Treatment of thyroid eye disease varies between North American, European providers
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First-line treatment of thyroid eye disease differs around the globe, with teprotumumab the most commonly prescribed treatment in North America and IV steroids most common in Europe, according to a speaker.
According to findings from a joint survey conducted by the American Thyroid Association and European Thyroid Association (ETA), providers had different opinions on first-line therapy for thyroid eye disease based on their country and identified different barriers to teprotumumab-trbw (Tepezza, Horizon Therapeutics) use.
“Teprotumumab has become the treatment of choice in North America for moderate active thyroid eye disease,” Juan P. Brito, MD, MS, an associate professor of medicine at the Mayo Clinic in Rochester, Minnesota, said during a presentation at the ATA annual meeting. “IV steroids continue to be the treatment of choice in Europe and other regions. The use of nonsteroidal immunosuppressive agents was rare, except in cases that were second-line therapy or cases in which we have a diabetes case.”
In June, the ATA and ETA emailed a 42-question survey to 1,712 member clinicians who treat patients with thyroid eye disease. The survey was completed by 227 providers, with most responses coming from Europe. Most respondents said they have treated patients with thyroid eye disease for more than 20 years. A greater proportion of European participants were academic affiliated and treated more thyroid eye disease patients during the past 12 months compared with those from other regions.
Most survey respondents reported no multidisciplinary thyroid eye disease clinic as part of their practice. A little more than half of clinicians from Europe said they had a multidisciplinary clinic, whereas a little more than 20% of providers from North America said they had a multidisciplinary clinic. More than 80% of respondents from Europe and North America said they were able to refer patients to an ophthalmology specialist.
Teprotumumab preferred in North America
Survey respondents were presented case studies for treating mild active and moderate to severe thyroid eye disease. For mild active thyroid disease, most respondents recommended more conservative treatments, such as smoking cessation and artificial tears and lubricants.
For moderate to severe active thyroid eye disease, most providers said they would refer the case to an ophthalmologist. More than 70% of European respondents said they would prescribe IV steroids, whereas teprotumumab was the most commonly prescribed treatment from North American respondents. When asked what second-line treatment would be prescribed if the first treatment failed, most European respondents suggested orbital radiotherapy, rituximab (Rituxan, Genentech) or IV steroids, whereas teprotumumab was again the most common response from North American providers.
“In this case [of second-line treatment], we do see an increase in the number of responses that favor nonsteroidal immunosuppressant agents, such as tocilizumab (Actemra, Genentech), mycophenolate and cyclosporin,” Brito said.
For moderate to severe inactive thyroid eye disease, more than 60% of European respondents suggested symptom therapy, whereas about half of North American respondents said they would refer the case to an ophthalmologist. About 20% of providers from North America recommended teprotumumab.
Barriers and concerns
The two most commonly mentioned barriers for prescribing teprotumumab were high cost and a lack of experience using the drug. European respondents also expressed concerns about lack of approval in their countries and lack of clinical practice guidelines.
More than half of respondents listed several concerns about thyroid eye disease treatment, including difficulty in predicting progression, likelihood that eyes will not revert to pre-disease appearance, lack of preventive measures, lack of shared decision-making tools to support treatment conversations and absence of recent clinical guidelines. North American respondents were also concerned about a lack of insurance coverage.
“We believe our results do have implications for research and policy,” Brito said. “Clearly, the practice demands the need to understand who will be developing severe thyroid eye disease and how can we prevent that. Also working on more effective treatments, mentioning the need for strategic decision-making tools to support conversations with patients given that we have multiple therapies, and more importantly, the coverage for newer medications.”
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Brito JP, et al. Thyroid Eye Disease Symposium. Presented at: American Thyroid Association Annual Meeting; Sept. 30-Oct. 3, 2021 (virtual meeting).
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