Mycophenolate Mofetil (CellCept®) in Combination With Low Dose Prednisolone in Moderate to Severe Graves' Orbitopathy

Abstract

Although corticosteroids are currently the first-choice drug for thyroid eye disease (TED), in 20–30% of cases, patients show poor or non-existent responses, and when the drug is withdrawn, 10–20% of patients relapse. Thus, in this study, we aimed to investigate the efficacy of the combined use of mycophenolate mofetil (CellCept®) and low dose oral prednisolone in patients with moderate to severe Graves' orbitopathy (GO). For the first time, we investigated the relationship between TED-related parameters and proptosis reduction. In a prospective, non-randomized, interventional case series, 242 patients with moderate-to-severe GO were, assigned to receive oral prednisolone (5 mg/ d) and mycophenolate mofetil (CellCept®) (one 500 mg tablet twice per day according to the therapeutic response). The patients were monitored regularly during the 3rd, 6th, 12th, and 18th month of treatment. The main outcome measures were the clinical activity score (CAS), intraocular pressure (IOP), diplopia, proptosis and visual acuity. We also assessed the relationship between the main outcomes with proptosis changes and time to improvement (months). Adverse effects were recorded during each visit. The clinical response rate increased from 67.7% on the third month to 89.2% on the sixth month, and 94.2% on the 12th month. This therapeutic response continued until the 18th month of follow-up. The CAS responses [disease inactivation (CAS <3)] improved during our study: 70.6% on the third month, 90.0% on the sixth month, and 92.5% at 12th month. These conditions continued until the 18th month of follow-up. Proptosis improvement was 52% on the third month, 71% on the sixth month, 83% on the 12th month, and 87.1% on the 18th month. Changes in IOP and visual acuity were not significant (P = 0.568 and 0.668, respectively). The patient showed significant improvement in the Gorman score. A Shorter duration of treatment was seen in patients with earlier onset of intervention, younger age, and lack of all extraocular muscle (EOM) enlargement on computed tomography (CT) scan (p < 0.05). In addition, a better response (more reduction) in proptosis was related to: younger age at disease, earlier treatment intervention (less interval from the time the diagnosis of moderate-to-severe GO was made until medication initiation), shorter treatment time (less time to improvement), less IOP, lack of EOM enlargement on CT scan, and lack of diplopia (P < 0.05). Adverse events occurred in six patients. Findings show that mycophenolate mofetil (CellCept®) plus low-dose prednisolone can be introduced as a new optimal dosing regimen in GO due to its better effect on chronic complications such as proptosis and diplopia.

Management of thyroid eye disease: a Consensus Statement by the American Thyroid Association and the European Thyroid Association

“…Mycophenolate has been used in a large number of patients, mostly for prevention of transplant rejection, and in patients with autoimmune diseases ( 105 ). The published experience in TED is limited to two RCTs ( 68 , 106 ), one nonrandomized trial ( 107 ) and one retrospective report ( 108 ).…”

“…A third study was a retrospective audit with a highly heterogeneous population of 20 patients with limited efficacy data and will not be considered any further ( 108 ). Finally, a recent nonrandomized trial examined the use of mycophenolate mofetil plus oral prednisolone in 242 patients with moderate-to-severe TED ( 107 ).…”

Efficacy and safety of mycophenolate mofetil in the treatment of moderate to severe Graves’ orbitopathy: a meta-analysis

“…In addition, our study found that MMF reduced CAS more significantly in GO patients. It has been reported that MMF combined with low-dose prednisolone therapy could be introduced as a new optimal administration for GO due to its advantages in chronic complications such as proptosis and diplopia [ 30 ]. Finally, our results also showed that fewer AEs occurred with MMF compared to GC therapy.…”

Notes for the general paediatrician: managing thyrotoxicosis in children and young people

“…In adults, Graves' orbitopathy is resistant to treatment with steroids in 20%-60%, prompting the need for alternative therapies. 17 Fortunately, in children, Graves' orbitopathy is rarely as problematic and simple measures to lubricate and protect the cornea are sufficient. In the rare cases where orbitopathy is prominent, a referral to a specialised ophthalmology service would be suggested 18 Recommendation: All children with eye signs should be promptly referred to specialist paediatric ophthalmology services.…”