Treatment options for Graves' orbitopathy

Oral selenium improved the disease activity in patients with mild Graves' orbitopathy

BACKGROUND

Graves' orbitopathy (GO) is the most common extrathyroidal manifestation of Graves' disease (GD), an autoimmune disorder arising from the activity of T lymphocytes against antigens that infiltrate thyroid tissue, orbital tissue and extraocular muscles. An increase in oxidative stress has been discovered in autoimmune thyroid disease, encouraging investigation into new forms of treatment. Selenium has been described as a treatment option given its antioxidant properties. The present study evaluates the decrease of progression and inflammatory signs in patients with mild GO with oral selenium supplementation.

METHODS

Controlled, randomized, single center trial at an ophthalmology referral center in Mexico City. Patients at least 18years of age with mild GO according to the CAS classification were included; exclusion criteria in addition to corticosteroid treatment included smokers or selenium allergy. Each patient was randomized into one of two groups. Group A took placebo tablets which consisted of 100μg of starch twice a day for 6months, and group B took a 100μg selenium tablet twice a day for 6months. The patients from both groups were examined and evaluated using a CAS score before and after the first, third and sixth month of treatment.

RESULTS

Thirty eyes of 30 patients were studied. The pretreatment values showed no statistically significant differences between groups (P>0.05). Intergroup analysis showed statistically significant differences in palpebral fissure and CAS score between the pretreatment values and six months after treatment in the selenium group (P<0.05). No differences were found in any variables in the placebo group during the study period (P>0.05). No adverse events were reported.

CONCLUSIONS

This is the first study in a Mexican population demonstrating that oral selenium decreases clinical activity and stops progression in patients with mild GO.

A survey of current practices by the British Oculoplastic Surgery Society (BOPSS) and recommendations for delivering a sustainable multidisciplinary approach to thyroid eye disease in the United Kingdom

Background

The Royal College of Physicians (RCP) and Thyroid Eye Disease Amsterdam Declaration Implementation Group (TEAMeD-5) have the common goal of improving access to high quality care for thyroid eye disease (TED). The TEAMeD-5 programme recommends all patients with moderate-to-severe TED should have access to multidisciplinary clinics (MDT)  with combined Ophthalmology and Endocrinology expertise.

Methods

The British Oculoplastic Surgery Society represents oculoplastic surgeons who usually lead TED care in the UK. A two-stage survey of the membership was conducted to ascertain current practice of existing resources.

Results

Seventy percent (45/65) of respondents in Survey 1 were aware of current RCP guidance, but only 49% (22/45) rated it as a good means of improving access to comprehensive TED service. Sixty percent (39/65) of respondents are working in a multidisciplinary TED clinic with co-location of ophthalmologists and endocrinologists. Care for TED appears not to be provided in a multidisciplinary context in up to 31% (20/65). Thirty five (54%) of the respondents rated their relationship with endocrinology colleagues as good. Best practice guidelines recommend routine quality of life assessments but only 6/28 (21%) of respondents use this modality in current practice. Six percent (4/65) of areas appear not to be using intravenous steroids. In many areas (25%, 16/65), second-line immunosuppression is provided in a different trust and in 8% (5/65), it appears not to be used at all.

Conclusion

This survey is a ‘snapshot’ of current TED management in the UK and findings suggest scope for improvement. We recommend a framework for more robust collaboration across specialties and propose standards endorsed by multidisciplinary stakeholder societies.

A 2018 European Thyroid Association Survey on the Use of Selenium Supplementation in Graves' Hyperthyroidism and Graves' Orbitopathy

OBJECTIVE

Selenium (Se) supplementation has been suggested in the treatment of Graves' disease (GD). We sought to investigate Se prescription patterns for GD across European countries.

METHODS

Members of the European Thyroid Association were invited to participate in an online survey investigating the use of Se in GD either without or with orbitopathy (GO). Of 872 invited members, 244 (28%) completed the survey. After exclusion of basic scientists and non-European members, 197 responses were retrieved out of clinical trials (nearly half of clinician members), of whom 61 do not use Se. Thus, 136 respondents remained for further analyses.

RESULTS

Among the 136 analyzed respondents, most (64.7%) were not aware of the Se status in their populations, did not assess Se levels (78.7%), nor considered iodine status (74.3%). In GD without GO, 38.2% recommend Se supplementation ("sometimes" [27.2%], "frequently" [5.9%] or "always" [5.1%]). When GO occurs, 94.1% recommend Se supplementation ("sometimes" [39%], "frequently" [30.1%] or "always" [25%]). Of these, 60.1% recommend Se as an alternative to watchful waiting in patients with mild ocular involvement and 44.9% as an adjuvant to the established treatment modalities in patients with moderate to severe ocular involvement.

