BioMed Research International

BioMed Research International / 2018 / Article

Research Article | Open Access

Volume 2018 |Article ID 4845894 | https://doi.org/10.1155/2018/4845894

Xiaofang Tu, Yan Dong, Hongmei Zhang, Qing Su, "Corticosteroids for Graves’ Ophthalmopathy: Systematic Review and Meta-Analysis", BioMed Research International, vol. 2018, Article ID 4845894, 9 pages, 2018. https://doi.org/10.1155/2018/4845894

Corticosteroids for Graves’ Ophthalmopathy: Systematic Review and Meta-Analysis

Academic Editor: Timothy Y. Lai
Received17 Sep 2018
Accepted12 Nov 2018
Published22 Nov 2018

Abstract

Background. Graves’ ophthalmopathy (GO) is a complicated autoimmune disease. Various therapies have been used to manage GO; however the optimum therapy is not clear. Glucocorticoids (GCs) therapy is the mainstay of treatment especially for active moderate to severe patients, which needs evidence-based support. Method. We searched all the randomized controlled trials (RCTs) involving corticosteroid treatment for patients diagnosed with GO from EMBASE, Medline, and the Cochrane library and then conducted a system review and meta-analysis. The electronic search covered the period from April 1966 to March 2018. Result. Twenty-nine trials were included. GCs were proved to be beneficial for GO patients [response rate, risk ratio (RR) = 1.72, 95% confidence interval (CI): 1.28~2.31, P=0.0003], and intravenous corticosteroids worked significantly better than oral corticosteroids as ever reported. When compared with the single treatment of GCs, the combination of radiotherapy and GCs showed similar effects on response rate (RR=1.25, 95%CI: 0.91~1.73). A study proved the advantage of mycophenolate mofetil over GCs in three outcomes (response rate, RR=0.74, 95%CI: 0.63~0.88). Additional treatments such as technetium-99 methylene diphosphate (99Tc-MDP) or cyclosporine enhanced the effect of GCs on proptosis reduction, respectively (P<0.00001 and P=0.02). Conclusion. Our meta-analysis confirmed the effects of GCs in the management of GO and intravenous GCs are proved to be better than oral GCs as ever reported. Combination of radiotherapy and GCs did not enhance the effects of GCs. However, if proptosis is the main issue, combination of 99Tc-MDP or cyclosporine with GCs may be taken into consideration. The reported advantages of mycophenolate mofetil over GCs are noteworthy and need more RCTs to confirm.

1. Introduction

Graves’ ophthalmopathy (GO), or thyroid eye disease (TED), is regarded as an autoimmune disorder closely related to Graves’s disease (GD). It may cause ocular symptoms including periorbital edema, chemosis, eyelid retraction, proptosis, altered ocular motility, and even diplopia, exposure keratopathy, and dysthyroid optic neuropathy (DON), which may result in visual loss. The prevalence rate of GO ranges from 0.1% to 0.3% [1].

The pathogenesis of GO is still not exactly known. It is difficult to assess and manage this complicated disease. Drug therapy, radiotherapy, and eye surgery have been used to improve the symptoms according to the activity and severity of GO. Lymphocytes and inflammation may play an important part in the pathogenesis. Thus, immunosuppression therapy, especially glucocorticoids (GCs), had become the mainstay of treatment for patients with active GO, which was also recommended by the European Group on Graves’ Orbitopathy (EUGOGO) [2].

However, more detailed evidences were needed to support GCs as first-line treatment of GO. Therefore, we conducted a meta-analysis to compare the efficacy of GCs with other treatments for patients diagnosed with GO and to explore the ideal treatment regimen of GCs.

2. Materials and Methods

2.1. Data Source and Search Strategy

We searched randomized controlled trials (RCTs) from EMBASE, Medline, and the Cochrane library online according to a broad search strategy (S1 Strategy). The strategy included all the RCTs relevant to the glucocorticoid treatment including the monotherapy or the combined therapy with irradiation or other drugs for Graves’ ophthalmopathy referring to some protocols from previous meta-analysis [35] and Cochrane Handbook for Systematic Reviews of Interventions. A manual search was done if necessary. The electronic search covered the period from April 1966 to March 2018.

2.2. Outcome Measures

The primary outcome was the response rate (i.e., the ratio of responders to a total number of patients) defined in each study. In addition, clinical activity score (CAS) and proptosis were also recorded to assess the therapeutic effects on the eye functions.

