Comment on the 2021 EUGOGO Clinical Practice Guidelines for the Medical Management of Graves’ Orbitopathy

Smith, Terry J.

doi:10.1530/eje-21-0861

Cited by 12 publications

(5 citation statements)

References 3 publications

(3 reference statements)

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“…The Chinese study revealed improved proptosis and diplopia, responses not seen in reports from other clinical studies. Smith ( 102 ) commented on what he considered to be important weaknesses in the existing evidence supporting the 2-drug therapy proposed by EUGOGO ( 94 ). Those comments stressed the importance of evenhandedness in evaluating newly introduced medications for TED, a goal he felt was not achieved by the guideline authors.…”

Section: Deciphering the Pathogenesis Of Tedmentioning

confidence: 99%

Understanding Pathogenesis Intersects With Effective Treatment for Thyroid Eye Disease

Smith

2022

The Journal of Clinical Endocrinology &Amp; Metabolism

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Context Thyroid eye disease (TED), a vision-threatening and disfiguring autoimmune process, has thwarted our efforts to understand its pathogenesis and develop effective and safe treatments. Recent scientific advances have facilitated improved treatment options. Objective Review historically remote and recent advances in understanding TED. Design/Setting/Participants PubMed was scanned using search terms including thyroid-associated ophthalmopathy, thyroid eye disease, Graves’ orbitopathy, autoimmune thyroid disease, and orbital inflammation. Main outcome measures Strength of scientific evidence, size, scope, and controls of clinical trials/observations. Results Glucocorticoid steroids are widely prescribed systemic medical therapy. They can lessen inflammation-related manifestations of TED but fail to reliably reduce proptosis and diplopia, 2 major causes of morbidity. Other current therapies include mycophenolate, rituximab (anti-CD20 B cell-depleting monoclonal antibody), tocilizumab (interleukin-6 receptor antagonist), and teprotumumab (IGF-I receptor inhibitor). Several new therapeutic approaches have been proposed including targeting prostaglandin receptors, vascular endothelial growth factor, mTOR, and cholesterol pathways. Of potentially greater long-term importance are attempts to restore immune tolerance. Conclusion Despite their current wide use, steroids may no longer enjoy first-tier status for TED as more effective and better tolerated medical options become available. Multiple current and emerging therapies, the rationales for which are rooted in theoretical and experimental science, promise better options. These include teprotumumab, rituximab, and tocilizumab. Restoration of immune tolerance could ultimately become the most effective and safe medical management for TED.

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Section: Deciphering the Pathogenesis Of Tedmentioning

confidence: 99%

Understanding Pathogenesis Intersects With Effective Treatment for Thyroid Eye Disease

Smith

2022

The Journal of Clinical Endocrinology &Amp; Metabolism

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“…GO was diagnosed based on Bartley’s diagnostic criteria ( 19 ). Two senior physicians who were blinded to the MRI results (an endocrinologist and an ophthalmologist both with >10 years of experience) determined the 7-point CAS and severity for each eye independently according to the EUGOGO atlas and guidelines ( 6 ). The CAS included assessment of spontaneous retrobulbar pain, pain on attempted upward or downward gaze, redness of eyelids, redness of conjunctiva, swelling of caruncle or plica, swelling of eyelids, and swelling of conjunctiva (chemosis) ( 20 ).…”

Section: Methodsmentioning

confidence: 99%

“…The activity of GO is usually assessed using a clinical activity score (CAS) ( 4 , 5 ), which is recommended by the European Group on Graves’ Orbitopathy (EUGOGO) guideline ( 6 ), but it is mainly based on clinical symptoms and is highly subjective ( 7 ). An accurate CAS assessment requires the assessor to have extensive experience in this specific field and access to specialist instruments, which may be difficult to obtain in most hospitals ( 8 ).…”

Section: Introductionmentioning

confidence: 99%

Evaluation of activity of Graves’ orbitopathy with multiparameter orbital magnetic resonance imaging (MRI)