CONCLUSIONS

In Graves' hyperthyroidism without GO, 38.2% of ETA (European Thyroid Association) members recommend Se supplementation. Conversely, Se is recommended by the majority of respondents in GO, both in patients with mild and moderate to severe ocular involvement. This clinical practice is partially in disagreement with current European treatment guidelines that recommend Se as a 6-month treatment in mild GO only.

Treatment of Graves' ophthalmopathy with an in-house Phosphorus-32 source: Initial clinical observations

The objective of the present study was to observe the therapeutic effect of radiation delivered via a ³²P source on Graves' ophthalmopathy. A³²P solution was injected into a 10-ml vacuum flask held inside a lead container. A window was cut in the lead, generating a treatment beam. Radiation was given to four areas: The upper and lower orbit (covering ~1/3 of the eyelid) and the inner and outer canthus. Each site received 10 daily doses of 20 cGy. Proptosis was measured by an exophthalmometer and the palpebral aperture was determined with a ruler. Measurements were taken before and after the treatment. After 5 days of treatment, the patient displayed a significant improvement, and by 10 days, the average reduction of proptosis in Graves' ophthalmopathy was 3.36±1.73 mm for the left and 3.05±2.04 mm for the right eyes. The treatment was effective in all patients, who uniformly reported rapid pain relief. Conjunctival congestion and eyelid edema also improved significantly. However, only 50% of patients showed improved diplopia after treatment, which was poor compared with other symptoms. No obvious side effects were found in the subsequent follow-up. In conclusion, ³²P brachytherapy for Graves' ophthalmopathy was simple and effective, with few side effects, and should be considered as a promising therapy.

Management of thyroid eye disease in the United Kingdom: A multi-centre thyroid eye disease audit

This article aims to provide baseline data and highlight any major deficiencies in the current level of care provided for adult patients with thyroid eye disease (TED). We undertook a prospective, nonrandomized cross-sectional multicenter observational study. During a 3-month period June-August 2014, consecutive adult patients with TED who presented to nominated specialist eye clinics in the United Kingdom, completed a standardized questionnaire. Main outcome measures were: demographics, time from diagnosis to referral to tertiary centre, time from referral to review in specialist eye clinic, management of thyroid dysfunction, radioiodine and provision of steroid prophylaxis, smoking, and TED classification. 91 patients (mean age 47.88 years) were included. Female-to-male ratio was 6:1. Mean time since first symptoms of TED = 27.92 (73.71) months; from first visit to any doctor with symptoms to diagnosis = 9.37 (26.03) months; from hyperthyroidism diagnosis to euthyroidism 12.45 (16.81) months. First, 13% had received radioiodine. All those with active TED received prophylactic steroids. Seven patients who received radioiodine and did not have TED at the time went on to develop it. Then, 60% patients were current or ex-smokers. 63% current smokers had been offered smoking cessation advice. 65% patients had active TED; 4% had sight-threatening TED. A large proportion of patients (54%) were unaware of their thyroid status. Not enough patients are being provided with smoking cessation advice and information on the impact of smoking on TED and control of thyroid function.

Graves' Ophthalmopathy: VISA versus EUGOGO Classification, Assessment, and Management

Graves' ophthalmopathy (GO) is an autoimmune inflammatory disorder associated with thyroid disease which affects ocular and orbital tissues. GO follows a biphasic course in which an initial active phase of progression is followed by a subsequent partial regression and a static inactive phase. Although the majority of GO patients have a mild, self-limiting, and nonprogressive ocular involvement, about 3–7% of GO patients exhibit a severe sight-threatening form of the disease due to corneal exposure or compressive optic neuropathy. An appropriate assessment of both severity and activity of the disease warrants an adequate treatment. The VISA (vision, inflammation, strabismus, and appearance), and the European Group of Graves' Orbitopathy (EUGOGO) classifications are the two widely used grading systems conceived to assess the activity and severity of GO and guide the therapeutic decision making. A critical analysis of classification, assessment, and management systems is reported. A simplified “GO activity assessment checklist” for routine clinical practice is proposed. Current treatments are reviewed and management guidelines according to the severity and activity of the disease are provided. New treatment modalities such as specific monoclonal antibodies, TSH-R antagonists, and other immunomodulatory agents show a promising outcome for GO patients.

A questionnaire survey on the management of Graves' orbitopathy in China: A comparison with Europe and Latin-America

OBJECTIVE

Management of Graves' orbitopathy (GO) continues to be a challenge to clinical endocrinologists. In the last few years, surveys on GO management have succeeded in elucidating trends in Europe and Latin America. To determine how endocrinologists in China assess and treat patients with GO and gain insight into how to make the management of this disease more uniform and standardized.

METHODS

Based on the questionnaire used in the European survey on GO, a questionnaire in China was drafted and circulated to the members of Chinese Society of Endocrinology (CSE) during the annual meeting.