2.3. Trial Selection

Two reviewers assessed the eligibility of the studies independently based on the following predetermined selection criteria: (1) study design: randomized, controlled clinical trials; (2) population: patients diagnosed with GO; (3) intervention: at least one treatment for the GO was relevant to the glucocorticoid. The studies, which compared the operative treatment with drug therapy, were not included; (4) outcome variables: at least reporting one of the three outcomes mentioned above (i.e., response rate, CAS, and proptosis). The duplicate studies were moved. Any disagreement was solved by discussing or asking the third author.

2.4. Data Extraction

Two independent authors extracted the data from trials, respectively, by a customized form and then checked together. The following data of each study was extracted if accessible: response rate, clinical activity score, proptosis, diplopia, lid aperture/width, visual acuity, and side effects. And the characteristics or other important information was also recorded if possible: the title, authors, study design, publication year, location, inclusion and exclusion criteria, measurement point, measure methods of the recorded outcomes, and the definition of response rate mentioned in the paper. In addition, interventions, patient age, and sex as well as the number of patients lost were also included in the customized form. We estimated the data from the graphs by the software Plot Digitizer (version 2.6.8) if exact data were not accessible in the article.

2.5. Qualitative Assessment

The quality of included studies was appraised and described by two reviewers via a table that contained the influence factors of the bias. The qualitative assessment system was as follows: (1) allocation generation; (2) allocation concealment; (3) blinding of participants, investigators, and examiners; (4) the number of the patients lost to follow-up; (5) intension-to-treat (ITT) analysis; (6) selective reporting as described by the Cochrane Handbook; (7) other factors which would impact the bias of studies such as the equality of baseline of groups in the studies.

2.6. Statistical Analysis

We used the Review Manager software (RevMan, version 5.3) to conduct the statistical analysis. Risk ratio (RR) was calculated for the dichotomous variables (i.e., response rate) and mean difference (MD) for the continuous variables (i.e., proptosis) and standardized mean difference (SMD) for CAS because different clinical activity score systems were used in different trials, with 95% confidence intervals (CI). The mixture of the change-from-baseline and final value scores was included for proptosis because when using the (unstandardized) mean difference method in RevMan, it would not cause statistical problems. If any of the final value scores of CAS in the trials was unavailable in the same subgroup, the change-from-baseline value would be adopted to compare in this subgroup. When the baseline of outcome was unequal, the change-from-baseline score was also used to correct the bias. For each contrast, we estimated the heterogeneity by χ2 test and I2 metrics, and P < 0.1 or I2> 50% indicated the significant heterogeneity, in which case we would search for the reasons for obvious heterogeneity and chose a random effects model to analyze the combined results; otherwise we chose the fixed effects model. We estimated the mean and standard deviation (SD) through the data of median and range if necessary using the method reported by StelaPudarHozo, etc [6]. We included the data of the worse one if both sides of eyes were measured separately in the study.

3. Results

Twenty-nine trials were included in our meta-analysis. The selection process was shown in the flow diagram (S2 Diagram). And the characteristics of RCTs are summarized in Table 1. Patients of included studies had active GO in twenty-three trials, moderate to severe GO in twenty trials, and severe GO in one trial. The quality assessment of included studies is presented in Table 2. It should be noticed that patients in study Kahaly1986 were assigned on the basis of the year of birth. The adverse events and additional treatment during follow-up period are summarized in S3 Side-effects. The results would be presented by different interventions as follows.


StudyLocationLengthAgeSex
(M/F)
StagePrior treatment (n)Treatment groupControl group
InterventionNInterventionN

