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).