RESULTS

A total of 124 valid responses were analysed. Almost all respondents (94.4%) claimed that a multidisciplinary approach for GO management was valuable. Over 80% of the participants advocated the assessment of exophthalmometry, vision, visual fields by perimetry, eye movements, and fundoscopy. Glucocorticoids were preferred as the first-line therapy by 92.7% of respondents, among them, 59.7% choose the intravenous route. The treatment strategy for GO with intravenous glucocorticoids therapy still remains debatable. Anti-thyroid drugs (ATDs) were the most common choice (72.6%) for first-line therapy of coexisting hyperthyroidism. Treatment options for GO were very similar among Chinese, Latin-American and European respondents, whereas radioactive iodine and surgical treatment were more often indicated for co-existing hyperthyroidism in China.

CONCLUSION

The appropriate treatment for patients with GO is controversial even among thyroid specialists. Further training of thyroid specialists, easier access of patients to multidisciplinary centres and establishment of practice guidelines are required for the management of this condition in China.

Critical Appraisal on Orbital Decompression for Thyroid Eye Disease: A Systematic Review and Literature Search

INTRODUCTION

Orbital decompression is the indicated procedure for addressing exophthalmos and compressive optic neuropathy in thyroid eye disease. There are an abundance of techniques for removal of orbital bone, fat, or a combination published in the scientific literature. The relative efficacy and complications of these interventions in relation to the specific indications remain as yet undocumented. We performed a systematic review of the current published evidence for the effectiveness of orbital decompression, possible complications, and impact on quality of life.

METHODS

We searched the current databases for medical literature and controlled trials, oculoplastic textbooks, and conference proceedings to identify relevant data up to February 2015. We included randomized controlled trials (RCTs) comparing two or more interventions for orbital decompression.

RESULTS

We identified only two eligible RCTs for inclusion in the review. As a result of the significant variability between studies on decompression, i.e., methodology and outcome measures, we did not perform a meta-analysis. One study suggests that the transantral approach and endonasal technique had similar effects in reducing exophthalmos but the latter is safer. The second study provides evidence that intravenous steroids may be superior to primary surgical decompression in the management of compressive optic neuropathy requiring less secondary surgical procedures.

CONCLUSION

Most of the published literature on orbital decompression consists of retrospective, uncontrolled trials. There is evidence from those studies that removal of the medial and lateral wall (balanced) and the deep lateral wall decompression, with or without fat removal, may be the most effective surgical methods with only few complications. There is a clear unmet need for controlled trials evaluating the different techniques for orbital decompression. Ideally, future studies should address the effectiveness, possible complications, quality of life, and cost of each intervention.

Selenium supplementation in thyroid associated ophthalmopathy: an update

The therapeutic effect of selenium (Se) has already been proven in thyroid disease and thyroid associated ophthalmopathy (TAO). In spite of clear scientific proof of its benefits in TAO, there appears to be no clear agreement among the clinicians regarding its optimum dose, duration of the treatment, efficacy and safety to date. In this review, the author summarises the findings of 135 English language articles published on this subject over the past four decades from 1973 to 2013. The regulation and metabolism of thyroid hormones require a steady supply of Se and recent studies have revealed several possible mechanisms by which Se improves the severity of thyroid disease and TAO. These mechanisms include 1) inhibitory effect of HLA-DR molecule expression on thyrocytes; 2) profound reductions of thyroid stimulating hormone (TSH) receptor antibodies (TSHR-Ab) and TPO antibodies (TPO-Ab); 3) prevention of dysregulation of cell-mediated immunity and B cell function; 4) neutralising reactive oxygen species (ROS) and inhibition of redox control processes required for the activation, differentiation and action of lymphocytes, macrophages, neutrophils, natural killer cells involved in both acute and chronic orbital inflammation in TAO; 5) inhibition of expression of pro-inflammatory cytokines and 6) inhibition of prostaglandin and leukotriene synthesis. An increased oxidative stress has been observed in both acute and chronic phases of thyroid disease with raised tissue concentrations of ROS. The benefits of Se supplementation in individuals with TAO appear to be proportionate to the degree of systemic activity of the thyroid disease. The maximal benefit of Se supplementation is therefore seen in the subjects who are hyperthyroid. Restoration of euthyroidism is one of the main goals in the management of TAO and when anti-thyroid drugs are combined with Se, the patients with Graves' disease (GD) and autoimmune thyroiditis (AIT) achieved euthyroidism faster than those treated with anti-thyroid drugs alone. Se status of normal adult humans can vary widely and Se supplementation may confer benefit only if serum Se levels are insufficient. The author recommends that serum Se levels of patients with TAO to be assessed prior to and during Se supplementation at regular intervals to avoid potential iatrogenic chronic Se overdose.