van Geest2008Utrecht1247.33/12Active, moderately severeUntreatedGCs6Placebo9
Lee2012Korea643.512/83InactiveNo GCs or ORGCs75Observation59
Salvi2015Italy651.15/26Active, moderate to severeNo GCs or cell depleting therapyGCs16Rituximab15
Savino2014Italy556.86/13Active, moderately severeNo GCsGCs10Rituximab9
Prummel1993Netherlands646.89/47Moderately severeUntreatedGCs28OR28
Prummel1989Netherlands350.510/26SevereUntreatedGCs18Cyclosporine18
Stamato2006Brazil342.48/14Active, moderate to severeUntreatedGCs11Colchicine11
Kahaly1996Germany547.59/31ActiveGCs/irradiation: 20GCs19Immunoglobulin21
Ye2016Nanjing641.152/106Active, moderate to severeImmunosuppressive or radiotherapy: 0GCs78Mycophenolate mofetil80
Kung1996Hong Kong342.19/9Moderately severeNAGCs10Octreotide8
Kahaly1986Germany1246.85/35NOSPECS III-V18 GCs, 3 irradiation, 1 cyclophosphamideGCs+ cyclosporine20GCs20
Kahaly2018Germany and Italy951.439/125Active, moderate to severeImmunosuppressive treatment: 0GCs+ mycophenolate73GCs68
Chen2016China333.626/70ActiveNAGCs+99Tc-MDP74GCs70
Kahaly1990Germany651.09/42Active, NOSPECS II-VISteroids/radiation: 40GCs+ ciamexone26GCs25
Ng2005Hong Kong1356.210/6 (1 died)Active, moderate to severeUntreatedGCs + OR8GCs7
Pinchera1987Italy264411/13ActiveNAGCs + OR12GCs12
Rajendram2018UK1249.333/93Active moderate-to-severeImmunosuppressive or radiotherapy: 0GCs + OR50GCs54
Roy 2015India1237.324/38Active, moderate to severeUntreatediv GCs31oral GCs31
Macchia2001ItalyTreat after43.611/40NAUntreatediv GCs25oral GCs26
Akarsu2011Turkey628.912/21Active, moderately severeNAiv GCs18oral GCs15
Aktaran2007Turkey342.724/28Active, moderately severeUntreatediv GCs25oral GCs27
Kahaly2005Germany35021/49Active, moderately severeUntreatediv GCs35oral GCs35
Kauppinen-Makelin2002Finland346.32/31Active, or proptosis or diplopiaNAiv GCs + oral GCs18oral GCs15
Marcocci2001Italy124914/68Active, severity: defined by ocular manifestationsGCs/ciclosporin/octreotide / surgery: 12iv GCs + OR41oral GCs + OR41
Alkawas2010Egypt6NA8/16Active, proptosisUntreatedoral GCs12GCs injection12
Bartalena20128 EUGOGO centers352.933/73Active, moderate to severeUntreatedIVMP (total 7.47g)52IVMP (total 4.98g)54
He2016China3-3.2541.814/26CAS≥3/7 or prolonged T2RTs; Moderate to severeUntreatedIVMP monthly (total 6.0g)17IVMP weekly (total 4.5g)15
Zhu2014China346.834/46Active, moderate to severeImmunosuppressive or radiotherapy: 0IVMP weekly39IVMP daily39
Philip2013India337.55/16Active, moderate to severeNADexa11IVMP10

Length: the time when final values included in our analysis were measured and represented as the number of months. GCs: glucocorticoids; OR: orbital radiotherapy; IVMP: intravenous methylprednisolone; iv: intravenous; N: numbers. Dexa: dexamethasone.

StudyAllocation generation;  concealmentBindingFollow-up lost (n)ITTSelective ReportingUnequal baseline or other remarks
ParticipantsInvestigatorsExaminers

van Geest2008A, AYNY1 at week 0YNA
Lee2012A, BNNY10NNSwelling grade
Salvi2015A, BYNY1NYProtocol amendment
Savino2014B, BNNN1NNA
Prummel1993A, BYNY3NNA
Prummel1989A, BNNY0YNA
Stamato2006A, BYNY3NNA
Kahaly1996A, BNNY0YNAVisual acuity
Ye2016A, BNNY16NNA
Kung1996A, BNNY0YNACAS
Kahaly1986C, CNNY0YNA
Kahaly2018A, ANYY23NN
Chen 2016A, BNNN0YNA
Kahaly1990B, BYNY0YNA
Ng2005B, BNNY1NNAAge
Pinchera1987A, BNNN0YNA
Rajendram2018A, BYYY69YNEthnicity
Roy2015A, BNNN3NNDiplopia, TSH
Macchia2001B, BNNN0YNACAS, OI
Akarsu2011B, BNNN0YNA
Aktaran2007A, ANNY0YNALid width
Kahaly2005A, BNNY0YNALid width
Kauppinen-Makelin2002A, ANNN0YNATSab titers, visual acuity
Marcocci2001A, BNNY0YNA
Alkawas2010B, BNNN5NNA
Bartalena2012A, AYNY6YNAAge, gender
He2016A, BNNY8NNA
Zhu2014A, ANNN2YNADuration of eye symptoms; TRAb
Philip 2013B, BNNN0YNA

ITT: intention to treat analysis; A: adequate; B: unknown; C: inadequate; N: no; Y: yes; NA: unable to assess; CAS: clinical activity score; TSH: thyroid stimulating hormone; OI: ophthalmopathy index score; TSab: thyroid stimulating antibodies; TRAb: TSH receptor antibody.
3.1. Corticosteroids vs. Placebo

Two studies [7, 8] compared corticosteroids with placebo or control. Treatment with corticosteroids showed better curative effects in response rate; the pooled RR is 1.72 (95%CI: 1.28~2.31, P=0.0003), with heterogeneity (I2=63%). Methylprednisolone was administered intravenously to active moderately severe GO patients in the study van Geest2008 [8], which also proved marginal effects on reduction of CAS (95% CI: −2.27~-0.00), but no obvious effects on proptosis. Subconjunctival triamcinolone injections were administrated to inactive GO patients in study Lee2012 [7]. There were no major events during corticosteroid treatment (S3 Side-effects). 19 and 7 additional treatments were needed in placebo and corticosteroids group, respectively, during follow-up period.

