Clinical Challenges: Stabilizing the Optimal Treatment for Thyroid Eye Disease

It could be an initial Thyroid Eye Disease (TED) call. DifficultHowever, once a diagnosis is made, settling on the correct treatment requires attention to several factors.

Terry J. said: Smith, MD, of the Kellogg Eye Center at the University of Michigan in Ann Arbor: “Treatment options for TED depend on the severity of the disease.” He added that most cases of TED only require topical, supportive care in the form of eye drops, eye gel, and protection from wind and strong light.

For patients with more serious disease, he explained, typical treatments include systemic steroids, radiotherapy (RT), or rehabilitative surgery. MedPage today. Steroids can Reduce TED symptoms, but does not work to modify the disease. surgical Rehabilitation They can include orbital decompression, eye muscle surgery, and eyelid repositioning, as well as soft tissue volume and resurfacing.

When assessing the severity of the disease, the doctor takes into account the amount of eye protrusion, double vision, soft tissue changes, as well as the effect on quality of lifeexplains Rachel Arakawa, MD, of Mount Sinai Health System in New York City.

Another factor that can drive a treatment decision is whether TED is in its active or inactive phase.

Arakawa said the active phase of the eye disease occurs initially and can present with dry eyes, swelling and eye pain that can last for 6 months to more than two years. MedPage today. “It is followed by the inactive phase where the scar-like tissue can cause chronic disfigurement and vision changes.”

She indicated that some patients with inactive disease may need surgical correction of eye bumps, cross eyes, eyelid abnormalities, and cosmetic concerns, adding that “in rare cases, surgery may be needed to relieve pressure on the optic nerve to preserve vision.”

For active disease, severity is key. For milder ailments, treatments usually consist of thyroid-normalizing medications, lubricating eye drops, and selenium supplementArakawa noted that it is an antioxidant that has been shown to reduce eye inflammation.

For moderate to severe active disease, intensive treatments such as steroids or radiotherapy are on the table. “These medications are sometimes effective, but can be associated with severe side effects and can leave patients with unsatisfactory results. Most importantly, steroids fail reliably to improve diplopia and exophthalmos. [bulging of the eyes]Smith warned.

Michael K. Yoon, MD, of the Center for Eye Disease, Thyroid, and Orbital Surgery at Mass Eye and Ear in Boston, notes that orbital RT isn’t done often in the United States, but the method can help improve some TED symptoms, vision Especially double. Tell MedPage today That RT is a ‘painless treatment’ [that] Usually 10 sessions over two weeks. Candidates for orbital RT They are those in the active early stage of the disease with moderate to severe or rapidly progressing disease.

Disease targeting mechanism

TED’s newest treatment, teprotumumab (Tepezza) FDA approval In January 2020, it is the first non-invasive treatment approved by the agency for TED. It is a complete human monoclonal antibody inhibitor of the insulin-like growth factor 1 receptor that is administered in eight doses, given 30 to 90 minutes, once every 3 weeks.

Smith said the drug specifically targets the underlying disease mechanism of TED, reducing inflammation and remodeling tissue around the eye, and improving symptoms of exophthalmos, diplopia, and eye pain. He also noted that teprotumab is “approved for the treatment of TED on a large scale, which includes patients in both acute (active) and chronic (inactive) phases of the disease.”

FDA approval was based on positive results from Phase II and 3rd stage visual Trials showing a mean reduction of 2.82 mm in exophthalmos 24 weeks after injection. However, trials have only tested the treatment in patients with active TED.

Yun noted that clinical trial participants received their diagnosis less than 9 months ago, so “patients with a relatively recent diagnosis of TED, exophthalmos, and sore eyes are most likely to see a benefit.” But he noted, “there is increasing evidence that patients with severe TED and vision loss are likely to benefit from teprotumumab as well.”

Smith added that a growing number of case reports show improvements in TED – including in exophthalmos and diplopia – with teprotumumab in the chronic phase, a basis The fourth stage of the trial which is currently taking place.

“Not all drugs … work on all patients or to the same degree,” Yoon said. “However, most professionals who treat TED have found that the amount of improvement seen with teprotumab is better than with other existing treatments.”

Arakawa cautioned that there are no head-to-head trials of tiprotumab against other treatment options, such as intravenous steroids, so “it is difficult to know if tiprotumab is better than other treatments. More research is needed to determine long-term responses as well. Such as who would benefit on the Most likely from medication.”

Yoon agreed, adding that “correct selection of the patient remains the single most important indicator of potential success.”

Of course, the factor has the possibility of negative events. Yoon advised that patients with TED and pre-existing diabetes should monitor their blood sugar because teprotumumab can lead to Increase diabetes level in the blood. Other potential toxicities with tiprotumab are: hearing lossIn rare cases it can be severe and permanent, he said, adding that hearing tests before treatment are recommended.

“There are no standard guidelines for when to use tiprotumab,” Arakawa explained. She recommended that the endocrinologist and ophthalmologist work together to individualize treatment, including taking into account obstacles such as drug availability and cost.

  • Christine Monaco She is a staff writer, focusing on endocrinology, psychiatry, and nephrology news. Operating out of a New York City office, she has been with the company since 2015.

Disclosures

Smith reported an affair with Horizon Therapeutics.

Arakawa did not make any disclosures.

Yoon reported his relationships with Sling and Viridian Therapeutics.