NEW YORK (Reuters Health) – The response rate to high-dose pulsed intravenous glucocorticoid therapy is about 80% for patients with active Graves’ orbitopathy, German clinicians report. However, they caution that potential for major adverse effects necessitates careful patient selection.

Writing in the February issue of the Journal of Clinical Endocrinology and Metabolism, online January 14, Dr. George J. Kahaly and colleagues at Gutenberg University Medical Center, Mainz, review current information on the “controversial” first-line treatment for active, moderate-to-severe Graves’ orbitopathy with high-dose IV glucocorticoid pulses.

In their introduction, the authors stress that glucocorticoid therapy can only be expected to be effective in active orbitopathy, not in patients who may have severe but inactive fibrotic disease. That may explain why 20%-25% of patients do not respond.

Oral glucocorticoids are effective and widely used for Graves’ orbitopathy, but “intravenous glucocorticoids have a statistically significant advantage over oral treatment,” the investigators point out. “However, major side effects related to preexisting diseases, administered dose, and treatment schedule have been reported. The morbidity and mortality of iv glucocorticoid therapy are 6.5 and 0.6%, respectively.”

Specifically, they advise that patients should be screened for recent hepatitis, liver dysfunction, cardiovascular morbidity, severe hypertension, inadequately managed diabetes, and glaucoma before IV glucocorticoid administration.

Intravenous glucocorticoids should preferably be administered in centers with appropriate expertise, Dr. Kahaly and colleagues suggest. “The currently recommended treatment for patients with active and moderate to severe Graves’ orbitopathy is a course of 0.5 g of methylprednisolone IV once weekly for 6 wk, followed by 0.25 g/wk for 6 wk (cumulative dose, 4.5 g).”

The total cumulative dose should not exceed 8 g, the authors advise. Their paper includes a recommended algorithm for IV glucocorticoid treatment in active and severe Graves orbitopathy.

J Clin Endocrinol Metab 2011;96.