The influence of Graves’ orbitopathy treatment with intravenous glucocorticoids on adrenal function

Ambroziak, Urszula; Bluszcz, Gabriela A.; Bednarczuk, Tomasz; Miśkiewicz, Piotr

doi:10.5603/ep.a2017.0036

Cited by 8 publications

(4 citation statements)

References 16 publications

(20 reference statements)

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“…Also, it is now clear that very high dose steroids used in COVID does not cause adrenal suppression and normal adrenal function was observed in patients who survived COVID-19 Infection (184). In line with this, withdrawal of iv glucocorticoid treatment in GO patients is not associated with adrenal failure (185,186).…”

Section: Management Of Go During Viral Pandemicmentioning

confidence: 55%

The 2021 European Group on Graves’ orbitopathy (EUGOGO) clinical practice guidelines for the medical management of Graves’ orbitopathy

Bartalena

Kahaly

Baldeschi

et al. 2021

European Journal of Endocrinology

520

497

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Graves’ orbitopathy (GO) is the main extrathyroidal manifestation of Graves’ disease (GD). Choice of treatment should be based on assessment of clinical activity and severity of GO. Early referral to specialized centers is fundamental for most patients with GO. Risk factors include smoking, thyroid dysfunction, high serum level of thyrotropin receptor antibodies, radioactive iodine (RAI) treatment, and hypercholesterolemia. In mild and active GO, control of risk factors, local treatments and selenium (selenium-deficient areas) are usually sufficient; if RAI treatment is selected to manage GD, low-dose oral prednisone prophylaxis is needed, especially if risk factors coexist. For both active moderate-to-severe and sight threatening GO, antithyroid drugs are preferred when managing Graves’ hyperthyroidism. In moderate-to-severe and active GO, intravenous (iv) glucocorticoids are more effective and better tolerated than oral glucocorticoids. Based on current evidence and efficacy/safety profile, costs and reimbursement, drug availability, long-term effectiveness and patient choice after extensive counselling, a combination of iv methylprednisolone and mycophenolate sodium is recommended as first-line treatment. A cumulative dose of 4.5 grams (g) of iv methylprednisolone in 12 weekly infusions is the optimal regimen. Alternatively, higher cumulative doses not exceeding 8 g can be used as monotherapy in most severe cases and constant/inconstant diplopia. Second-line treatments for moderate-to-severe and active GO include: a) a second course of iv methylprednisolone (7.5 g) subsequent to careful ophthalmic and biochemical evaluation, b) oral prednisone/prednisolone combined with either cyclosporine or azathioprine; c) orbital radiotherapy combined with oral or iv glucocorticoids, d) teprotumumab; e) rituximab and f) tocilizumab. Sight threatening GO is treated with several high single doses of iv methylprednisolone per week and, if unresponsive, with urgent orbital decompression. Rehabilitative surgery (orbital decompression, squint and eyelid surgery) is indicated for inactive residual GO manifestations.

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Section: Management Of Go During Viral Pandemicmentioning

confidence: 55%

The 2021 European Group on Graves’ orbitopathy (EUGOGO) clinical practice guidelines for the medical management of Graves’ orbitopathy

Bartalena

Kahaly

Baldeschi

et al. 2021

European Journal of Endocrinology

520

497

View full text Add to dashboard Cite

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“…In our research, we did not find a statistically significant decrease of serum and salivary cortisol before administration of the 12th IVMP pulse in comparison to evaluation before treatment, while one study showed a statistically significant decrease of serum cortisol concentration before administration of the 12th IVMP pulse [ 11 ]. The results of our study show that none of the patients developed secondary AI at the cessation of IVMP treatment in a cumulative dose of 4.5 g. Previous studies did not prove secondary AI after therapy with standard EUGOGO protocol (cumulative dose of 4.5 g IVMP) as well [ 11 , 12 , 13 ]. However, dynamic testing with synthetic ACTH has low sensitivity in ruling out secondary AI, especially when considering short-lasting (less than 4–6 weeks) AI [ 14 ].…”

Section: Discussionmentioning

confidence: 55%

Treatment with Intravenous Methylprednisolone in Patients with Graves’ Orbitopathy Significantly Affects Adrenal Function: Assessment of Serum, Salivary Cortisol and Serum Dehydroepiandrosterone Sulfate

