Orbital decompression versus teprotumumab for the treatment of chronic Thyroid Eye Disease. And the winner is?
Author: Arnaud Martel
Base Hospital / Institution: University Hospital of Nice, France
ePoster presentation
Abstract ID: 24-113
Purpose
Last year, at the 41st ESOPRS Congress in Naples, we learned 3 things about teprotumumab. First, teprotumumab was officially approved by the FDA in the US for the treatment of chronic Thyroid Eye Disease (TED). Second, about 70 minutes of the conference was devoted to promoting IGF1-R antagonists while a single 5-minute presentation (by myself) attempted to introduce some nuance and criticism on the routine prescription of IGF1-R antagonists. Third, the 2 main sponsors of the conference were the anti-IGF1-R industry. According to the author, it is essential to critically address the exact place of teprotumumab in chronic TED based on the recent literature.
Methods
Literature review and critical analysis by an independant academic practitioner.
Results
1- teprotumumab is the only FDA-approved treatment for chronic TED and has been proposed as the gold standard by several authors in the literature and in several conferences. From a philosophical point of view, it is questionable whether a treatment can become the gold standard without being compared to the historical treatment (i.e. orbital decompression).
2- In a retrospective study of 31 patients with chronic TED, the authors found that teprotumumab reduced proptosis by 3.5 mm. When reading the article, about half of the patients had a CAS = 3 and would have been considered active TED in Europe. I said in Naples that these results were overestimated. At the end of 2023, an industrial clinical trial in patients with chronic TED with CAS ≤ 1 found that teprotumuab improved proptosis by only 2.41 mm compared to 0.92 mm in the placebo group. Overall the difference was 1.49mm. if the price of 8 injections is $350,000, 1 mm of proptosis reduction costs $243,000.
3- In a retrospective study of 119 patients, recurrence of proptosis occurred in 75% of patients within 1 year of teprotumumab discontinuation.
4- Oculomotor disorders were not clinically improved
5- ototoxicity
Conclusion
Orbital decompression remains the gold standard, although teprotumumab has several useful indications such as inoperable patients and residual proptosis despite maximal decompression
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