Benvenga
- d Department of Clinical and Experimental Medicine, Section of Endocrinology , University of Messina , Messina , Italy
| | - Clodoveo Ferri
- c Department of Medical, Surgical, Maternal, Pediatric and Adult Sciences , University of Modena & Reggio Emilia , Modena , Italy
| | - Alessandro Antonelli
- a Department of Clinical and Experimental Medicine , University of Pisa , Pisa , Italy
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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: 584] [Impact Index Per Article: 73.0] [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.
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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
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Orlans HO, Bremner FD. Dysthyroid Orbitopathy Presenting with Gaze-Evoked Amaurosis: Case Report and Review of the Literature. Orbit 2015; 34:324-6. [PMID: 26505217 DOI: 10.3109/01676830.2015.1078374] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
BACKGROUND Gaze-evoked amaurosis (GEA) describes visual loss associated with eccentric gaze that recovers when the eye is returned to primary position. Here we describe an unusual case of bilateral GEA as the presenting feature of dysthyroid orbitopathy. This is only the third such case to be reported in the literature and the first to feature bilateral GEA in all positions of gaze without accompanying proptosis or ophthalmoplegia. CASE PRESENTATION A 50-year-old man who had recently commenced treatment for thyrotoxicosis presented with a 3-week history of typical GEA in both eyes in all positions of gaze. He subsequently developed a bilateral compressive optic neuropathy which was only partially responsive to high dose steroid therapy. CONCLUSION Although an uncommon presenting feature of dysthyroid orbitopathy, GEA is an ominous symptom that may precede sight-threatening optic nerve compromise. When present, early immunosuppressive and/or decompressive treatment should be considered.
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Affiliation(s)
- Harry O Orlans
- a Department of Ophthalmology , Moorfields Eye Hospital , London , United Kingdom and
| | - Fion D Bremner
- b Consultant Ophthalmologist, Department of Neuro-ophthalmology, National Hospital for Neurology & Neurosurgery , Queen Square , London , United Kingdom
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Ostrowski RA, Bussey MR, Shayesteh Y, Jay WM. Rituximab in the Treatment of Thyroid Eye Disease: A Review. Neuroophthalmology 2015; 39:109-115. [PMID: 27928343 DOI: 10.3109/01658107.2015.1039140] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/06/2015] [Revised: 03/27/2015] [Accepted: 04/06/2015] [Indexed: 01/08/2023] Open
Abstract
Graves disease is an autoimmune thyroid disease classically characterised by a clinical triad consisting of hyperthyroidism, diffuse goitre, and thyroid eye disease. Thyroid eye disease is an immunologically mediated condition in which humoral immunity is thought to play a central role. Thyroid eye disease is traditionally treated with high-dose glucocorticosteroids and surgical orbital decompression. However, responses are inadequate and alternative treatment options are needed. Rituximab, an anti-CD20 monoclonal antibody, shows promise as a novel therapeutic option for thyroid eye disease. There are 43 cases of thyroid eye disease treated with rituximab in the medical literature, and larger studies are warranted to determine the long-term effectiveness of rituximab. Rituximab may represent an attractive new treatment option for thyroid eye disease, especially in the case of disease that is refractory to current treatment strategies.
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Affiliation(s)
- Rochella A Ostrowski
- Division of Allergy, Immunology, and Rheumatology, Department of Medicine, Loyola University Chicago, Stritch School of Medicine Maywood, Illinois USA and
| | - Melissa R Bussey
- Division of Allergy, Immunology, and Rheumatology, Department of Medicine, Loyola University Chicago, Stritch School of Medicine Maywood, Illinois USA and
| | - Yasmin Shayesteh
- Department of Ophthalmology, Loyola University Chicago, Stritch School of Medicine Maywood, Illinois USA
| | - Walter M Jay
- Department of Ophthalmology, Loyola University Chicago, Stritch School of Medicine Maywood, Illinois USA
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Salvi M, Vannucchi G, Currò N, Campi I, Covelli D, Dazzi D, Simonetta S, Guastella C, Pignataro L, Avignone S, Beck-Peccoz P. Efficacy of B-cell targeted therapy with rituximab in patients with active moderate to severe Graves' orbitopathy: a randomized controlled study. J Clin Endocrinol Metab 2015; 100:422-31. [PMID: 25494967 PMCID: PMC4318899 DOI: 10.1210/jc.2014-3014] [Citation(s) in RCA: 235] [Impact Index Per Article: 26.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
Abstract
BACKGROUND Preliminary studies have shown that rituximab (RTX) is effective in the treatment of active Graves' orbitopathy (GO). METHODS We conducted a double-blind, randomized trial (European Clinical Trials Database [EudraCT] 2007-003910-33) to compare RTX with iv methylprednisolone (ivMP) in patients with active moderate to severe GO. Thirty-two patients were randomized to receive either ivMP (7.5 g) or RTX (2000 or 500 mg). The primary end point was the decrease of the clinical activity score of 2 points or to less than 3 at week 24. Changes of proptosis, lid fissure, diplopia and eye muscle motility, and quality of life score were secondary end points. The number of therapeutic responses, disease reactivation, and surgical procedures required during follow-up and the patients' quality of life were also assessed. RESULTS The clinical activity score decreased with both treatments but more after RTX at 16, 20, and 24 weeks (P < .04, P < .02, P < .006, respectively), whether 1000 mg RTX twice or 500 mg RTX once was used (P = NS). At 24 weeks 100% of RTX patients improved compared with 69% after ivMP (P < .001). Disease reactivation was never observed in RTX patients but was observed in five after ivMP. Patients treated with RTX scored better motility at 52 weeks in both the right (P = .014) and the left eye (P = .026). Overall rehabilitative surgical procedures carried out during follow-up (at 76 wk) were 12 in 16 ivMP patients and 5 in 15 RTX patients (P = .049). CONCLUSIONS The results of this trial confirm preliminary reports on a better therapeutic outcome of RTX in active moderate to severe GO, when compared with ivMP, even after a lower RTX dose. The better eye motility outcome, visual functioning of the quality of life assessment, and the reduced number of surgical procedures in patients after RTX seem to suggest a disease-modifying effect of the drug.
