The 2016 European Thyroid Association/European Group on Graves' Orbitopathy Guidelines for the Management of Graves' Orbitopathy

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.

The role of selenium in thyroid gland pathophysiology

“…Main characteristics of major clinical studies concerning the relationship between selenium and benign thyroid diseases after 12 months, already after selenium withdrawal, were analogous to those obtained before [145]. The results, as presented above, have contributed to the inclusion of selenium supplementation in the recommendations of European Group on Graves' orbitopathy (EUGOGO), issued in 2016, according to which, in benign forms of short-term thyroid orbitopathy, the use of sodium selenate is recommended twice daily in dose of 100 µg for six months [146], although its use was already encouraged before that [147]. Two interesting clinical trials are currently underway [148,149], the results of which may bring us closer to a more conclusive answer to the question of whether supplementation with selenium significantly influences the state of patients with Graves' disease [148] and the quality of life of patients with CAT [149].…”

“…Uzyskane po 12 miesią-cach wyniki już po odstawieniu selenu, były analogiczne do uzyskanych wcześniej [145]. Zaprezentowane powyżej rezultaty przyczyniły się do uwzględnienia suplementacji selenem w wydanych w 2016 roku rekomendacjach Europejskiego Towarzystwa Tyreologicznego, zgodnie z którymi w łagodnych formach krótko trwającej orbitopatii tarczycowej zaleca się stosowanie selenianu sodu (100 µg 2 ×dziennie) przez 6 miesięcy [146] [147]. Aktualnie trwają dwa interesujące badania kliniczne [148,149], których wyniki mogą nas przybliżyć do bardziej jednoznacznej odpowiedzi na pytanie czy suplementacja selenem istotnie wpływa na stan pacjentów z chorobą Gravesa i Basedowa [148] oraz jakość życia chorych z PAZT [149].…”

MANAGEMENT OF ENDOCRINE DISEASE: Rituximab therapy for Graves’ orbitopathy – lessons from randomized control trials

“…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. At the moment, RTX might be considered as second-line intervention in patients with moderate-to-severe, early and active disease that has failed initial therapy, as long as this treatment is administered in center with GO expertise where the risks and benefits of this therapy can be properly discussed, as also suggested by EUGOGO in the recently published guidelines (33).…”

Sight Threatening Thyroid Eye Disease Complicating Hashimoto’s Thyroiditis

“…This group, similar to our case, represent a therapeutic dilemma. There is no clear recommendation in current guidelines [13,14].…”

“…XRT is reserved as second line treatment, in refractory cases or where GC are associated with significant morbidity [13]. Decompression surgery is indicated in sight threatening disease (despite GC and/or XRT) although does not alter the course of disease.…”