Clinical review: Intravenous glucocorticoids for Graves’ orbitopathy: efficacy and morbidity

J Clin Endocrinol Metab. 2011 Feb;96(2):320-32. Epub 2011 Jan 14 Department of Medicine, Gutenberg University Medical Center, Langenbeckstrasse 1, Mainz 55131, Germany.

Zang S, Ponto KA, Kahaly GJ.

The administration of iv glucocorticoid pulses has been advocated as a treatment approach for patients with inflammatory and moderate to severe Graves’ orbitopathy (GO). This review offers an update on this controversial regimen.

PubMed and the MeSH-Database were searched (with no temporal limit) for the following topics: management of active and severe GO; glucocorticoid therapy of GO; iv glucocorticoid administration; mechanism and pharmacokinetics of iv glucocorticoids; and adverse events, morbidity, and mortality of iv glucocorticoids. The articles were evaluated according to their setting and study design.

The current first-line treatment for active, moderate-to-severe GO is a 12-wk course of high-dose iv glucocorticoid pulses. The response rate of this regimen is approximately 80%. Intravenous glucocorticoids have a statistically significant advantage over oral treatment and cause significantly fewer adverse events. However, major side effects related to preexisting diseases, administered dose, and treatment schedule have been reported. The morbidity and mortality of iv glucocorticoid therapy are 6.5 and 0.6%, respectively. Thus, careful patient selection is warranted. Before iv glucocorticoid administration, patients should be screened for recent hepatitis, liver dysfunction, cardiovascular morbidity, severe hypertension, inadequately managed diabetes, and glaucoma. The cumulative dose should not exceed 8 g, and with the exception of sight-threatening GO the single doses preferably should not be administered on consecutive days. Monthly monitoring during subsequent treatment is warranted.

Author’s Recommendation

The currently recommended treatment for patients with active and moderate to severe GO is a course of 0.5 g of methylprednisolone iv once weekly for 6 wk, followed by 0.25 g/wk for 6 wk (cumulative dose, 4.5 g). If there is negative clinical response, iv glucocorticoid treatment may be stopped after 6 wk of 0.5 g/wk dosing. Although effective, this treatment may be accompanied with major side effects related to preexisting diseases, dose, and treatment schedule.