Background and importance Graves orbithopathy (OG) is an autoimmune disease and the most common and important manifestation of Graves disease. For patients with moderate-severe disease, initial treatment with corticosteroids is recommended. However, some off-label treatments have been used that have suggested efficacy in various cohort studies and case series, such as tocilizumab.
Aim and objectives We present the case of a 62-year-old male patient. In 2018, Ophthalmology diagnosed OG according to the criteria of the European Group on Graves Orbithopathy (EUGOGO), with greater proptosis in the left eye compared to the right eye (13–17 mm). He also presented polyarthrosis, hypercholesterolaemia and hypertension. His treatment included carbimazole, losartan, hydrochlorothiazide, loratadine and atorvastatin. Hyperthyroidism was previously treated with tiamazol.
Material and methods For the evaluation of the disease, measures such as the clinical activity score (CAS) are used. First, the patient was treated with methylprednisolone and radiotherapy without improvement. The Maxillofacial Surgery Service dismissed an intervention considering that there still remained non-invasive treatments with potential benefit. In February 2020, the Ophthalmology Service requested Pharmacy Service off-label use of tocilizumab. The Pharmacy Service carried out bibliographic research and made a report with positive assessment for approval of treatment, supported mainly by a clinical trial. Five 8 mg/kg monthly doses of tocilizumab were administered. Finally, at week 44 (after 32 weeks free of treatment) there arose the possibility of administering two extra doses.
Results A notable improvement was observed with the first five doses of tocilizumab, achieving a CAS of 2 (low disease activity), with improvement in proptosis (11–15 mm) and good tolerance. A new improvement was achieved after week 44 over the one already shown with the first five doses, and both clinical and analytical parameters (antithyroglobulin levels) improved, with a decrease in the proptosis of both eyes (10–13 mm). The patient reported a good quality of life in the GO-Quality of Life questionnaire.
Conclusion and relevance The favourable evolution of our patient is consistent with the published data. We only found one clinical trial and some case series, with different dosage of tocilizumab. There still remain doubts about the optimal duration and the possibility of re-treatment with tocilizumab. Collaboration between Ophthalmology and Pharmacy Services is crucial for the rationalisation of therapy with tocilizumab.
Conflict of interest No conflict of interest
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