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

Abstract

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 NOSPECS 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.