Role of Methotrexate in Thyroid-related Orbitopathy

Objective: To report the experience of a tertiary care orbital service in treating severe active thyroid related orbitopathy with methotrexate (MTX) managed by the Ophthalmologist.

Design: Retrospective consecutive case series.

Participants: Nineteen consecutive patients (5 males and 14 females) with severe active thyroid related orbitopathy.

Methods: Severe active thyroid orbitopathy patients with partial or no response to intravenous glucocorticoids were treated with MTX and observed for inflammatory scale reduction and treatment complications.

Results: Nineteen consecutive patients (5 males and 14 females) with severe active thyroid related orbitopathy were evaluated. Mean follow-up time was 1206 days (standard deviation (SD) 576). Months passed from beginning of TRO symptoms to initiation of MTX therapy showed a mean of 12 (SD 9). After the initiation of MTX 91% of eyes demonstrated a clinically significant improvement to a VISA inflammatory scale of <3 within a mean of 189 days (SD 119); A subset of patients (29%) demonstrated a rapid response, reaching a VISA inflammatory score of <3 within 90 days. One patient (5%) discontinued the medication secondary to an adverse event (elevated liver enzymes) which normalized after discontinuation of MTX. During the follow up period 12 patients (63%) have ended their MTX treatment due to TRO inactivity; One patient (8%) developed a recurrence of inflammation after discontinuing MTX which resolved with the re-initiation of MTX treatment. Adjunctive treatments including glucocorticoids and/or external beam radiotherapy were administered to 21% of patients.

Conclusion: Our experience suggests that methotrexate managed by an Ophthalmologist is a safe and effective treatment for severe active thyroid related orbitopathy.