Medical therapy is offered during the early active or progressive phase of TED: the intention is to block specific steps in the immune-mediated, inflammatory process to reduce ultimate collateral damage to orbital tissues.
Dose: 0.5-1.0 mg/kg/day. Usually given as tapering dose once or twice daily for several months
Indications: Optic neuropathy (V), Inflammatory soft tissue changes (I), progressive strabismus (S)
Effectiveness: Retrospective studies show 60% short-term benefit in reducing inflammatory signs; no proof of ultimate reduction in strabismus (diplopia) or ocular restriction
Side-effects: Cushing’s disease (moon-face, weight gain, acne, adrenal insufficiency), diabetes, insomnia, mood disturbances, osteopenia, necrosis of femoral head, susceptibility to infections
Dose: 1 gm methylprednisolone alternate days for 3 sessions; repeat cycle every 3 – 6 weeks PRN
500 mg MP weekly for 4 weeks, then 250 mg weekly for 16 weeks: maximal dose 8.0 gms
Indications: Same as oral prednisone
Effectiveness: 85% effective in reducing inflammatory signs
Side-effects: Fewer than oral prednisone; however, electrolyte disturbances and cardiac arrhythmias have been reported monitoring is important; liver toxicity and death have been reported in cumulative dosing over 9 gms MP.
Azathioprine: Inhibitor of DNA synthesis, immunosuppressive
Indications: May allow weaning of corticosteroids for long-term therapy and may reduce ultimate complications of proptosis, and motility problems in TED. Currently being studied for its benefits in combination with Radiotherapy by British CIRTED trial.
Side-effects: Nausea, fatigue, hair loss, rash. Bone marrow suppression and possible secondary infections. Human carcinogen. May interact with allopurinol (gout therapy)
Possible reduction in orbital discomfort during active phase, but no convincing proof of reduction in inflammatory signs nor benefit in reducing restriction in motility
Anti-TNF alpha (infliximab, etanercept): sporadic case reports showing potential benefit
Rituximab: several individual and small case-series showing benefit in patients with severe TED poorly responsive to corticosteroid therapy from use of this B-cell lymphocyte depleting biologic agent. At least two randomized, controlled trials are underway to assess effectiveness of this agent.
This toxic non-metallic element is a component of an antioxidant enzyme. It occurs naturally in soil and is required in trace quantities through food supplies (garlic, red meat, fish, grains) to help regulate the immune system. A recent EUGOGO prospective randomized trial showed significant benefit when selenium supplements were taken for one year in reducing lid retraction and improving quality of life in patients with mild, non-inflammatory orbitopathy (Appearance/exposure changes).