Advances in treatment of active, moderate-to-severe Graves' ophthalmopathy.
Wiersinga Wilmar M
The lancet. Diabetes & endocrinology
Graves' ophthalmopathy is defined as autoimmune inflammation of extraocular muscles and orbital fat or connective tissue, usually in patients with Graves' disease. About one in 20 patients with Graves' hyperthyroidism has moderate-to-severe Graves' ophthalmopathy. Corticosteroids have been the mainstay of treatment, but new evidence about immune mechanisms has provided a basis to explore other drug classes. Intravenous methylprednisolone pulses are more effective and better tolerated than oral prednisone in the treatment of active, moderate-to-severe Graves' ophthalmopathy. Rituximab has also been suggested as a possible replacement for intravenous corticosteroids. Two randomised controlled trials of rituximab reached seemingly contradictory conclusions-rituximab was not better with respect to the primary outcome (clinical activity score) than placebo in one trial (which, however, was confounded by rather long Graves' ophthalmopathy duration), but was slightly better than intravenous methylprednisolone pulses in the other (disease flare-ups occurred only in the latter group). On the basis of evidence published so far, rituximab cannot replace intravenous methylprednisolone pulses, but could have a role in corticosteroid-resistant cases. Open-label studies of tumour-necrosis-factor-α blockade had limited efficacy, but other studies showed that interleukin-6 receptor antibodies were effective. Results of randomised controlled trials investigating the efficacy of the IGF-1 receptor antibody teprotumumab and the interleukin-6 receptor antibody tocilizumab are expected shortly. Approaches that target the causal mechanism of Graves' ophthalmopathy (antibodies or antagonists that block thyroid-stimulating-hormone receptors) also look promising.
10.1016/S2213-8587(16)30046-8
Factors predicting endocrine late effects in childhood cancer survivors from a Japanese hospital.
Shimazaki Shunsuke,Kazukawa Itsuro,Mori Kyoko,Kihara Makiko,Minagawa Masanori
Endocrine journal
We retrospectively analyzed endocrine late effects in 81 childhood cancer survivor (CCS) patients who had been referred to our endocrinology department in Chiba Children's Hospital between January 1, 2008 and December 31, 2016. Among 69 eligible patients (33 male, 36 female), endocrine late effects were identified in 56 patients (81.1%). The median age at the last visit to our endocrinology department was 17.4 years (range: 7.1-35.3 years). The most common primary cancer was acute lymphoblastic leukemia (22 patients, 31.8%). Forty-four patients (64%) were treated using radiation therapy. A primary brain tumor and high doses (≥6 g/m) of cyclophosphamide were significantly associated with growth hormone deficiency (GHD). Our present study suggests that high doses of cyclophosphamide is a risk factor for GHD. Adult heights and pubertal growth spurts of patients treated with radiation therapy were significantly lower than patients not treated with radiation therapy. Our retrospective study reconfirmed that hematopoietic stem cell transplantation and chronic graft versus host disease (GVHD) were associated with elevated risks of primary hypothyroidism. However, it is unclear whether GVHD induces thyroid dysfunction. Gonadal radiation and busulfan were associated with primary hypogonadism as reported in previous studies. We found high doses of cyclophosphamide to be involved in pituitary disorders. We suggest that pediatric endocrinologists should discuss the potential effects of radiation therapy on adult height and pubertal growth spurt in CCS patients. Moreover, patients who have been treated with high doses of cyclophosphamide or have chronic GVHD require long-term follow-up for endocrine late effects.
10.1507/endocrj.EJ19-0228
Neutrophil-to-Lymphocyte, Monocyte-to-Lymphocyte and Platelet-to-Lymphocyte Ratios in Relation to Clinical Parameters and Smoking Status in Patients with Graves' Orbitopathy-Novel Insight into Old Tests.
