Treatment of Factitious Hyperthyroidism with Moderate to Severe Active Thyroid Eye Disease (CAS ≥ 3)
This protocol covers factitious hyperthyroidism in patients with moderate to severe Graves' orbitopathy (thyroid eye disease) in its active phase, defined by a Clinical Activity Score (CAS) of 3 or above.
Clinical Scenario
Thyroid eye disease severity is classified into three categories — mild, moderate to severe, and sight-threatening — each guiding a distinct therapeutic strategy. Activity is established with the Clinical Activity Score; a CAS of 3 or above identifies the active inflammatory phase in which targeted treatment has the greatest impact.
Treatment Approach
References
DOI: 10.1089/thy.2016.0229
- The tool grades the severity of thyroid eye disease into 3 categories mild, moderate to severe, and sight threatening thyroid eye disease and is a useful tool for directing therapy.
- Thyroid orbitopathy is considered active in patients with a CAS ≥ 3.
- Rapid correction of hyperthyroidism with anti-thyroid drugs.
- Intravenous steroid i.e. 4.5g methylprednisolone (IVMP) given in 12 weekly infusions (0.5g weekly X 6 weeks followed by 0.25g weekly for an additional 6 weeks) is indicated.
- The cumulative dose of intravenous methylprednisolone should not be more than 8g.
- In the case of use of oral glucocorticoids, treatment should be with prednisolone 60mg-100mg daily, gradually tapered down by 5–10 mg/week until withdrawal in 3 months.
- Local subconjunctival/periocular injections of triamcinolone acetate may be considered when systemic glucocorticoids are absolutely contraindicated.