The 2016 European Thyroid Association/European Group on Graves' Orbitopathy Guidelines for the Management of Graves' Orbitopathy

TLDR

Graves' orbitopathy is the primary extrathyroidal manifestation of Graves' disease, with severe forms uncommon and current management often inadequate because therapies do not target the disease’s pathogenic mechanisms. The guideline recommends that treatment decisions be based on a comprehensive assessment of GO activity, severity, and its impact on patients’ quality of life. Management includes local measures and risk‑factor control for all patients, watchful waiting or a 6‑month selenium course for mild disease, high‑dose intravenous glucocorticoids (4.5–5 g methylprednisolone, up to 8 g for severe cases) as first‑line therapy, shared decision‑making for second‑line options, and rehabilitative surgery when conservative treatment fails.

Abstract

Graves' orbitopathy (GO) is the main extrathyroidal manifestation of Graves' disease, though severe forms are rare. Management of GO is often suboptimal, largely because available treatments do not target pathogenic mechanisms of the disease. Treatment should rely on a thorough assessment of the activity and severity of GO and its impact on the patient's quality of life. Local measures (artificial tears, ointments and dark glasses) and control of risk factors for progression (smoking and thyroid dysfunction) are recommended for all patients. In mild GO, a watchful strategy is usually sufficient, but a 6-month course of selenium supplementation is effective in improving mild manifestations and preventing progression to more severe forms. High-dose glucocorticoids (GCs), preferably via the intravenous route, are the first line of treatment for moderate-to-severe and active GO. The optimal cumulative dose appears to be 4.5-5 g of methylprednisolone, but higher doses (up to 8 g) can be used for more severe forms. Shared decision-making is recommended for selecting second-line treatments, including a second course of intravenous GCs, oral GCs combined with orbital radiotherapy or cyclosporine, rituximab or watchful waiting. Rehabilitative treatment (orbital decompression surgery, squint surgery or eyelid surgery) is needed in the majority of patients when GO has been conservatively managed and inactivated by immunosuppressive treatment.