Hashimoto’s Thyroiditis Associated Thyroid Eye Disease:A Success Story of Teprotumumab

Background: Thyroid-associated eye disease is more common in patients with Graves’ disease. However, patients with Hashimoto’s may also be affected by thyroid-associated eye disease in up to 6% of patients. Clinical Case: 44 year old female patient with history of Hashimoto’s thyroiditis presented to the clinic for her hypothyroidism and evaluation of thyroid eye disease. The patient was experiencing episodes of bilateral and unilateral inflammation of her eyes described as redness, dryness, bulging of the eyes. She was evaluated by ophthalmology and was diagnosed with thyroid eye disease and was prescribed a course of steroids with partial improvement of the symptoms. Orbital MRI was ordered and it showed symmetrical enlargement of the inferior rectus muscles bellies bilaterally with the left being slightly more enlarged than the right, retro orbital fat pad was grossly inflamed. TPO was elevated,TSI and TRAb were negative. Patient continued to have frequent flare ups with suboptimal response to steroid therapy. A discussion about starting Teprotumumab was made due to lack of optimal response to steroids and worsening of her symptoms and therapy was started. Patient did develop significant hyperglycemia, but she did not have recurrent flare ups. Studies have found that Thyroid-associated eye disease was present in up to (6%) of Hashimoto’s thyroiditis patients, those with thyroid-associated eye disease tended to be older, have a longer duration of Hashimoto’s thyroiditis, heavy smokers, and were less likely to present with another associated autoimmune disease. TSAb was positive in 5.5% in the patients with Hashimoto’s and thyroid-associated eye disease. Teprotumumab ([IGF-1] receptor inhibitor) was approved for the treatment of Graves’ orbitopathy by the (FDA) in 2020. Conclusion: Hashimoto’s thyroiditis associated thyroid eye disease is a rare clinical presentation. Teprotumumab is a new FDA approved treatment for thyroid eye disease that was successful in treating the symptoms and prevented flare ups in this patient. Careful monitoring of side effects is recommended. References: Kahaly GJ et al Thyroid stimulating antibodies are highly prevalent in Hashimoto’s thyroiditis and associated orbitopathy. J Clin Endocrinol Metab. March 10, 2016\Krassas GE, Wiersinga WM. - Thyroid eye disease: current concepts and the EUGOGO perspective. Thyroid International. 2005;4:3–4. Teprotumumab for Thyroid-Associated Ophthalmopathy. Smith TJ, Kahaly GJ, Ezra DG, Fleming JC, Dailey RA, Tang RA, Harris GJ, Antonelli A, Salvi M, Goldberg RA, Gigantelli JW, Couch SM, Shriver EM, Hayek BR, Hink EM, Woodward RM, Gabriel K, Magni G, Douglas RS SO N Engl J Med. 2017;376(18):1748.