Journal of clinical medicine
Graves' orbitopathy (GO) is an autoimmune disease with a chronic inflammatory background. Smoking behavior is the main environmental factor responsible for the transition of this major extra thyroidal manifestation of Graves' disease (GD) from the subclinical to the overt form. Complete blood count-derived parameters are suggested to be novel inflammatory indices. The aim of this retrospective study was to investigate the association between neutrophil-to-lymphocyte (NLR), monocyte-to-lymphocyte (MLR), and platelet-to-lymphocyte ratios (PLR) with selected clinical parameters and smoking status in 406 GD patients with ( = 168) and without GO ( = 238). The control group consisted of 100 healthy individuals. The activity of GO was graded according to Clinical Activity Score. Significantly higher white blood cells (WBC), neutrophil, and NLR ( < 0.05) values were observed in GD patients with GO compared with those without GO. PLR values were significantly higher in GO patients than in the controls. WBC (6.81 ± 1.56 vs. 5.70 ± 1.23) and neutrophils (3.89 ± 1.06 vs. 3.15 ± 0.95) count was higher in active GO patients than in those with inactive GO. Positive correlation ( < 0.05) between CAS score and WBC, neutrophil and monocyte count, and NLR was found. Smoking was associated with higher WBC ( = 0.040), neutrophil ( = 0.049), PLR ( = 0.032) values. Multivariate analysis revealed that WBC, NLR may be risk factors for GO development. WBC, neutrophil, NLR and PLR values seem to be useful tools in the assessment of inflammation in GD.
10.3390/jcm9103111
Relationship between serum cholesterol and Graves' orbitopathy (GO): a confirmatory study.
Lanzolla G,Sabini E,Profilo M A,Mazzi B,Sframeli A,Rocchi R,Menconi F,Leo M,Nardi M,Vitti P,Marcocci C,Marinò M
Journal of endocrinological investigation
BACKGROUND:It has been suggested that high cholesterol represents a risk factor for Graves' orbitopathy (GO). In a recent cross-sectional study, a correlation between cholesterol and the presence of GO was found in patients with a Graves' disease (GD) of recent onset. To confirm this observation, we conducted a retrospective investigation in consecutive patients with GD. The primary outcome was the relationship between the presence of GO and low-density lipoprotein (LDL)-cholesterol. METHODS:The design entailed the inclusion of consecutive patients with a GD of recent onset, with or without GO, who came to our observation to receive radioiodine over a period of 6 months, and a stratification aimed at having two homogeneous group of patients in terms of thyroid function. A total of 86 patients fulfilled the inclusion and evaded the exclusion criteria. All patients underwent an ophthalmological assessment and serum lipids were measured. RESULTS:Serum levels of LDL-cholesterol were significantly higher in patients with GO (135.3 ± 41.3 mg/dL) compared with those without GO (106.6 ± 23.9 mg/dL, P = 0.0007). In a similar manner, serum levels of total cholesterol were higher in patients with GO (211.6 ± 44.0 mg/dL) than in those without GO (176.0 ± 27.2 mg/dL, P = 0.0001). There was no relationship between GO severity and activity and cholesterol. There was no relationship between GO and high-density lipoprotein-cholesterol or triglycerides. CONCLUSIONS:Our study confirms a relationship between the presence of GO and cholesterol in patients with GD of recent onset. Whether lowering of cholesterol ameliorates, GO remains to be established.
10.1007/s40618-018-0915-z
Serum uric acid levels are associated with increased risk of newly developed diabetic retinopathy among Japanese male patients with type 2 diabetes: A prospective cohort study (diabetes distress and care registry at Tenri [DDCRT 13]).
