Consensus statement on thyroid eye disease focuses on new therapies, individualized care
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Individualized care and patient satisfaction are among the areas of emphasis in a new consensus statement on management of thyroid eye disease.
A task force consisting of members from the American Thyroid Association and the European Thyroid Association (ETA) crafted the statement with the goal of giving state-of-the-art advice to general endocrinologists who treat the disease, according to Henry B. Burch, MD, co-chair of the task force, program director in the division of diabetes, endocrinology and metabolic diseases at the NIH’s National Institute of Diabetes and Digestive and Kidney Diseases, and professor of medicine at the Uniformed Services University of the Health Sciences.
“Endocrinologists are the caregivers most often responsible for the management of Graves’ disease and should therefore be familiar with the assessment of risk factors for the development of thyroid eye disease, diagnosing thyroid eye disease when it occurs, assessing its activity and severity, ensuring the patient receives appropriate intervention, including referral for expert specialty care and early involvement of ophthalmologists with expertise in managing thyroid eye disease,” Burch told Endocrine Today.
The consensus statement details background on thyroid eye disease and gives providers a breakdown for assessing patients, approaches to therapy, therapy options for mild thyroid eye disease, management of moderate to severe thyroid eye disease and therapy for sight-threatening thyroid eye disease.
One of the biggest changes in guidance was regarding therapies for moderate to severe thyroid eye disease. According to the statement, IV glucocorticoid therapy is the preferred treatment for moderate to severe thyroid eye disease when disease activity is the prominent feature rather than significant proptosis or diplopia. Those who are unresponsive to glucocorticoid therapy may be prescribed rituximab (Rituxan, Genentech) or tocilizumab (Actemra, Genentech).
For patients with substantial proptosis or diplopia, teprotumumab (Tepezza, Horizon Therapeutics) is the preferred treatment, if available. While the agent has been approved in the U.S., it has not yet been approved for use in Europe. The statement suggests radiotherapy for adults with active moderate to severe disease and progressive diplopia, though the task force notes this treatment modality should be used cautiously for people with diabetes to avoid retinopathy.
“The process involved in selecting therapy with these drugs and other drugs includes a consideration of both short- and long-term efficacy, adverse effects that are both known and unknown, the likelihood of disease aggravation or relapse after a previously beneficial response, and the relative cost and availability,” Burch said.
A multidisciplinary, individualized approach to care
There were several points of emphasis in the statement, one of which focused on taking a multidisciplinary approach toward treating thyroid eye disease. The task force cited a recent survey of ATA and ETA members that found 53% had no access to a multidisciplinary clinic. The consensus statement said the delivery of multidisciplinary care is crucial and breaks down the roles endocrinologists and general ophthalmologists have in treating thyroid eye disease.
“Management of thyroid eye disease should be considered a multidisciplinary approach, involving the endocrinologist, ophthalmologist and other allied health professionals,” Burch said.
Treatment satisfaction is another key component, according to Burch. In the statement, the task force acknowledged that thyroid eye disease has a major effect on quality of life and that the physical and psychosocial impact of the disease should be assessed for each patient, as it informs treatment decisions.
In the overview section on thyroid eye disease management, the task force emphasized providing an individualized approach to care based on several factors, including disease activity, severity, duration, the disease trend across time, the impact on daily living, treatment goals, patient age, comorbidities and the availability and costs of therapies.
More research into the management of thyroid eye disease is needed, according to the task force. The report included a table listing many knowledge gaps where more studies needed to be performed. Burch said some of the biggest topics that need to be studied further include whether reliable biomarkers can predict thyroid eye disease development and assess activity, more objective methods to document thyroid eye disease features, where selenium is useful in selenium-sufficient areas for mild thyroid eye disease, how teprotumumab compares with glucocorticoid therapy, the durability of clinical response for moderate to severe thyroid eye disease therapies, what impact drug costs, affordability and availability have on health disparities with thyroid eye disease, and more.
More research needed on teprotumumab, other therapies
In a related editorial, Terry F. Davies, MD, the Florence and Theodore Baumritter Professor of Medicine at the Icahn School of Medicine at Mount Sinai, applauded the creation of the consensus statement and referred to it as a “tour de force in the field and a reference document for us all.” He acknowledged how the statement went into great detail regarding teprotumumab as well as other therapy options.
“[Teprotumumab] is not yet available outside the United States and so international guides to treatment must take this into account just as the ATA/ETA consensus article does,” Davies wrote. “Furthermore, more treatments are on the way including the potential use of a thyroid stimulating-hormone receptor blocking monoclonal antibody, which may improve the patient’s thyroid status as well the eyes with or without IGF-I receptor blockade.”
In another related editorial, Wilmar M. Wiersinga, MD, PhD, emeritus professor of endocrinology at the University of Amsterdam, similarly praised the ATA and ETA for the consensus statement. He suggested a few further recommendations, including having endocrinologists and ophthalmologist evaluate patients together at the same time, a greater emphasis on quality of life, the development of better metrics than clinical activity score to assess thyroid eye disease activity and a deeper look at another alternative therapy to teprotumumab for treating moderate to severe thyroid eye disease.
“Intravenous methylprednisolone pulses may sometimes substantially reduce exophthalmos,” Wiersinga wrote. “This might come as a relief to those among us who cannot afford the very high price attached to teprotumumab. Furthermore, I cannot resist to remark that a head-to-head comparison is usually preferred between the standard treatment (up to now, intravenous glucocorticoids) and any new experimental treatment (teprotumumab), to assess not only efficacy, but also tolerability and cost-effectiveness.” by Michael Monostra
For more information:
Henry B. Burch, MD, can be reached at henry.burch@nih.gov.
References:
- Davies TF. Thyroid. 2022;doi:10.1089/thy.2022.0628.
- Wiersinga WM. Thyroid. 2022;doi:10.1089/thy.2022.29143.wie.
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