3.2. Corticosteroids vs. Other Nonsurgical Therapy

Eight studies compared corticosteroids alone with other nonsurgical therapy including radiotherapy [9], rituximab [10, 11], cyclosporine [12], colchicine [13], immunoglobulin [14], mycophenolate mofetil (MMF) [15], and somatostatin [16]. And except for the rituximab, all of them reported the response rate.

The sensitive analysis indicated that the study Ye2016, [15] which compared the methylprednisolone with MMF, increased the I2 value of heterogeneity from 8% to 69%. The MMF performed better in response rate (RR = 0.74, 95%CI: 0.63~0.88, P = 0.0005) (Figure 1) and reduction of CAS and proptosis (Figure 2) compared with GCs. On the contrary, the response rate of GCs was similar to immunoglobulin, colchicine, somatostatin, and radiotherapy and better than cyclosporine; in addition, GCs did not work better in proptosis reduction (MD = 0.42, 95%CI = 0.00~0.85, P = 0.05) (Figure 2).

Compared with systematic methylprednisolone treatment (total 4.5g), rituximab local injections did not work better in CAS or proptosis reduction in one study [11]. However, in another study, [10] systematic rituximab treatment was more effective in reduction of CAS than methylprednisolone treatment (total 7.5g) (SMD = 0.78, 95%CI: 0.05~1.52).

3.3. Combined Therapy vs. Monotherapy

Corticosteroid was combined with cyclosporine, [17] ciamexone, [18] technetium-99 methylene diphosphate (99Tc-MDP) [19], mycophenolate [20], or radiotherapy [2123]. The result indicated that the combination of radiotherapy did not show extra effects compared with GCs alone (response rate, RR=1.25, 95%CI: 0.91~1.73, P=0.17) (Figure 1). On the contrary, combination of mycophenolate improved the response rate (RR=1.47, 95%CI: 1.09~2.00, P=0.01) and 99Tc-MDP or cyclosporine improved the proptosis (P<0.00001 and P=0.02).

3.4. Ideal Regimen of Corticosteroids Therapy
3.4.1. Intravenous Corticosteroids vs. Oral Corticosteroid

Six trials [2429] compared intravenous glucocorticoids (IVGC) with oral glucocorticoids (ORGC) alone. IVGC were significantly better than ORGC in improvement of response rate (RR=1.49, 95%CI: 1.25~1.77, P<0.00001) (Figure 1) and CAS (SMD=-0.64, 95%CI: −1.12~-0.16, P=0.010) (Figure 3). There were six major adverse events recorded in oral group and none in the IVGC group (S3 Side-effects). And for the proptosis, there were no significant differences between two groups (MD = -0.28, 95% CI: −0.66~0.09, P = 0.14) (Figure 2).

3.4.2. Different Doses and Protocols

Three regimens were mentioned in two trials [30, 31]: (1) monthly: 0.5g daily for 3 consecutive days in weeks 1, 5, 9, and 13 for a total dose of 6.0g over 3 months; (2) weekly: 0.5g weekly for 6 weeks, followed by 0.25g weekly for 6 weeks for a total dose of 4.5g over 12 weeks; (3) daily: 0.5g daily for 3 consecutive days per week for 2 weeks, followed by 0.25g daily for 3 consecutive days per week for another 2 weeks and by tapering oral prednisone. Weekly protocol was more effective than daily protocol and showed less adverse events than the other two protocols. Another trial [32] compared three different cumulative dosages of GCs and higher cumulative dosage (7.47g) provided a transient advantage. But considering the greater toxicity of higher dose, the intermediate-dose regimen (4.98g) was recommended.

3.4.3. Others

Of the remaining three RCTs, one of them [33] compared the IVGC plus radiotherapy with ORGC plus radiotherapy, of which the result affirmed the advantage of IVGC against ORGC. Another trial [34] compared ORGC with peribulbar triamcinolone acetonide injection, which showed comparable effects. The other [35] proved the efficacy of dexamethasone instead of methylprednisolone.