Kuwata Hirohito,Okamura Shintaro,Hayashino Yasuaki,Tsujii Satoru,Ishii Hitoshi,
Diabetes/metabolism research and reviews
OBJECTIVE:We assessed the prospective association between baseline serum uric acid levels and consequent risk of developing diabetic retinopathy. RESEARCH DESIGN AND METHODS:Data for 1839 type 2 diabetes patients without diabetic retinopathy were obtained from a Japanese diabetes registry. A Cox proportional hazards model with time-varying exposure information by sex was used and adjusted for potential confounders to assess the independent correlations between baseline serum uric acid levels and incidence rate of diabetic retinopathy. RESULTS:Newly developed diabetic retinopathy was recognized in 188 patients (10.2%) during the observation period of 2 years. Compared to the first serum uric acid quartile level, the multivariate adjusted hazards ratio for diabetic retinopathy development in male patients was 1.97 (95% CI, 1.14-3.41; P = .015), 1.92 (95% CI, 1.18-3.13; P = .008), and 2.17 (95% CI, 1.40-3.37; P = .001) for the second, third, and fourth serum uric acid quartile levels, respectively. But this was not the case with female patients. CONCLUSION:Higher serum uric acid levels were associated with increased risk of developing diabetic retinopathy in male patients with type 2 diabetes, but not in female patients. Serum uric acid may be a useful biomarker for predicting the future risk of developing diabetic retinopathy in male patients with type 2 diabetes.
10.1002/dmrr.2905
Relationships between eyelid position and levator-superior rectus complex and inferior rectus muscle in patients with Graves' orbitopathy with unilateral upper eyelid retraction.
Byun Jun Soo,Lee Jeong Kyu
Graefe's archive for clinical and experimental ophthalmology = Albrecht von Graefes Archiv fur klinische und experimentelle Ophthalmologie
PURPOSE:To assess the relationships between eyelid position and levator palpebrae superioris (LPS)-superior rectus (SR) complex and inferior rectus (IR) muscle volume in patients with Graves' orbitopathy (GO) with unilateral upper eyelid retraction. METHODS:This was a cross-sectional observational study of 48 patients with GO with unilateral upper eyelid retraction. To measure muscle volume, computerized tomography scans were performed, and 3D images were analyzed. Digital photographs were taken, and vertical eyelid height was measured using computed eyelid analysis software. The measured muscle volumes and eyelid heights were assessed, and correlation analysis was performed. To verify the parameters that are predictive for the presence of upper eyelid retraction, receiver operating characteristic curves were analyzed, and logistic regression was performed. RESULTS:The volume of the LPS/SR muscle complex in the eyes with upper eyelid retraction was increased in 41 eyes (85.4%). The mean volume of the LPS/SR complex was 0.92 ± 0.40 cm in the eyes with upper eyelid retraction and 0.72 ± 0.27 cm in the contralateral eyes (p < 0.0001). While there was no correlation between LPS/SR complex volume and margin reflex distance1 (MRD1, the vertical distance between the center of the pupil to the center of the upper eyelid margin) (R = 0.024, p = 0.869), MRD1 and MRD2 (the vertical distance between the center of the pupil and the center of the lower eyelid margin) in the retracted eyes were negatively correlated (R = - 0.441, p = 0.002). In patients with upper eyelid retraction without increased LPS/SR complex volume, IR volume and MRD2 of the contralateral eye were 0.48 ± 0.10 cm and 5.92 ± 0.45 mm, respectively. In the retracted eye, they were 0.37 ± 0.17 cm and 5.32 ± 0.59 mm, respectively (p = 0.018, and 0.028). Regression models incorporating LPS/SR complex volume, MRD1, and lid lag could predict the presence of upper eyelid retraction with an accuracy of 92.5%. CONCLUSIONS:In patients with GO, increased LPS/SR complex volume in the retracted eye and increased IR volume of the contralateral eye were both associated with unilateral upper eyelid retraction. The combination of LPS/SR complex volume, MRD1, and lid lag can be used as a reliable index of upper eyelid retraction in patients with GO.
10.1007/s00417-018-4056-z
Thyrotropin receptor autoantibodies are independent risk factors for Graves' ophthalmopathy and help to predict severity and outcome of the disease.
