Does early response to intravenous glucocorticoids predict the final outcome in patients with moderate-to-severe and active Graves' orbitopathy?
OBJECTIVE
Intravenous glucocorticoids (ivGCs) given as 12-weekly infusions are the first-line treatment for moderate-to-severe and active Graves' orbitopathy (GO), but they are not always effective. In this study, we evaluated whether response at 6 weeks correlated with outcomes at 12 (end of intervention) and 24 (follow-up) weeks, particularly in patients initially unresponsive.


METHODS
Our database (Bartalena et al. J Clin Endocrinol Metab 97:4454-4463, 10), comprising 159 patients given three different cumulative doses of methylprednisolone (2.25, 4.98, 7.47 g) was analyzed, pooling data for analyses. Responses at 6 weeks were compared with those at 12 and 24 weeks using three outcomes: overall ophthalmic involvement [composite index (CI)]; quality of life (QoL); Clinical Activity Score (CAS). Responses were classified as "Improved", "Unchanged", "Deteriorated", compared to baseline.


RESULTS
Deteriorated patients at 6 weeks for CI (n = 8) remained in the same category at 12 weeks and 7/8 at 24 weeks. Improved patients at 6 weeks for CI (n = 51) remained in the same category in 63% and 53% of cases at 12 and 24 weeks, respectively. Unchanged patients at 6 weeks (n = 100) eventually improved in 28% of cases (CI), 58% (CAS), 32% (QoL). There was no glucocorticoid dose-dependent difference in the influence of early response on later outcomes.


CONCLUSIONS
Patients who deteriorate at 6 weeks after ivGCs are unlikely to benefit from continuing ivGCs. Patients unresponsive at 6 weeks still have a significant possibility of improvement later. Accordingly, they may continue ivGC treatment, or, alternatively, possibly stop ivGCs and be switched to a second-line treatment.
Department of medicine and surgery, University of Insubria, Endocrine Unit, ASST dei Sette Laghi, Viale Borri, 57, 21100, Varese, Italy. luigi.bartalena@uninsubria.it.
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L
Bartalena
Department of medicine and surgery, University of Insubria, Endocrine Unit, ASST dei Sette Laghi, Viale Borri, 57, 21100, Varese, Italy.
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G
Veronesi
IASIO Medical Center, Thessaloniki, Greece.
G E
GE
Krassas
Academic Medical Center, University of Amsterdam, Amsterdam, The Netherlands.
W M
WM
Wiersinga
University of Pisa, Pisa, Italy.
C
C
Marcocci
University of Pisa, Pisa, Italy.
M
M
Marinò
Fondazione Policlinico, University of Milan, Milan, Italy.
M
M
Salvi
CatholicUniversity of Louvain, Brussels, Belgium.
C
C
Daumerie
Lyon 1 University, Lyon, France.
C
C
Bournaud
Kantonsspital Baselland, University Clinic of Internal Medicine, Bruderholz, Switzerland.
M
M
Stahl
Department of medicine and surgery, University of Insubria, Endocrine Unit, ASST dei Sette Laghi, Viale Borri, 57, 21100, Varese, Italy.
L
L
Sassi
Department of medicine and surgery, University of Insubria, Endocrine Unit, ASST dei Sette Laghi, Viale Borri, 57, 21100, Varese, Italy.
C
C
Azzolini
University Department of Ophthalmology, AHEPA Hospital, Thessaloniki, Greece.
K G
KG
Boboridis
Academic Medical Center, University of Amsterdam, Amsterdam, The Netherlands.
M P
MP
Mourits
Academic Medical Center, University of Amsterdam, Amsterdam, The Netherlands.
M R
MR
Soeters
CatholicUniversity of Louvain, Brussels, Belgium.
L
L
Baldeschi
University of Pisa, Pisa, Italy.
M
M
Nardi
Fondazione Policlinico, University of Milan, Milan, Italy.
N
N
Currò
CatholicUniversity of Louvain, Brussels, Belgium.
A
A
Boschi
Lyon 1 University, Lyon, France.
M
M
Bernard
Admedico Orbital Center, Olten, Switzerland.
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G
von Arx
Newcastle upon Tyne Hospitals NHS Trust, Newcastle upon Tyne, UK.
P
P
Perros
Gutenberg University Medical Center, Mainz, Germany.
G J
GJ
Kahaly
D061605:Administration, Intravenous; D005500:Follow-Up Studies; D005938:Glucocorticoids / Q000008:administration & dosage*; D049970:Graves Ophthalmopathy / Q000188:drug therapy*; D006801:Humans; D011788:Quality of Life; D012720:Severity of Illness Index; D016896:Treatment Outcome
D005938:Glucocorticoids
Clinical Activity Score; Cyclosporine; Graves’ orbitopathy or ophthalmopathy; Intravenous glucocorticoids; Orbital radiotherapy; Shared decision-making