4. Discussion

Immunosuppressant drugs are often used to treat GO, with glucocorticoids being the most common choice in the past decades depending on its anti-inflammatory function. However, it is still a challenge for us to manage GO with GCs for the following reasons. First, if it will be beneficial to receive another immunomodulatory drug instead of GCs to manage GO which is not clear. Second, the regimen of GCs, ranging from the administration route and drug dosage to the drug administration time, varied from study to study. In the present study, we performed a meta-analysis entirely around the usage of GCs in GO including twenty-nine RCTs, to help in confronting the challenge mentioned above.

The RCTs confirmed the effect of GCs whether given systemically or by local route. Compared with the placebo or observation group, GCs group had better response rate. GCs decreased the activity of GO in active GO patients and improved the eyelid swelling and retraction in recent-onset inactive ones. And most importantly, GCs treatment reduced the need for additional treatment such as ophthalmologic surgery.

Various nonsurgical therapies such as radiotherapy, colchicine, immunoglobulin, somatostatin rituximab, MMF, and cyclosporine were compared with GCs treatment; however, most of them have similar or inferior effects except MMF. However, the obvious advantage of MMF over GCs was only proved by one study and needs more RCT to confirm it. Therefore, it is still reasonable to regard GCs as first-line treatment for active moderate to severe GO. Considering its side effects, the usage of GCs depends on the health condition of patients and should be monitored to avoid serious side effects especially on liver function, glycaemia, and mood disorder.

A part of GO patients was not responsive to GCs treatment or relapsed after the withdrawal of GCs. Thus, combined therapy was taken into consideration. The combination of radiotherapy and GCs was not superior to GCs alone according to the results. As mentioned above, the effect of GCs treatment in proptosis improvement is not obvious. Firstly, GCs did not alleviate the proptosis more obviously compared with the placebos or other nonsurgical therapies. Secondly, although the IVGC performed better than ORGC, there still was not significant difference between these two groups in the reduction of proptosis. Thus, if the proptosis is the main symptom of patient, the combination of 99Tc-MDP or cyclosporine may be taken into consideration with cautious control of side effects.

Corticosteroids can be administered orally, intravenously, or locally, but locally administered corticosteroids, like subconjunctival or retrobulbar injections, may result in injuries, need more operative skills, and were not proved to be more effective, so they are not recommended first. Intravenous injection of GCs worked better than oral GC in response rate and CAS improvement, in accordance with the result reported by previous meta-analysis [3638], which may be ascribed to rapidly increased and higher concentration of GCs in blood. Furthermore, intravenous injection of GCs also keeps patients healthy for a longer time and results in less advanced events. The result did not change when combined with radiotherapy. Therefore, the treatment of intravenous GCs should be recommended for active moderate to severe GO patients as suggested by the consensus made by EUGOGO. A few trials explored the optimal regimen of GCs, and the intermediate-dose (cumulative doses of 4.98g) and weekly protocol were recommended which however need more evidence.

In addition, it will be valuable to carry out more trails to confirm the advantage of MMF against GCs because it was proved obviously superior to GCs no matter as monotherapy or combination with GCs.

Our meta-analysis was also limited by some factors especially the small number of included studies. We used response rate, CAS, and proptosis as outcome measures. However, some studies only reported part of the outcomes. The characteristics of included studies are shown in Table 1. Most subjects recruited in the trials were active moderate to severe GO patients; therefore, the result of our analysis should be more suitable for this kind of patients. The quality of trails is summarized in Table 2. All of the trials were randomized controlled trails, but study Kahaly1986 was assigned on the basis of the year of birth, which would contribute to the inadequate allocation and the bias of study. What is more, the different dosage of GCs between studies comparing the GCs with other monotherapies can also bring the bias. Last, the number of RCTs was too small to support another drug as substitution for GCs or to guide the ideal regimen of GCs.

5. Conclusion

Our meta-analysis confirmed the effects of GCs in the management of GO and intravenous GCs is proved to be better than oral GCs as ever reported. Combination of radiotherapy and GCs did not show extra effects compared with GCs alone. However, if proptosis is the main issue, combination of 99Tc-MDP or cyclosporine with GCs may be taken into consideration. Recently, there have not been any suitable drugs for substitution of GCs; however, the reported advantage of mycophenolate mofetil over GCs is noteworthy and needs more RCTs to confirm.

Data Availability

The data used to support the findings of this study are included within the article.

Disclosure

The funding sponsors had no role in the design of the study; in the collection, analyses, or interpretation of data; in the writing of the manuscript; and in the decision to publish the results.

Conflicts of Interest

The authors declare no conflicts of interest.