Eckstein Anja K,Plicht Marco,Lax Hildegard,Neuhäuser Markus,Mann Klaus,Lederbogen Sebastian,Heckmann Christian,Esser Joachim,Morgenthaler Nils G
The Journal of clinical endocrinology and metabolism
OBJECTIVE:The objective of this study was to examine whether TSH-receptor antibody [TSH binding inhibitory antibodies (TBII)] levels are associated with the severity of Graves' ophthalmopathy (GO) over the entire course of the disease. METHODS AND PATIENTS:A total of 159 patients with GO were followed for 12-24 months. One year after the first symptoms of GO, all patients were classified into mild or severe GO according to their clinical manifestations. TBII were measured every 3 months after onset of GO. Receiver operating characteristic plot analysis was performed to assess the power to discriminate both patient groups by TBII (specificity >90%). RESULTS:TBII levels and prevalence at each time point during follow-up were significantly higher in patients with a severe course of GO compared with patients with a mild course of GO. Prognostic statements on the course of the disease were possible for about half of the GO patients at all time points (except the first). If at first presentation and at consecutive time points TBII levels were less than 5.7, 2.6, 1.5, 1.5, 1.5, and 1.5 IU/liter, the patients had a 2.3- to 15.6-fold higher chance of a mild course. If 5-8 months after GO onset and at consecutive time points TBII levels were above 8.8, 5.1, 4.8, 2.8, and 2.8 IU/liter, the patients had a 8.7- to 31.1-fold higher risk of a severe course. This relationship of TBII to the severity was independent from age and smoking. CONCLUSION:Follow-up measurements of TBII allow, in half of the patients, assessment of the prognosis of GO and, therefore, could be of additional help for the disease management.
10.1210/jc.2005-2813
High Serum Cholesterol Is a Novel Risk Factor for Graves' Orbitopathy: Results of a Cross-Sectional Study.
Sabini Elena,Mazzi Barbara,Profilo Maria Antonietta,Mautone Teresa,Casini Giamberto,Rocchi Roberto,Ionni Ilaria,Menconi Francesca,Leo Marenza,Nardi Marco,Vitti Paolo,Marcocci Claudio,Marinò Michele
Thyroid : official journal of the American Thyroid Association
BACKGROUND:Limited data suggest that treatment with statins is associated with a reduced risk of Graves' orbitopathy (GO) in patients with Graves' disease (GD), attributed to the anti-inflammatory rather than to the hypolipemic effects of these medications. The aim of the present study was to investigate whether there is an association between high cholesterol and GO. The primary outcome was the relation between GO and low-density lipoprotein (LDL)-cholesterol. The secondary outcomes were the relation between severity or activity (the clinical activity score [CAS]) of GO and LDL-cholesterol. METHODS:A cross-sectional investigation was conducted in consecutive patients with GD who came under the authors' observation to undergo radioiodine treatment, a stratification aimed at forming two distinct groups of patients under the same conditions. A total of 250 patients were enrolled, 133 with and 117 without GO. Ophthalmological assessments and serum lipids measurements were performed. RESULTS:In multivariate analyses with correction for the duration of hyperthyroidism, a variable that differed between patients with respect to the presence or absence of GO, a correlation between the presence of GO and both total (p = 0.01) and LDL-cholesterol (p = 0.02) was observed. In patients with hyperthyroidism lasting <44 months, total and LDL-cholesterol were higher (p = 0.01 and p = 0.008, respectively) among GO patients. In this subgroup, based on the presence/absence of GO, cutoff values were established for total (191 mg/dL) and LDL-cholesterol (118.4 mg/dL), above which an increased risk of GO was observed (total cholesterol relative risk: 1.47; p = 0.03; LDL-cholesterol relative risk: 1.28; p = 0.03). GO severity and CAS did not correlate with serum lipids. However, CAS was found to be higher (p = 0.02) in patients with high total cholesterol. When the analysis was restricted to untreated GO patients, a correlation was found between CAS and both total (p = 0.04) and LDL-cholesterol (p = 0.03), after adjustment for GO duration. CONCLUSIONS:In patients with a short duration of hyperthyroidism, total and LDL-cholesterol correlate with the presence of GO, suggesting a role of cholesterol in the development of GO. Depending on GO duration, total and LDL-cholesterol correlate with GO activity, suggesting a role of cholesterol in the clinical expression of GO.
10.1089/thy.2017.0430
Risk factors for developing thyroid-associated ophthalmopathy among individuals with Graves disease.