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Affiliation(s)
- Mario Salvi
- Graves' Orbitopathy Center, Endocrinology Unit, Departments of Clinical Sciences and Community Health (M.S., G.V., I.C., D.C., P.B.-P.), Ophthalmology (N.C., S.S.), Otolaryngology (C.G., L.P.), and Neuroradiology (S.A.), Fondazione Cà Granda Istituto di Ricovero e Cura a Carattere Scientifico and University of Milan, I-20122 Milan, Italy; and Division of Internal Medicine (D.D.), Ospedale di Fidenza, I-43036 Fidenza, Italy
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Stan MN, Garrity JA, Carranza Leon BG, Prabin T, Bradley EA, Bahn RS. Randomized controlled trial of rituximab in patients with Graves' orbitopathy. J Clin Endocrinol Metab 2015; 100:432-41. [PMID: 25343233 PMCID: PMC4318907 DOI: 10.1210/jc.2014-2572] [Citation(s) in RCA: 214] [Impact Index Per Article: 23.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/07/2023]
Abstract
CONTEXT Graves' orbitopathy (GO) is a potentially sight-threatening disease for which available medical therapy is not uniformly successful. Multiple case series suggest that rituximab (RTX) may be effective therapy for GO patients. OBJECTIVE To determine the efficacy of RTX in GO. DESIGN It is a prospective, randomized, double-masked, placebo-controlled trial. SETTING The study was conducted at a large academic private practice. PATIENTS Twenty five patients with active moderate to severe GO were enrolled, and 21 completed the study to the primary endpoint. INTERVENTIONS Two RTX infusions (1000 mg each) or two saline infusions were given 2 weeks apart. MAIN OUTCOME MEASURES The primary endpoint was a reduction in clinical activity score (CAS) assessed as a continuum and separately as improvement by ≥ 2 points at 24 weeks. Secondary endpoints included success and failure rates, proportions showing clinically significant improvement in proptosis, lid fissure width, diplopia score, lagophthalmos and disease severity, and changes in those parameters, orbital fat/ muscle volume and quality-of-life. RESULTS The treatment groups were similar in all parameters at baseline. The last observation was carried forward if the patient discontinued prematurely. No differences were found in the proportions of patients showing CAS improvement at 24 weeks (25% placebo; 31% RTX, P = .75) or in CAS decrease from baseline to 24 or 52 weeks [mean 1.5 points (1.8 SD) placebo; 1.2 (2 SD) RTX at 24 weeks, P = .73]. Similarly, there were no differences between groups in any of the secondary endpoints at either 24 or 52 weeks. There were four adverse events (AE) in 3/12 placebo patients and 11 AE in 8/13 RTX-treated patients; 5/6 moderate or severe AE occurred in the RTX group. CONCLUSION RTX offered no additional benefit over placebo to our patients with active and moderate to severe GO and carried with it non-negligible adverse effects.
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Affiliation(s)
- Marius N Stan
- Division of Endocrinology and Metabolism (M.N.S., B.G.C.L., R.S.B.), Department of Ophthalmology (J.A.G., E.A.B.), and Department of Health Sciences Research (T.P.), Mayo Clinic, 200 First St SW, Rochester, Minnesota 55905
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Abstract
PURPOSE OF REVIEW In recent years, immunosuppressive therapy, as an alternative to corticosteroids, has been proposed as novel agents which target the various antigens involved in the pathogenesis of Graves' ophthalmopathy. Although the lack of randomized and controlled studies suggests caution in generalizing results, some data show interesting results. RECENT FINDINGS Potential targets for immune therapy in Graves' ophthalmopathy are the antigens expressed on the target organ of inflammation, namely the receptor and the insulin growth factor -1 receptor on fibroblasts, inflammatory cytokines, and B and T cells. The most promising results are observed with small thyroid stimulating hormone receptor molecules interacting with the receptor on thyrocytes and fibroblasts and with the anti-IGF-1 receptor antibody teprotumumab. A recent open study with tocilizumab, an anti-soluble interleukin-6 receptor, has shown inactivation of Graves' ophthalmopathy. Consistent reports on the efficacy of rituximab will have to be confirmed by randomized controlled trials, which are now in progress. SUMMARY Current clinical practice for Graves' ophthalmopathy will greatly benefit from the availability of immunosuppressors that act as disease-modifying drugs, as compared to steroids, the current standard treatment for Graves' ophthalmopathy. Rituximab seems to be a good candidate, as preliminary results from ongoing randomized trials suggest good efficacy with a relative well tolerated profile.
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Affiliation(s)
- Mario Salvi
- Graves' Orbitopathy Unit, Fondazione Cà Granda, IRCCS, Department of Clinical and Community Sciences, University of Milan, Milan, Italy
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