Pelewicz

Szewczyk

Miśkiewicz

2020

JCM

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Treatment of active, moderate-to-severe Graves’ orbitopathy (GO) is the administration of intravenous methylprednisolone (IVMP). IVMP may be followed by additional therapy with oral prednisone. The aim of this study was to analyze the impact of IVMP on adrenal function by evaluation of serum, salivary cortisol and serum dehydroepiandrosterone sulfate (DHEA-S). Fourteen patients received IVMP treatment (cumulative dose of 4.5 g in 12 weekly infusions) followed by oral prednisone (for three months). All patients showed normal adrenal function before the 12th IVMP pulse and one patient was diagnosed with secondary adrenal insufficiency (AI) after prednisone treatment. DHEA-S was significantly lower before the 12th IVMP pulse and after oral prednisone (p = 0.015 and p = 0.00002, respectively) in comparison to evaluation before therapy. DHEA-S levels were below the reference range in one and three patients before the 12th IVMP pulse and after prednisone therapy, respectively. We observed decreased serum (p = 0.05) and salivary (p = 0.011) cortisol levels after oral prednisone therapy in comparison to evaluation before therapy. Treatment with IVMP in a cumulative dose of 4.5 g affects adrenal function, causing more severe impairment of DHEA-S secretion than that of cortisol but does not cause secondary AI. Additional therapy with oral glucocorticoids after IVMP can cause secondary AI.

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“…glucocorticosteroids according to the standard of administration recommended by EUGOGO (12week cumulative dose of 4.5 g), does not lead to secondary adrenal insufficiency. On the other hand, supplementing the treatment at the end of intravenous therapy with low doses of oral glucocorticosteroids (prednisone in a gradually decreasing dose from 30 mg/day for 3 months) may lead to secondary adrenal insufficiency in some patients [65].…”

Section: Treatment Of Moderate-to-severe To With Respect To the Limit...mentioning

confidence: 99%

Treatment of moderate to severe and active thyroid orbitopathy during SARS-CoV-2 pandemic.

Nowak

Nowak²

2022

Ophthalmol J

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Thyroid orbitopathy (TO) is the most common non-thyroid manifestation of Graves' and Basedow disease. Assessment of the inflammatory activity of TO can be performed using the clinical activity score (CAS) and using imaging methods -mainly magnetic resonance imaging (MRI). The severity of TO is assessed using a seven-grade NOSPE-CS classification and a three-grade scale proposed by the European Group on Graves' Orbitopathy (EUGOGO). In moderate to severe and active TO, the recommended standard as first-line treatment is the combined use of methylprednisolone intravenously (i.v.) with concurrent oral (p.o.) administration of mycophenolate sodium. Second-line treatment options are orbital radiotherapy with or without oral or i.v. systemic glucocorticosteroid therapy, cyclosporine, or azathioprine in combination with p.o. glucocorticosteroid, methotrexate monotherapy, and a group of biologic drugs (riuximad, tocilizumab, teprotumumab). All recommended therapies for moderate to severe and active TO involve immunosuppressive and immunomodulatory drugs, which are a risk for the unfavorable course of COVID-19. There are no available recommendations for treating TO in Graves' and Basedow disease patients during the SARS-CoV-2 pandemic. Moderate to severe and active TO patients present a serious dilemma during SARS-CoV-2 pandemic. It seems reasonable that in patients with moderate to severe TO, who are not at risk of sight deterioration, i.v. glucocorticosteroids should be avoided, and an observational strategy should be used, whereas in patients with more severe TO and at risk of sight worsening, i.v. glucocorticosteroids are the therapeutic choice regardless of SARS-CoV-2 infection or clinical signs of COVID-19

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The influence of Graves’ orbitopathy treatment with intravenous glucocorticoids on adrenal function

Abstract: Therapy with ivGCS for GO does not lead to secondary adrenocortical insufficiency. Further low-dose oral glucocorticoid therapy may result in secondary adrenocortical insufficiency in some patients.

Cited by 8 publications

References 16 publications

The 2021 European Group on Graves’ orbitopathy (EUGOGO) clinical practice guidelines for the medical management of Graves’ orbitopathy

The 2021 European Group on Graves’ orbitopathy (EUGOGO) clinical practice guidelines for the medical management of Graves’ orbitopathy

Treatment with Intravenous Methylprednisolone in Patients with Graves’ Orbitopathy Significantly Affects Adrenal Function: Assessment of Serum, Salivary Cortisol and Serum Dehydroepiandrosterone Sulfate

Treatment of moderate to severe and active thyroid orbitopathy during SARS-CoV-2 pandemic.

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