Stein Joshua D,Childers David,Gupta Shivani,Talwar Nidhi,Nan Bin,Lee Brian J,Smith Terry J,Douglas Raymond
JAMA ophthalmology
IMPORTANCE:Thyroid-associated ophthalmopathy (TAO) is a common and debilitating manifestation of Graves disease (GD). Presently little is known about factors that may increase the risk of developing TAO among patients with GD. OBJECTIVE:To identify risk factors associated with the development of TAO among individuals with newly diagnosed GD. DESIGN, SETTING, AND PARTICIPANTS:In this longitudinal cohort study, all beneficiaries 18 years of age or older with newly diagnosed GD who were continuously enrolled in a large nationwide US managed care network and who visited an eye care professional 1 or more times from 2001 to 2009 were identified. International Classification of Diseases, Ninth Revision, Clinical Modification billing codes were used to identify those who developed manifestations of TAO. Multivariable Cox regression was used to determine the hazard of developing TAO among persons with newly diagnosed GD, with adjustment for sociodemographic factors, systemic medical conditions, thyrotropin levels, and medical and surgical interventions for management of hyperthyroidism. MAIN OUTCOMES AND MEASURES:Manifestations of TAO measured by hazard ratios (HRs) with 95% CIs. RESULTS:Of 8404 patients with GD who met the inclusion criteria, 740 (8.8%) developed TAO (mean follow-up, 374 days since initial GD diagnosis). After adjustment for potential confounders, surgical thyroidectomy, alone or in combination with medical therapy, was associated with a 74% decreased hazard for TAO (adjusted HR, 0.26 [95% CI, 0.12-0.51]) compared with radioactive iodine therapy alone. Statin use (for ≥60 days in the past year vs <60 days or nonuse) was associated with a 40% decreased hazard (adjusted HR, 0.60 [CI, 0.37-0.93]). No significant association was found for the use of nonstatin cholesterol-lowering medications or cyclooxygenase 2 inhibitors and the development of TAO. CONCLUSIONS AND RELEVANCE:If prospective studies can confirm our finding that a thyroidectomy and statin use are associated with substantially reduced hazards for TAO among patients with GD, preventive measures for this burdensome manifestation of GD may become a reality.
10.1001/jamaophthalmol.2014.5103
Clinical Implications of Immunoglobulin G4 to Graves' Ophthalmopathy.
Yu Sung Hoon,Kang Jun Goo,Kim Chul Sik,Ihm Sung-Hee,Choi Moon Gi,Yoo Hyung Joon,Lee Seong Jin
Thyroid : official journal of the American Thyroid Association
BACKGROUND:This study aimed to explore the relation of immunoglobulin G4 (IgG4) to clinical and laboratory characteristics of patients newly diagnosed with Graves' disease (GD) without or with Graves' ophthalmopathy (GO) and to analyze association of IgG4 with development and grade of GO in GD patients. METHODS:Sixty-four GD patients and 64 sex- and age-matched euthyroid subjects were enrolled. Serum levels of thyroid hormones, thyroid autoantibodies, immunoglobulin G (IgG), and IgG4 were measured, and ophthalmological and ultrasonographical evaluation was performed. RESULTS:In GD patients compared with euthyroid subjects, levels of thyroid hormones, thyroid autoantibodies and IgG4 as well as the IgG4/IgG ratio were elevated. GD patients having GO in comparison to not having GO were characterized by a female predominance; a high incidence of smoking history; high levels of T3, free T4, TSH receptor autoantibody (TRAb) and IgG4; and a high IgG4/IgG ratio after adjusting for sex. In GD patients, the IgG4 level was the independent factor associated with GO development on multivariate analysis. When severity and activity of GO were classified using the European Group on Graves' Orbitopathy criteria in GD patients with GO, IgG4 levels and IgG4/IgG ratio were elevated in the moderate-to-severe group compared with the mild group and in the active group compared with the inactive group. IgG4 levels and IgG4/IgG ratio became elevated as clinical activity score increased. IgG4 levels were positively correlated with TRAb levels. The high IgG4 group in comparison to the normal IgG4 group had a high incidence of family history of autoimmune thyroid disease, high levels of free T4, TRAb and IgG4, a high IgG4/IgG ratio and extensive hypoechogenicity. CONCLUSIONS:These results suggest that IgG4 levels are elevated in newly diagnosed GD patients compared with euthyroid subjects and in the presence of GO compared with the absence of GO. Moreover, our findings suggest that IgG4 levels are associated with the development and grade of GO in GD patients.
