Endocrine Abstracts

Introduction: Graves’ ophthalmopathy (GO) is an autoimmune disorder that constitutes a major clinical and therapeutic challenge. Current treatment options for moderate-to-severe GO include immunotherapy, orbital radiotherapy and decompression surgery. Limited drugs of proven efficacy are available for the treatment of people with GO. Given the role in the pathogenesis of GO of interleukin (IL)-6 expression in adipocytes, fibroblasts and macrophages, the proposed theory is that inhibition of IL-6 by tocilizumab may be an effective treatment in GO by directly reducing the inflammatory response. We report a case of severe GO treated with tocilizumab. Efficacy and safety of the therapy is discussed.

Case report: A 48-year-old woman, former smoker and diagnosed with Graves’ hyperthyroidism was referred by Ophthalmology Department to Internal Medicine Unit because of corticoid-resistant GO. She had been diagnosed with hyperthyroidism ten years ago and undergone thyroid radio ablation therapy at the onset of her disease, reaching euthyroidism since then. At the time of our evaluation, the patient had no general symptoms of thyroid disease. A biochemical profile including thyroid hormones was also normal. She presented with bilateral eyelid swelling, orbital pain, redness and tearing. Her Clinical Activity Score (CAS) was 5 out of 7. She previously received bolus of methylprednisolone with a weak response. A magnetic resonance imaging orbits scan showed intense gadolinium-enhanced images and enlargement of the extraocular muscles, more prominent of the medial and lateral recti muscles in both orbits. The patient rejected radiotherapy. ‘Off-label’ authorization for the use of tocilizumab was asked to Pharmacy Commission of our centre. After its approbation, she received tocilizumab 8 mg/kg monthly. Three months later, the patient was well, no side effect was documented and her CAS was 1 out of 7.

Conclusions: This clinical report confirm the relative efficacy and tolerability profile of intravenous tocilizumab in severe or corticosteroid-resistant GO.