Graves’ Orbitopathy Clinical Practice Guidelines (EUGOGO, 2021)

European Group on Graves’ Orbitopathy (EUGOGO)

These are some of the highlights of the guidelines without analysis or commentary. For more information, go directly to the guidelines by clicking the link in the reference.

October 01, 2021

Clinical practice guidelines for the medical management of Graves' orbitopathy by the European Group on Graves' Orbitopathy were published in August 2021 in the European Journal of Endocrinology.[1]

Give oral prednisone/prednisolone prophylaxis to patients who have been treated with radioactive iodine (RAI) and who are at risk for progression or de novo development of Graves orbitopathy. These include smokers and those with severe/unstable hyperthyroidism or high serum thyrotropin receptor antibody (TSHR-Ab). Use the following regimen:

  • High risk: 0.3–0.5 mg/kg/body weight as starting dose, tapered, and withdrawn after 3 months

  • Low risk: 0.1–0.2 mg/kg/body weight, tapered, and withdrawn after 6 weeks.

Patients with longstanding and stably inactive GO can receive RAI without prednisone/prednisolone cover if risk factors for GO progression (particularly smoking and high serum TSHR-Ab titers) are absent. Avoid uncontrolled post-RAI hypothyroidism.

All patients with GO should receive extensive local treatment with artificial tears at all times during the course of their disease unless corneal exposure requires higher protection than ophthalmic gels or ointment, especially at nighttime.

Treat mild GO with local treatments and general measures to control risk factors; give a 6-month selenium supplementation to patients with mild and active GO of recent onset, because it improves eye manifestations and quality of life, and usually prevents GO progression to more severe forms.

Do not exceed a cumulative dose of 8 g of IV glucocorticoids for each cycle; do not give IV glucocorticoids to patients with GO who have evidence of recent viral hepatitis, significant hepatic dysfunction, severe cardiovascular morbidity, or uncontrolled hypertension; diabetes should be well controlled before starting treatment. The authors strongly recommend only applying such treatment in centers with experience managing potentially serious adverse events.

Give an intermediate dose of IV glucocorticoids (ie, a starting dose of methylprednisolone 0.5 g IV once weekly for 6 weeks, followed by 0.25 g once weekly for 6 weeks, with a cumulative dose of 4.5 g) in most cases of moderate-to-severe and active GO.

Reserve high-dose treatment (ie, a starting dose of methylprednisolone 0.75 g IV once weekly for 6 weeks, followed by 0.5 g once weekly for 6 weeks, with a cumulative dose of 7.5 g) for the more severe cases (constant/inconstant diplopia, severe proptosis, severe soft-tissue pathology or involvement) within the moderate-to-severe and active GO spectrum.

Intravenous methylprednisolone in combination with oral mycophenolate sodium (or mofetil) represents the first-line treatment for moderate-to-severe and active GO.

Monotherapy with methylprednisolone at the highest cumulative dose (7.5 g per cycle) represents an additional valid first-line treatment for those with more severe forms of moderate-to-severe and active GO, including constant/inconstant diplopia, severe inflammatory signs, and exophthalmos >25 mm.

Severe corneal exposure should be urgently treated medically or by means of progressively more invasive surgeries to avoid progression to corneal breakdown, the latter of which requires immediate surgery.

Sight-threatening GO is an emergency; treatment is an absolute priority; treat hyperthyroidism with antithyroid drugs until treatment of GO is completed.

For more information, see Thyroid-Associated Orbitopathy.

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