10.1089/thy.2017.0126
Predicting the response to glucocorticoid therapy in thyroid-associated ophthalmopathy: mobilizing structural MRI-based quantitative measurements of orbital tissues.
Hu Hao,Xu Xiao-Quan,Chen Lu,Chen Wen,Wu Qian,Chen Huan-Huan,Zhu Hui,Shi Hai-Bin,Wu Fei-Yun
Endocrine
PURPOSE:We aimed to evaluate the performance of structural magnetic resonance imaging (MRI)-based quantitative measurements at extraocular muscle (EOM), orbital fat (OF), and especially lacrimal gland (LG) in predicting response to glucocorticoid (GC) in patients with active and moderate-severe thyroid-associated ophthalmopathy (TAO). METHODS:Forty-seven active and moderate-severe TAOs (responsive group, 29 patients and 58 eyes; unresponsive group, 18 patients and 36 eyes) were enrolled. Pretreatment MRI-based parameters of EOM, OF, and LG, and clinical factors were retrospectively collected and compared between two groups. Logistic regression and receiver operating characteristic curve analyses were used to assess the predictive value of identified independent variables. RESULTS:Responsive group showed significantly higher minimum signal intensity ratio of EOM (EOM-SIR) (p < 0.001), higher EOM-SIR (p = 0.034), higher LG herniation (LGH) (p = 0.019), lower OF thickness (OFT) (p = 0.017), higher LGH/OFT ratio (p = 0.001), and shorter disease duration (p = 0.004) than unresponsive group. Multivariate analysis showed that EOM-SIR, LGH/OFT ratio, and disease duration were independent predictors for responsive TAOs (all p < 0.05). Integration of three independent predictors demonstrated optimal predictive efficiency (area under curve, 0.829). Combining EOM-SIR ≥1.43 and LGH/OFT ratio ≥1.65, optimal predictive specificity (94.4%) could be obtained, while optimal predictive sensitivity (82.8%) was achieved when integrating disease duration ≤3.5 and LGH/OFT ratio ≥1.65. CONCLUSIONS:Structural MRI-based quantitative measurements at EOM, OF, and LG, specially EOM-SIR and LGH/OFT ratio, together with disease duration, may serve as promising markers to predict response to GC in patients with active and moderate-severe TAO.
10.1007/s12020-020-02367-5
Defective Regulatory B Cells Are Associated With Thyroid-Associated Ophthalmopathy.
The Journal of clinical endocrinology and metabolism
PURPOSE:To investigate the change in IL-10-producing regulatory B cells (Breg), which suppress peripheral immune responses, in patients with thyroid-associated ophthalmopathy (TAO). METHODS:Peripheral blood mononuclear cells (PBMCs) were isolated from healthy controls (n = 54), patients with Graves disease (n = 26), and patients with TAO (N=125), and stimulated with CpG/CD40L. The frequency of IL-10-producing Bregs and the expression of IL-10 in response to TSH stimulation were measured by flow cytometry. CD4+ T cells were cultured with Breg-depleted PBMCs to elucidate the function of Bregs in patients with TAO. The potential immunoregulatory mechanism was also investigated by Western blot and chromatin immunoprecipitation assays. RESULTS:Patients with active TAO had higher baseline levels of Bregs in their peripheral blood than both healthy controls and inactive patients. TSH promoted Bregs. Bregs from patients with TAO were defective in suppressing the activation of interferon (IFN)-γ+ and IL-17+ T cells in vitro. CONCLUSIONS:Regulatory B cells in patients with TAO are functionally defective, suggesting that the defective Bregs might be responsible for the pathogenesis of TAO.
