Kotwal Anupam, Stan Marius
Division of Endocrinology, Diabetes, Metabolism, and Nutrition, Mayo Clinic, MN, USA.
Horm Metab Res. 2018 Dec;50(12):871-886. doi: 10.1055/a-0739-8134. Epub 2018 Oct 4.
The course and pathogenesis of Graves' disease and Graves' ophthalmopathy are interdependent, influencing each other's therapeutic choices. Multiple factors including geographic location, access to medical services, patient and physician preferences influence the management of these conditions. Graves' disease is classically managed with one of three treatment options - antithyroid drugs, radioactive iodine, and thyroidectomy. In recent years, there has been a shift towards antithyroid drugs, including long term therapy with these agents, given the advantage of avoiding hypothyroidism and the apparent safety of this approach. In addition, new therapies are (slowly) emerging, focusing on immunomodulation. Technological advances are opening doors to non-pharmaceutical interventions that aim to deal with both structural thyroid abnormalities as well as biochemical abnormalities of hyperthyroidism. Graves' ophthalmopathy management is guided by its activity and severity status, with treatment options including smoking cessation, control of hyperthyroidism, local eye measures, glucocorticoids, selenium, orbital radiotherapy, and surgery. In addition to these established treatment choices, new immunotherapy-based approaches are being tested. Some of them (tocilizumab and teprotumumab) are very promising but further evaluation is needed before we can establish their role in clinical care. Agents identified as beneficial in Graves' disease management will likely be tested in Graves' ophthalmopathy as well. In the coming years, our main clinical responsibility will be to find the proper balance between the benefits and potential risks of these incoming therapies, and to identify the subgroups of patients where this ratio is most likely to favor a safe and successful therapeutic outcome.
格雷夫斯病和格雷夫斯眼病的病程及发病机制相互依存，影响着彼此的治疗选择。包括地理位置、医疗服务可及性、患者及医生偏好等多种因素会影响这些病症的管理。经典的格雷夫斯病治疗方法有三种——抗甲状腺药物、放射性碘和甲状腺切除术。近年来，鉴于避免甲状腺功能减退的优势以及这种方法明显的安全性，治疗已转向抗甲状腺药物，包括使用这些药物进行长期治疗。此外，新的疗法（正在缓慢）出现，重点是免疫调节。技术进步为旨在处理甲状腺结构异常以及甲亢生化异常的非药物干预打开了大门。格雷夫斯眼病的管理依据其活动度和严重程度状况进行指导，治疗选择包括戒烟、控制甲亢、局部眼部措施、糖皮质激素、硒、眼眶放疗和手术。除了这些既定的治疗选择外，基于免疫疗法的新方法正在进行测试。其中一些（托珠单抗和替普罗单抗）非常有前景，但在确定它们在临床治疗中的作用之前还需要进一步评估。在格雷夫斯病管理中被确定为有益的药物也可能会在格雷夫斯眼病中进行测试。在未来几年，我们的主要临床责任将是在这些新疗法的益处和潜在风险之间找到适当的平衡，并确定最有可能使治疗结果安全且成功的患者亚组。
