Medical Therapy

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.

 

Oral Prednisone: 

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

 

Intravenous Corticosteroids:

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)

 

Cyclosporine:

Indications

Effectiveness:

Side-effects:

 

Non-steroidal anti-inflammatories:

Possible reduction in orbital discomfort during active phase, but no convincing proof of reduction in inflammatory signs nor benefit in reducing restriction in motility

 

 

Biologic Agents:  

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.

 

Selenium:

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).