10.1210/jc.2018-01812
Clinical results of anti-inflammatory therapy in Graves' ophthalmopathy and association with thyroidal autoantibodies.
Eckstein Anja K,Plicht Marco,Lax Hildegard,Hirche Herbert,Quadbeck Beate,Mann Klaus,Steuhl Klaus P,Esser Joachim,Morgenthaler Nils G
Clinical endocrinology
OBJECTIVE:Graves' ophthalmopathy (GO) is clinically associated with autoimmune thyroid disease, and autoantibodies to thyroidal antigens, especially to the TSH-receptor (TRAb), might be involved in the disease process. While there is mounting evidence that TRAb are associated with GO at the onset of the disease, so far no studies have looked at the association between thyroidal autoantibodies and the clinical outcome of GO therapy. The aim of this retrospective study was to evaluate whether TSH binding inhibitory immunoglobulins (TBII) and thyroid stimulating antibodies (TSAb) are still associated with the clinical activity and severity of GO after the completion of anti-inflammatory therapy. In addition, we wanted to elucidate whether thyroid peroxidase (TPO) or thyroglobulin (TG) autoantibodies (TPOAb and TGAb) are in any way related to GO. DESIGN PATIENTS AND MEASUREMENTS: Clinical activity score (CAS) and the severity of GO (modified NOSPECS score) were assessed in 108 patients with GO after steroid therapy and, if indicated, orbital irradiation. Patients were grouped according to their clinical presentation and autoantibody levels (TBII, TSAb, TPOAb and TGAb) were measured. After therapy for hyperthyroidism, all patients were clinically euthyroid but showed clear heterogeneity for GO 4-12 months after the end of anti-inflammatory therapy. Fifty-two patients had inactive GO, 41 had moderately active and 15 still had very active (non-responsive) GO. Concerning severity, 27 patients had mild GO, 64 moderately severe and 17 severe GO. RESULTS:TBII titres were still positive in 14 (93%) of 15 patients in the non-responsive group (CAS > 6) compared to 22 (42%) of 52 patients (P < 0.001) with post-therapeutic inactive GO (CAS </= 2). A similar result was seen between TBII levels and the NOSPECS score. The simultaneous presence of TBII and TSAb was associated with significantly higher activity and severity [odds ratios: 4.9 (activity); 9.0 (severity)] than the presence of TBII without measurable TSAb [odds ratios: 2.1 (activity), 2.0 (severity)] in comparison to absence of both antibodies. Only TBII and TSAb, but not TPOAb or TGAb medians, increased statistically significantly with CAS or NOSPECS scores. Both scores were positively associated with TBII (CAS: r = 0.31 P < 0.001; NOSPECS: r = 0.38, P < 0.0001) and, to a lesser degree, with TSAb (CAS: r = 0.27, P < 0.007, and NOSPECS: r = 0.29, P < 0.003). This association was independent of the treatment of hyperthyroidism, although highest levels of TBII were seen after radioiodine treatment. The NOSPECS score was negatively associated with TGAb (r =-0.27, P < 0.01) but not with TPOAb, while both showed no association with the CAS score. CONCLUSIONS:We conclude that the persistence of TBII and TSAb levels in patients with therapy-resistant disease in comparison to patients with inactive disease supports the role of TRAb in the pathogenesis of GO. Furthermore, the fact that, even after anti-inflammatory therapy, TBII and TSAb levels and prevalence still correlate with the severity and activity of GO suggests not only a trigger but also a possible role in the maintenance of the autoimmune process in the orbits.
10.1111/j.1365-2265.2004.02143.x
Smoking was associated with poor response to intravenous steroids therapy in Graves' ophthalmopathy.
