SAT-606 Graves' Orbitopathy Treated with Kahaly's Protocol: IV High Dose Glucocorticoids

Abstract

Graves’ Orbitopathy (GO) is present in approximately 25-50-% of patients with Graves’ hyperthyroidism. Treatment should rely on a thorough assessment of the clinical activity score (CAS), severity of GO and its impact on the patient’s quality of life. Most patients can be managed with non surgical treatments alone, and those requiring surgical intervention often benefit from concurrent medical therapy. We are presenting a case of active and moderate GO successfully treated with high dose glucocorticoids (GCs). 48 yo female presented with history of subclinical hyperthyroidism since age 40 with only complaint of excessive tearing and redness in both eyes for last 1 yr. Physical exam was remarkable for exophthalmos of bilateral eyes with minimal inferior scleral show with no evidence of goiter. Her labs showed TSH of 0.05 (0.27-4.2 microIU/ml), FT4 2.36(0.90-1.7 ng/dL), TPO 502(<9.0 IU/ml), TSI 132(<=122%) and TRAb 12.43(<=1.75IU/L). She was treated with methimazole, currently requiring 2.5 mg daily to maintain euthyroid status. Initially she was treated with artificial tears for 2 weeks followed by tapering dose of oral prednisone for 3 weeks. 3 months later patient presented with double, blurry vision while trying to read. On exam she had exophthalmos, mild lid lag, conjunctival injection, and early pannus formation on left cornea with CAS 3,TSH 1.41,FT4 0.83 and FT3 76.2. Patient was treated with dexamethasone/ neomycin/ polymyxin B eye drops at bedtime with doxycycline 50 mg BID PO for 3 months with improvement in her symptoms and remained symptom free for 2 yrs. 2 yrs later patient presented with bilateral eye pain, redness with tearing, left > right and diplopia with horizontal gaze with CAS of 6. She was again treated with oral prednisone taper over 3 weeks without any improvement. Then she was treated with IV methylprednisolone 500 mg weekly for 6 weeks, followed by 250 mg weekly for another 6 weeks with marked improvement in her symptoms of eye pain, redness of eyelid and conjunctiva and caruncle swelling and mild improvement in eyelid swelling 4 weeks after treatment. Our patient was successfully treated with high dose IV GCs. Corticosteroids activate transcription of anti inflammatory mediators and inhibit the transcription of proinflammatory mediators (ie. cytokines and prostaglandins). IV steroids suppress immune system through genomic pathway and non genomic pathway. IV GCs are more effective and have a lower side effects burden than oral steroids and thus are the preferred mode of administration. Patient should be screened for contraindications to IV GCs, including liver dysfunction, recent viral hepatitis, severe cardiovascular morbidity, uncontrolled HTN and diabetes. High dose IV GCs can be safely used for treatment of active, moderate to severe GO and should be used as firstline treatment in patients with active and moderate to severe GO.