Authors’ Contributions

Hongmei Zhang and Xiaofang Tu conceived and designed the experiments. Xiaofang Tu, Hongmei Zhang, and Yan Dong performed the experiments. Qing Su contributed to project administration. Xiaofang Tu contributed to writing-original draft preparation. Hongmei Zhang and Qing su contributed to writing-review.

Acknowledgments

This work was supported by the National Natural Science Foundation of China (81300642).

Supplementary Materials

S1 Strategy: the search strategy. S2 Diagram: the selection process of eligible randomized controlled trails. S3 Side-effects: the adverse events and additional treatments during follow-up period. (Supplementary Materials)

References

  1. Y. Hiromatsu, H. Eguchi, J. Tani, M. Kasaoka, and Y. Teshima, “Graves' ophthalmopathy, Graves' disease, epidemiology, prevalence, ethnicity,” Internal Medicine, vol. 53, no. 5, pp. 353–360, 2014. View at: Publisher Site | Google Scholar
  2. L. Bartalena, L. Baldeschi, K. Boboridis et al., “The 2016 European Thyroid Association/European Group on Graves' Orbitopathy Guidelines for the Management of Graves' Orbitopathy,” European Thyroid Journal, vol. 5, no. 1, pp. 9–26, 2016. View at: Publisher Site | Google Scholar
  3. J. M. Glanville, C. Lefebvre, J. N. V. Miles, and J. Camosso-Stefinovic, “How to identify randomized controlled trials in MEDLINE: Ten years on,” Journal of the Medical Library Association, vol. 94, no. 2, pp. 130–136, 2006. View at: Google Scholar
  4. N. Minakaran and D. G. Ezra, “Rituximab for thyroid-associated ophthalmopathy,” Cochrane Database of Systematic Reviews, vol. 2013, no. 5, Article ID Cd009226, 2013. View at: Google Scholar
  5. J. A. Walters, D. J. Tan, C. J. White, P. G. Gibson, R. Wood-Baker, and E. H. Walters, “Systemic corticosteroids for acute exacerbations of chronic obstructive pulmonary disease,” The Cochrane Database of Systematic Reviews, Article ID Cd001288, 2014. View at: Google Scholar
  6. S. P. Hozo, B. Djulbegovic, and I. Hozo, “Estimating the mean and variance from the median, range, and the size of a sample,” BMC Medical Research Methodology, vol. 5, article 13, 2005. View at: Publisher Site | Google Scholar
  7. S. J. Lee, T. H. T. Rim, S. Y. Jang et al., “Treatment of upper eyelid retraction related to thyroid-associated ophthalmopathy using subconjunctival triamcinolone injections,” Graefe's Archive for Clinical and Experimental Ophthalmology, vol. 251, no. 1, pp. 261–270, 2013. View at: Publisher Site | Google Scholar
  8. R. J. van Geest, I. V. Sasim, H. P. F. Koppeschaar et al., “Methylprednisolone pulse therapy for patients with moderately severe Graves' orbitopathy: a prospective, randomized, placebo-controlled study,” European Journal of Endocrinology, vol. 158, no. 2, pp. 229–237, 2008. View at: Publisher Site | Google Scholar
  9. M. F. Prummel, M. P. Mourits, L. Blank, A. Berghout, L. Koornneef, and W. M. Wiersinga, “Randomised double-blind trial of prednisone versus radiotherapy in Graves' ophthalmopathy,” The Lancet, vol. 342, no. 8877, pp. 949–954, 1993. View at: Publisher Site | Google Scholar
  10. M. Salvi, G. Vannucchi, N. Currò et al., “Efficacy of B-cell targeted therapy with rituximab in patients with active moderate to severe graves' orbitopathy: a randomized controlled study,” The Journal of Clinical Endocrinology & Metabolism, vol. 100, no. 2, pp. 422–431, 2015. View at: Publisher Site | Google Scholar
  11. G. Savino, E. Mandarà, M. Gari, R. Battendieri, S. M. Corsello, and A. Pontecorvi, “Intraorbital injection of rituximab versus high dose of systemic glucocorticoids in the treatment of thyroid-associated orbitopathy,” Endocrine Journal, vol. 48, no. 1, pp. 241–247, 2014. View at: Publisher Site | Google Scholar
  12. M. F. Prummel, M. P. Mourits, A. Berghout et al., “Prednisone and Cyclosporine in the Treatment of Severe Graves' Ophthalmopathy,” The New England Journal of Medicine, vol. 321, no. 20, pp. 1353–1359, 1989. View at: Publisher Site | Google Scholar