Xing Lijing,Ye Lei,Zhu Wei,Shen Liyun,Huang Fengjiao,Jiao Qin,Zhou Xiaoyi,Wang Shu,Wang Weiqing,Ning Guang
The British journal of ophthalmology
BACKGROUND:Previous studies have shown that smoking is closely related to the occurrence, severity and response to orbital radiation in Graves' ophthalmopathy (GO). The aim of this study was to investigate whether smoking impacts the response to intravenous 4.5 g methylprednisolone therapy in patients with active moderate-to-severe GO. METHODS:Ninety-two individuals with active moderate-to-severe GO who were treated with cumulative doses of 4.5 g intravenous methylprednisolone within 3 months were recruited. The patients were grouped as never smokers, active smokers (including smokers and quit smokers) and passive smokers. RESULTS:We observed significantly greater response rate in never smokers compared with active smokers (73.9% vs 29.0%, p=0.001). After adjusting the confounding factors such as age, sex, body mass index, clinical activity score, thyroid-stimulating hormone receptor antibody and the duration of GO, smoking was independently associated with poor intravenous glucocorticoid (GC) response (OR 12.40, 95% CI 1.20 to 128.14, p=0.035). We also found the response rate was significantly higher in never smokers than in quit smokers (73.9% vs 16.7%, p=0.001), while no statistical significance between current smokers and quit smokers (36.8% vs 16.7%, p=0.228). There was a trend of poor response for passive smokers compared with never smokers (64.7% vs 72.2%, p=0.583). CONCLUSIONS:Smoking, even past smoking, was an independent risk factor associated with impaired response to intravenous corticosteroids in patients with GO. Smokers with GO should be given optimised treatment strategy such as higher dose of GC or combined radiation therapy.
10.1136/bjophthalmol-2014-306463
Cohort study on radioactive iodine-induced hypothyroidism: implications for Graves' ophthalmopathy and optimal timing for thyroid hormone assessment.
Stan Marius N,Durski Jolanta M,Brito Juan P,Bhagra Sumit,Thapa Prabin,Bahn Rebecca S
Thyroid : official journal of the American Thyroid Association
BACKGROUND:Graves' ophthalmopathy (GO) develops or worsens in up to one-third of patients treated with radioactive iodine (RAI) for Graves' hyperthyroidism. We sought to identify the prevalence of development or worsening of GO in patients treated with RAI for Graves' hyperthyroidism and to identify the risk factors associated with that outcome. METHODS:We identified a retrospective cohort of consecutive patients treated with RAI at Mayo Clinic (Rochester, MN) between 2005 and 2006. We assessed their medical records for evidence of hypothyroidism and development or worsening of GO in the year after therapy. Hypothyroidism was defined as thyrotropin >3.0 mIU/L or free thyroxine <0.8 ng/dL. RESULTS:We identified 291 consecutive patients who received RAI therapy during the study period, with 195 out of 291 having complete follow-up data for a one-year period. GO was present in 46 out of 195 patients (23.6%) at baseline. After RAI treatment, GO developed or worsened in 25 out of 195 patients (12.8%) and it was associated with hypothyroidism at first follow-up (p=0.011) with an odds ratio (OR) of 3.3 [95% confidence interval (CI) 1.3-8.7]. More smokers than nonsmokers developed new or worse GO (17.7% vs. 11.8%), but that difference did not reach statistical significance (p=0.35). Preexisting GO (24% of patients) was associated with a higher risk for negative GO outcome compared with patients who had no GO at baseline (11%; p=0.021). Both development of hypothyroidism by the first visit after RAI therapy (OR 3.6) and preexistent GO (OR 2.8) remained significant in a multivariate analysis. Development of hypothyroidism was more likely in patients with longer duration to first follow-up (p<0.001). By 6-8 weeks after RAI treatment, the prevalence of hypothyroidism was ∼40%, while that of hyperthyroidism was only 20%. CONCLUSIONS:The presence of hypothyroidism at the first assessment of thyroid function after RAI administration is a strong predictor for adverse GO outcome. This risk is highest in patients with preexisting GO. We suggest that in order to prevent clinical hypothyroidism and the associated risk for GO, the optimal time for first measurement of fT4 is before 6 weeks after RAI therapy.
10.1089/thy.2012.0258