Cheng¹,

Zhang²,

Lian³

et al. 2023

Quant Imaging Med Surg

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Background: When quantitative magnetic resonance imaging (MRI) is used to assess the activity of Graves' orbitopathy (GO), the examination is generally focused on a specific orbital tissue, especially the extraocular muscles (EOMs). However, GO usually involves the entire intraorbital soft tissue. The aim of this study was to use multiparameter MRI on multiple orbital tissues to distinguish the active and inactive GO. Methods: From May 2021 to March 2022, consecutive patients with GO were prospectively enrolled at Peking University People's Hospital (Beijing, China) and divided into those with active disease and those with inactive disease based on a clinical activity score. Patients then underwent MRI, including sequences of conventional imaging, T1 mapping, T2 mapping, and mDIXON Quant. Width, T2 signal intensity ratio (SIR), T1 values, T2 values, and fat fraction of EOMs, as well as water fraction (WF) of orbital fat (OF), were measured. Parameters were compared between the 2 groups, and a combined diagnostic model was constructed using logistic regression analysis. Receiver operating characteristic analysis was used to test the diagnostic performance of the model. Results: Sixty-eight patients with GO (27 with active GO, 41 with inactive GO) were included in the study.The active GO group had higher values of EOM thickness, T2 SIR, and T2 values, as well as higher WF of OF. The diagnostic model, which included EOM T2 value and WF of OF, demonstrated a good ability to distinguish between active and inactive GO (area under the curve, 0.878; 95% CI: 0.776-0.945; sensitivity, 88.89%; specificity, 75.61%).Conclusions: A combined model incorporating the T2 value of EOMs and the WF of OF was able to identify cases of active GO, potentially offering an effective and noninvasive method to assess pathological changes in this disease.

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“…87 The recommendation has been challenged based on inadequate evidence supporting its use. 88 A statement including mycophenolate as first-line therapy for thyroid eye disease is not included in the even more recently published joint statement from the European-American Thyroid Association. 89…”

Section: Current Therapeutic Landscape For Tao: An Expanding Role For...mentioning

confidence: 99%

Fibrocyte Participation in Thyroid-Associated Ophthalmopathy Suggests New Approaches to Therapy

Smith

2023

Ophthalmic Plastic &Amp; Reconstructive Surgery

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Purpose: Review the historical context of research and changing therapeutic landscape of thyroid-associated ophthalmopathy (TAO) by focusing on the relationship between TAO, CD34+ fibrocytes, thyrotropin receptor (TSHR), and insulin-like growth factor-I receptor (IGF-IR). Methods: A literature review using search terms, including fibrocytes, IGF-IR, TSHR, TAO, and thyroid eye disease. Results: The mechanisms involved in TAO have been partially identified. Substantial progress has been made over several decades, including 1) recognizing the interplay between the professional immune system and orbital tissues; 2) TSHR and IGF-IR act interdependently in mediating the pathogenesis of TAO; 3) Multiple cytokines and specific immune cells are involved in activating and remodeling orbital tissue; 4) Recognition of these mechanisms is allowing the development of target therapies such as teprotumumab, a monoclonal antibody IGF-IR inhibitor approved by the US Food and drug administration for treatment of TAO; and 5) It appears that teprotumumab acts on the systemic immune system peripheral to the orbit. Conclusion: Additional molecules targeting IGF-IR and other plausible disease mechanisms are currently under development. This activity in the TAO therapeutic space portends even greater improvements in patient care.

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Comment on the 2021 EUGOGO Clinical Practice Guidelines for the Medical Management of Graves’ Orbitopathy

Cited by 12 publications

References 3 publications

Understanding Pathogenesis Intersects With Effective Treatment for Thyroid Eye Disease

Understanding Pathogenesis Intersects With Effective Treatment for Thyroid Eye Disease

Evaluation of activity of Graves’ orbitopathy with multiparameter orbital magnetic resonance imaging (MRI)

Fibrocyte Participation in Thyroid-Associated Ophthalmopathy Suggests New Approaches to Therapy

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