  13. F. J. da Cunha Stamato, R. M. de Barros Maciel, P. G. Manso et al., “Colchicine in the treatment of the inflammatory phase of graves' ophthalmopathy: a prospective and randomized trial with prednisone,” Arquivos Brasileiros de Oftalmologia, vol. 69, no. 6, pp. 811–816, 2006. View at: Publisher Site | Google Scholar
  14. G. Kahaly, S. Pitz, W. Müller-Forell, and G. Hommel, “Randomized trial of intravenous immunoglobulins versus prednisolone in Graves' ophthalmopathy,” Clinical & Experimental Immunology, vol. 106, no. 2, pp. 197–202, 1996. View at: Publisher Site | Google Scholar
  15. X. Ye, X. Bo, X. Hu et al., “Efficacy and safety of mycophenolate mofetil in patients with active moderate-to-severe Graves’ orbitopathy,” Clinical Endocrinology, vol. 86, no. 2, pp. 247–255, 2017. View at: Publisher Site | Google Scholar
  16. A. W. C. Kung, J. Michon, K. S. Tai, and F. L. Chan, “The effect of somatostatin versus corticosteroid in the treatment of Graves' ophthalmopathy,” Thyroid, vol. 6, no. 5, pp. 381–384, 1996. View at: Publisher Site | Google Scholar
  17. G. Kahaly, J. Schrezenmeir, U. Krause et al., “Ciclosporin and prednisone v. prednisone in treatment of Graves' ophthalmopathy: a controlled, randomized and prospective study,” European Journal of Clinical Investigation, vol. 16, no. 5, pp. 415–422, 1986. View at: Publisher Site | Google Scholar
  18. G. Kahaly, W. Lieb, W. Muller-Forell et al., “Ciamexone in endocrine orbitopathy. A randomized double-blind, placebo-controlled study,” Acta Endocrinologica, vol. 122, no. 1, pp. 13–21, 1990. View at: Publisher Site | Google Scholar
  19. R.-Q. Chen, C.-R. Guan, and L. Ding, “Safety and efficacy of technetium-99 methylene diphosphate combined with glucocorticoid for Graves ophthalmopathy,” International Eye Science, vol. 16, no. 4, pp. 716–718, 2016. View at: Google Scholar
  20. G. J. Kahaly, M. Riedl, J. Konig et al., “Mycophenolate plus methylprednisolone versus methylprednisolone alone in active, moderate-to-severe graves' orbitopathy (mingo): A randomised, observer-masked, multicentre trial,” The Lancet Diabetes & Endocrinology, vol. 6, no. 4, pp. 287–298, 2018. View at: Google Scholar
  21. C. M. Ng, H. K. L. Yuen, K. L. Choi et al., “Combined orbital irradiation and systemic steroids compared with systemic steroids alone in the management of moderate-to-severe Graves' ophthalmopathy: A preliminary study,” Hong Kong Medical Journal, vol. 11, no. 5, pp. 322–330, 2005. View at: Google Scholar
  22. A. Pinchera, C. Marcocci, L. Bartalena et al., “Orbital cobalt radiotherapy and systemic or retrobulbar corticosteroids for graves’ ophthalmopathy,” Hormone Research in Paediatrics, vol. 26, no. 1-4, pp. 177–183, 1987. View at: Publisher Site | Google Scholar
  23. R. Rajendram, P. N. Taylor, V. J. Wilson et al., “Combined immunosuppression and radiotherapy in thyroid eye disease (CIRTED): a multicentre, 2×2 factorial, double-blind, randomised controlled trial,” The Lancet Diabetes & Endocrinology, vol. 6, no. 4, pp. 299–309, 2018. View at: Publisher Site | Google Scholar
  24. A. Roy, D. Dutta, S. Ghosh, P. Mukhopadhyay, S. Mukhopadhyay, and S. Chowdhury, “Efficacy and safety of low dose oral prednisolone as compared to pulse intravenous methylprednisolone in managing moderate severe Graves' orbitopathy: A randomized controlled trial,” Indian Journal of Endocrinology and Metabolism, vol. 19, no. 3, pp. 351–358, 2015. View at: Publisher Site | Google Scholar
  25. P. E. Macchia, M. Bagattini, G. Lupoli, M. Vitale, G. Vitale, and G. Fenzi, “High-dose intravenous corticosteroid therapy for Graves' ophthalmopathy,” Journal of Endocrinological Investigation, vol. 24, no. 3, pp. 152–158, 2001. View at: Publisher Site | Google Scholar
  26. E. Akarsu, H. Buyukhatipoglu, Ş. Aktaran, and N. Kurtul, “Effects of pulse methylprednisolone and oral methylprednisolone treatments on serum levels of oxidative stress markers in Graves' ophthalmopathy,” Clinical Endocrinology, vol. 74, no. 1, pp. 118–124, 2011. View at: Publisher Site | Google Scholar
