What are the guideline sources, guidelines and references for Thyroid eye disease ?
Guideline sources The following summarized guidelines for the evaluation and management of thyroid eye disease (TED) are prepared by our editorial team based on guidelines from the American Thyroid Association (ATA/ETA 2022), the European Thyroid Association (ETA 2022; 2018), the European Group of Graves' Orbitopathy (EUGOGO 2021), the American College of Radiology (ACR 2018), and the American Thyroid Association (ATA 2016). 1 2 3 4 5 6 Calculator Calculator Graves' orbitopathy clinical activ Severity classification of Graves' Guidelines https://web.pathway.md/diseases/recwv05GUl5Yd7G2e 1/7 6/24/23, 4:06 PM Thyroid eye disease Pathway 1. Classification and risk stratification Severity assessment: As per ATA 2022 guidelines, assess disease activity, severity (with particular attention to impaired ocular motility and visual loss), the trend across time, and impact on daily living in patients with TED. E Show 2 more As per EUGOGO 2021 guidelines: Assess clinical activity and severity of Graves' orbitopathy according to standardized criteria and categorize disease as active or inactive, and mild, moderate-to-severe, or sight- threatening. B Evaluate quality of life by the EUGOGO disease-specific Graves' orbitopathy quality of life questionnaire. B 2. Diagnostic investigations Orbital imaging: As per ATA 2022 guidelines: Obtain orbital contrast-enhanced CT or MRI for atypical or severe cases of TED to help determine activity and to exclude other etiologies. E Obtain non-contrast CT in patients with TED considered for surgery. E As per ACR 2018 guidelines, consider obtaining orbital contrast-enhanced CT or MRI for the evaluation of orbital asymmetry or exophthalmos. C 3. Medical management Management of mild orbitopathy: As per ATA 2022 guidelines, consider offering selenium selenite 100 g BID for 6 months in patients with mild, active TED, particularly in regions of selenium insufficiency. E As per EUGOGO 2021 guidelines, treat patients with mild Graves' orbitopathy with local treatments and general measures to control risk factors. B Show 2 more As per ATA 2016 guidelines, consider offering radioactive iodine therapy, antithyroid drugs, or performing thyroidectomy as equally acceptable therapeutic options in patients with mild, active Graves' orbitopathy with no risk factors for deterioration. B Show 2 more Management of moderate-to-severe orbitopathy, first-line therapy: As per ETA/ATA 2022 guidelines, administer infusion therapies for TED in a facility with appropriate monitoring under the supervision of experienced specialists. Monitor for adverse side effects throughout the treatment period. E https://web.pathway.md/diseases/recwv05GUl5Yd7G2e 2/7 6/24/23, 4:06 PM Thyroid eye disease Pathway Show 4 more As per EUGOGO 2021 guidelines, administer IV methylprednisolone in combination with oral mycophenolate sodium (or mofetil) as first-line therapy in patients with moderate-to-severe and active Graves' orbitopathy. B Show 6 more Management of moderate-to-severe orbitopathy, second-line therapy: As per ETA/ATA 2022 guidelines, consider administering rituximab (particularly in patients with a disease duration of < 9 months, and with prominent soft tissue involvement) or tocilizumab in corticosteroid-resistant patients with active moderate-to-severe TED. Administer teprotumumab, if available, in patients with active moderate-to-severe TED with significant proptosis and/or diplopia. E Show 6 more As per EUGOGO 2021 guidelines, consider administering the following second-line therapies if the response to primary treatment is poor in patients with moderate-to-severe and active Graves' orbitopathy, after careful ophthalmic and biochemical (liver enzymes) evaluation: second course of IV methylprednisolone monotherapy, starting with high single doses (0.75 g) and a maximal cumulative dose of 8 g per cycle oral prednisone/prednisolone combined with either cyclosporine or azathioprine orbital radiotherapy combined with oral or IV corticosteroids teprotumumab rituximab tocilizumab. B Show 7 more Management of sight-threatening orbitopathy: As per ATA 2022 guidelines, initiate urgent