With multiple viable treatments for Graves ophthalmopathy, this network meta-analysis performed on existing research asks what the most efficient and tolerable treatments are.
Study design
The authors searched a number of databases for randomized controlled trials investigating Graves ophthalmopathy treatments. Thirty-three studies with 1,846 patients were included. A network meta-analysis was performed to comprehensively compare the efficacy and tolerability of different interventions for active and moderate to severe disease. Sensitivity analyses were also conducted.
Outcomes
Compared with no treatment, patients showed significant improvement with various treatment strategies: orbital radiotherapy plus IV glucocorticoids, mycophenolate mofetil, oral glucocorticoids plus cyclosporine, IV glucocorticoids plus mycophenolate, teprotumumab, orbital radiotherapy plus oral glucocorticoids, rituximab, somatostatin analogues, oral glucocorticoids plus azathioprine, and IV glucocorticoids showed significantly better improvement than no treatment. Radiotherapy plus IV glucocorticoids ranked first, followed by mycophenolate mofetil. All treatment regimens, with the exception of oral glucocorticoids plus azathioprine, seemed to be as tolerable as no treatment. These results were consistent with previous meta-analyses.
Limitations
This is a network meta-analysis, comparing many different studies with different measurements, interventions, time periods and endpoints. As such, these findings are limited by those variations. Most randomized controlled trials recruited patients who were euthyroid at enrollment, and only 1 study investigated patients with Graves who all had hyperthyroidism. Thus, the current evidence may not be applicable to patients with Graves and thyroid dysfunction.
Clinical significance
Currently, there are a multitude of proven successful treatments for Graves ophthalmopathy. These treatments differ in many ways with regards to route of administration, duration of treatment, and cost. Unfortunately, most of the studies compared the individual treatment with placebo. Ideally, a prospective, randomized, case-controlled trial comparing the most promising treatments should be undertaken at some point. Until then, we will be dependent on meta-analyses to attempt to answer the question of the most effective and tolerable treatment for Graves.