Efficacy and Safety of Immunosuppressive Agents for Thyroid Eye Disease

Purpose: To present an update on the efficacy and safety of immunosuppressive therapy for thyroid eye disease (TED) and to offer a general recommendation for management of TED, in light of these reports. Methods: Data were retrieved from a literature search on PubMed, using the following words: thyroid eye disease, immunosuppressant, corticosteroid, methotrexate, azathioprine, cyclosporine, cyclophosphamide, rituximab, etanercept, adalimumab, tocilizumab, teprotumumab, adverse effects, side effects, and complications. Results: Corticosteroids continue to be the primary medical therapy for TED. Recent research has offered insight into potential differences between oral corticosteroid and intravenous corticosteroid treatment regimens in terms of efficacy and side-effect profiles, which proved more favorable for the latter. The use of some traditional immunosuppressive agents, such as methotrexate and mycophenolate, seems suitable as steroid-sparing medications. In recent years, many scientific reports demonstrated the effectiveness of biologic immunosuppressive agents in the management of TED. Etanercept, adalimumab, and tocilizumab have been shown to be effective in reduction of the inflammatory signs with the possible added advantage of preventing relapse of the disease. Teprotumumab may control the disease activity, and it seems to be very effective in preventing disease progression. Infliximab might be useful in severe TED resistant to steroids and orbital decompression. Conclusions: Steroid therapy remains the first-line therapy for moderate/severe and severe vision-threatening TED. The biological agents may provide a deep and long-standing block of inflammatory activity in TED, with the hope to lower the risk of recurrences and to reduce the need of surgical intervention in moderate-to-severe disease. Indeed, the actual incidence of adverse effects is not yet well assessed because of the paucity of studies. Therefore, their use should be limited to those cases that really need an alternative therapy to steroids, handled by expert physician in this field. Accepted for publication March 24, 2018. Presented at the 4th International ITEDS Course and Symposium on June 24 and 25, 2016 in London, United Kingdom. The authors have no financial or conflicts of interest to disclose. Address correspondence and reprint requests to Diego Strianese, M.D., Ph.D., King Khaled Eye Specialist Hospital, KSA Central Province Riyadh City, King Khaled Road, P.O. Box 7191, Riyadh 11462, Saudi Arabia. E-mail: dstrianese@kkesh.med.sa © 2018 by The American Society of Ophthalmic Plastic and Reconstructive Surgery, Inc., All rights reserved.