Will biological agents supplant systemic glucocorticoids as the first-line treatment for thyroid-associated ophthalmopathy?

Abstract

In this article, the two authors present their opposing points of view concerning the likelihood that glucocorticoids will be replaced by newly developed biological agents in the treatment of active, moderate-to-severe thyroid-associated ophthalmopathy (TAO). TAO is a vexing, disfiguring and potentially blinding autoimmune manifestation of thyroid autoimmunity. One author expresses the opinion that steroids are nonspecific, frequently fail to improve the disease and can cause sometimes serious side effects. He suggests that glucocorticoids should be replaced as soon as possible by more specific and safer drugs, once they become available. The most promising of these are biological agents. The other author argues that glucocorticoids are proven effective and are unlikely to be replaced by biologicals. He reasons that while they may not uniformly result in optimal benefit, they have been proven effective in many reports. He remains open minded about alternative therapies such as biologicals but remains skeptical that they will replace steroids as the first-line therapy for active, moderate-to-severe TAO without head-to-head comparative clinical trials demonstrating superiority. Despite these very different points of view, both authors are optimistic about the availability of improved medical therapies for TAO, either as single agents or in combination. Further, both agree that better treatment options are needed to improve the care of our patients with active moderate-to-severe TAO.

Teprotumumab as a Novel Therapy for Thyroid-Associated Ophthalmopathy

“…More recent reports suggest that IV pulse may be more effective and associated with fewer side effects than those delivered by the oral route ( 41 ). But even staunch advocates of steroid use in TAO typically concede that these agents fail to consistently provide benefit to patients and that only 50% respond meaningfully ( 42 ). Further, many experts acknowledge that responses to steroids are essentially limited to amelioration of inflammatory signs and symptoms.…”

The 2021 European Group on Graves’ orbitopathy (EUGOGO) clinical practice guidelines for the medical management of Graves’ orbitopathy

“…After publication of the 2016 European Thyroid Association (ETA)/European Group on GO (EUGOGO) guidelines for the management of GO (8), several relevant studies have been published, particularly randomized clinical trials (RCTs) of newer biological agents for the treatment of moderate-to-severe and active GO (1, [9][10][11][12]. This prompted the EUGOGO Executive Committee to appoint an ad hoc task force committed to updating the guidelines, focusing on the medical management of GO.…”

Efficacy and Safety of Different Intravenous Glucocorticoid Regimens in the Treatment of Graves’ Ophthalmopathy: A Meta-Analysis

“…As mentioned above, our study also found no significant difference of the rate of proptosis improvement between the two regimens. e underlying mechanism is yet to be completely elucidated; it might be that the patient's orbital remodeling and Journal of Ophthalmology eventual fibrosis occur very early in the course of the disease, so there is no hope that whatsoever medical treatment be effective if these changes have taken place [28]. Although effective, GC treatment is not devoid of adverse events [12,29].…”