  27. Ş. Aktaran, E. Akarsu, I. Erbaǧci, M. Araz, S. Okumuş, and M. Kartal, “Comparison of intravenous methylprednisolone therapy vs. oral methylprednisolone therapy in patients with Graves' ophthalmopathy,” International Journal of Clinical Practice, vol. 61, no. 1, pp. 45–51, 2007. View at: Publisher Site | Google Scholar
  28. G. J. Kahaly, S. Pitz, G. Hommel, and M. Dittmar, “Randomized, single blind trial of intravenous versus oral steroid monotherapy in graves' orbitopathy,” The Journal of Clinical Endocrinology & Metabolism, vol. 90, no. 9, pp. 5234–5240, 2005. View at: Publisher Site | Google Scholar
  29. R. Kauppinen-Mäkelin, A. Karma, E. Leinonen et al., “High dose intravenous methylprednisolone pulse therapy versus oral prednisone for thyroid-associated ophthalmopathy,” Acta Ophthalmologica Scandinavica, vol. 80, no. 3, pp. 316–321, 2002. View at: Publisher Site | Google Scholar
  30. Y. He, K. Mu, R. Liu, J. Zhang, and N. Xiang, “Comparison of two different regimens of intravenous methylprednisolone for patients with moderate to severe and active Graves’ ophthalmopathy: A prospective, randomized controlled trial,” Endocrine Journal, vol. 64, no. 2, pp. 141–149, 2017. View at: Publisher Site | Google Scholar
  31. W. Zhu, L. Ye, L. Shen et al., “A prospective, randomized trial of intravenous glucocorticoids therapy with different protocols for patients with Graves' ophthalmopathy,” The Journal of Clinical Endocrinology & Metabolism, vol. 99, no. 6, pp. 1999–2007, 2014. View at: Publisher Site | Google Scholar
  32. L. Bartalena, G. E. Krassas, W. Wiersinga et al., “Efficacy and safety of three different cumulative doses of intravenous methylprednisolone for moderate to severe and active Graves' orbitopathy,” The Journal of Clinical Endocrinology & Metabolism, vol. 97, no. 12, pp. 4454–4463, 2012. View at: Publisher Site | Google Scholar
  33. C. Marcocci, L. Bartalena, M. L. Tanda et al., “Comparison of the effectiveness and tolerability of intravenous or oral glucocorticoids associated with orbital radiotherapy in the management of severe Graves' ophthalmopathy: results of a prospective, single-blind, randomized study,” The Journal of Clinical Endocrinology & Metabolism, vol. 86, no. 8, pp. 3562–3567, 2001. View at: Publisher Site | Google Scholar
  34. A. A. Alkawas, A. M. Hussein, and E. A. Shahien, “Orbital steroid injection versus oral steroid therapy in management of thyroid-related ophthalmopathy,” Clinical & Experimental Ophthalmology, vol. 38, no. 7, pp. 692–697, 2010. View at: Publisher Site | Google Scholar
  35. R. Philip, S. Saran, M. Gutch, P. Agroyia, R. Tyagi, and K. Gupta, “Pulse dexamethasone therapy versus pulse methylprednisolone therapy for treatment of Gravess ophthalmopathy,” Indian Journal of Endocrinology and Metabolism, vol. 17, no. 7, p. 157, 2013. View at: Publisher Site | Google Scholar
  36. P. Mou, L. Jiang, Y. Zhang et al., “Common Immunosuppressive Monotherapy for Graves’ Ophthalmopathy: A Meta-Analysis,” PLoS ONE, vol. 10, no. 10, p. e0139544, 2015. View at: Publisher Site | Google Scholar
  37. H. Stiebel-Kalish, E. Robenshtok, M. Hasanreisoglu, D. Ezrachi, I. Shimon, and L. Leibovici, “Treatment modalities for Graves' ophthalmopathy: systematic review and metaanalysis,” The Journal of Clinical Endocrinology & Metabolism, vol. 94, no. 8, pp. 2708–2716, 2009. View at: Publisher Site | Google Scholar
  38. G. Gao, J. Dai, Y. Qian, and F. Ma, “Meta-analysis of methylprednisolone pulse therapy for Graves' ophthalmopathy,” Clinical & Experimental Ophthalmology, vol. 42, no. 8, pp. 769–777, 2014. View at: Publisher Site | Google Scholar

Copyright © 2018 Xiaofang Tu et al. This is an open access article distributed under the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.


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