treatment with IV corticosteroids in patients with dysthyroid optic neuropathy, with close monitoring of response and early (after 2 weeks) consideration for decompression surgery if baseline visual function is not restored and maintained with medical therapy. E Show 2 more As per EUGOGO 2021 guidelines, administer 0.5-1 g IV methylprednisolone daily for either 3 consecutive days or more preferably on every second day in patients with optic neuropathy. Perform urgent orbital decompression in the absence or poor response within 1-2 weeks. B Show 2 more As per ETA 2018 guidelines, initiate antithyroid drugs in patients with sight-threatening Graves' orbitopathy. B As per ATA 2016 guidelines, consider performing surgery or offering antithyroid drugs as preferred treatment options in patients with sight-threatening Graves' orbitopathy. Do not offer radioactive iodine therapy. B Management of hyperthyroidism: https://web.pathway.md/diseases/recwv05GUl5Yd7G2e 3/7 6/24/23, 4:06 PM Thyroid eye disease Pathway As per EUGOGO 2021 guidelines, restore euthyroidism promptly and maintain stably in all patients with Graves' orbitopathy. A Show 5 more As per ETA 2018 guidelines: Control hyperthyroidism promptly by antithyroid drugs and maintain euthyroidism stably in patients with Graves' orbitopathy. A Consider selecting treatment for hyperthyroidism in patients with inactive Graves' orbitopathy independently of Graves' orbitopathy. B As per ATA 2016 guidelines, achieve and maintain euthyroidism in hyperthyroid patients with Graves' orbitopathy or risk factors for the development of orbitopathy. B 4. Nonpharmacologic interventions Smoking cessation: As per ATA 2022 guidelines, advise smoking reduction or cessation and offer support for this goal. E As per EUGOGO 2021 guidelines, advise smoking cessation in all patients with Graves' hyperthyroidism, irrespective of the presence/absence of Graves' orbitopathy. A As per ATA 2016 guidelines, advise patients with Graves' disease to stop smoking and refer them to a structured smoking cessation program. Identify patients exposed to second-hand smoke and advise of its negative impact, as both first-hand and second-hand smoking increase the risk of Graves' orbitopathy. B Artificial tears: As per ATA 2022 guidelines: Offer local ocular measures and lifestyle intervention in all patients with TED. E Consider offering ubricants and nocturnal eye masks for the prevention or treatment of corneal exposure. E As per EUGOGO 2021 guidelines, offer extensive local treatment with artificial tears in all patients with Graves' orbitopathy at all times in the course of disease unless corneal exposure requires higher protection than ophthalmic gels or ointment, especially at nighttime. B Ocular occlusion: consider offering ocular occlusion and prisms to relieve diplopia. E Selenium supplementation: As per ATA 2022 guidelines, consider offering selenium selenite 100 g BID for 6 months in patients with mild, active TED, particularly in regions of selenium insufficiency. E As per EUGOGO 2021 guidelines, offer selenium supplementation for 6 months to improve eye manifestations and quality of life and to prevent disease progression to more severe forms in patients with mild and active Graves' orbitopathy of recent onset. B https://web.pathway.md/diseases/recwv05GUl5Yd7G2e 4/7 6/24/23, 4:06 PM Thyroid eye disease Pathway 5. Therapeutic procedures Local triamcinolone injections: consider performing local subconjunctival/periocular injections of triamcinolone acetate if systemic corticosteroids are absolutely contraindicated. C Orbital radiotherapy: As per ATA 2022 guidelines, offer radiotherapy in patients with active moderate-to-severe TED with a principal feature being progressive diplopia. E Show 2 more As per EUGOGO 2021 guidelines, consider offering orbital radiotherapy as an effective second- line therapy in patients with moderate-to-severe and active Graves' orbitopathy, in combination with corticosteroids, particularly in the presence of diplopia and/or restriction of extraocular motility. B 6. Specific circumstances Pediatric patients: refer pediatric patients with eye symptoms to an orbital specialist, preferably in combined (ophthalmologist/physician) thyroid eye clinics. B Show 3 more 7. Patient education General counseling: Counsel patients with moderate-to-severe and active Graves' orbitopathy explaining aims and expectations, benefits and risks of different therapies. B Select treatment for patients with moderate-to-severe and active Graves' orbitopathy based on evidence-based effectiveness, safety, evaluation of costs, reimbursement by the health system, drug availability, facilities for delivering highly specialized treatments, and personal choice of the informed patient within a shared decision-making process. B 8. Preventative measures Corticosteroid prophylaxis: As per EUGOGO 2021 guidelines, administer oral prednisone/prednisolone prophylaxis in patients treated with radioactive iodine at risk of progression or de novo development of Graves' orbitopathy (smokers, severe/unstable hyperthyroidism, high serum thyrotropin receptor antibody) with the following regimens: 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. A Show 3 more https://web.pathway.md/diseases/recwv05GUl5Yd7G2e 5/7 6/24/23, 4:06 PM Thyroid eye disease Pathway As per ETA 2018 guidelines, administer corticosteroid prophylaxis in patients treated with radioactive iodine if mild and active Graves' orbitopathy preexists or there are risk factors for radioactive iodine-associated Graves' orbitopathy occurrence or progression. A As per ATA 2016 guidelines, consider offering radioactive iodine therapy without concurrent corticosteroids, antithyroid drugs, or performing thyroidectomy as equally acceptable therapeutic options in regard to risk of Graves' orbitopathy in nonsmoking B or smoking patients with Graves' disease without apparent Graves' orbitopathy. C Show 2 more 9. Follow-up and surveillance Indications for referral: As per ATA 2022 guidelines, consult with an ophthalmologist when the diagnosis of thyroid disease is uncertain, in cases of moderate-to-severe TED, and when surgical intervention needs to be considered. Arrange urgent referral when sight-threatening TED is suspected or confirmed. E As per EUGOGO 2021 guidelines, refer patients with overt Graves' orbitopathy and patients with mild disease at risk to deteriorate (clinically active Graves' orbitopathy, smokers, severe/unstable hyperthyroidism, high serum thyrotropin receptor antibody titers) to combined thyroid-eye clinics or specialized centers providing both endocrine and ophthalmic expertise, as this will provide an accurate and timely diagnosis to improve prognosis and quality of life. B Assessment of treatment response: monitor every patient receiving corticosteroids for response to treatment and adverse events. Consider withdrawing corticosteroids in favor of another modality or watchful monitoring if drug-induced side effects outweigh benefits. B References 1. Ross DS, Burch HB, Cooper DS et al. 2016 American Thyroid Association Guidelines for Diagnosis and Management of Hyperthyroidism and Other Causes of Thyrotoxicosis. Thyroid. 2016 Oct;26 10 1343 1421. Open 2. Henry B Burch, Petros Perros, Tomasz Bednarczuk et al. Management of thyroid eye disease: a Consensus Statement by the American Thyroid Association and the European Thyroid Association. Eur Thyroid J. 2022 Dec 8;11 6):e220189. Open 3. L Bartalena, G J Kahaly, L Baldeschi et al. The 2021 European Group on Graves' orbitopathy EUGOGO clinical practice guidelines for the medical management of Graves' orbitopathy. Eur J Endocrinol. 2021 Aug 27;185 4 G43 G67. Open 4. Kahaly GJ, Bartalena L, Heged s L et al. 2018 European Thyroid Association Guideline for the Management of Graves' Hyperthyroidism. Eur Thyroid J. 2018 Aug;7 4 167 186. Open 5. Christiaan F Mooij, Timothy D Cheetham, Frederik A Verburg et al. 2022 European Thyroid Association Guideline for the management of pediatric Graves disease. Eur Thyroid J. 2022 Jan 1;11 1):e210073. Open https://web.pathway.md/diseases/recwv05GUl5Yd7G2e 6/7 6/24/23, 4:06 PM Thyroid eye disease Pathway 6. Expert Panel on Neurologic Imaging:, Tabassum A Kennedy, Amanda S Corey et al. ACR Appropriateness Criteria Orbits Vision and Visual Loss. J Am Coll Radiol. 2018 May;15 5S S116 S131. Open https://web.pathway.md/diseases/recwv05GUl5Yd7G2e 7/7