Adjunctive Therapies, Surgery, and Special Populations in TED

Management of thyroid eye disease (TED) may require adjunctive medical therapies and surgical intervention, particularly in patients with severe, refractory, or high-risk disease features.

In this video, Sonalika Khachikian, MD, an endocrinologist at Monument Health Hospital in South Dakota,reiterates that high-dose intravenous glucocorticoids often function as bridge therapy, providing rapid but temporary relief of inflammation. Orbital radiotherapy remains in use among some specialists but does not address the underlying disease mechanism and may contribute to scarring, limiting its role in the biologic era.

Khachikian notes that teprotumumab has reshaped this treatment landscape by offering a targeted, disease-modifying approach through IGF-1 receptor inhibition. She describes practical considerations around access and coordination for eligible patients. In contrast, older immunomodulatory agents historically used in TED were often selected due to limited alternatives and are not strongly supported by current evidence. For patients with optic nerve compression or sight-threatening disease, orbital decompression surgery remains essential, with timing guided by disease activity and multidisciplinary input.

Special populations require tailored management. In pregnancy, TED activity may fluctuate with immune changes, and teprotumumab is contraindicated, necessitating contraception for at least 6 to 12 months after treatment. In patients with diabetes mellitus, glycemic optimization is critical to reduce inflammatory burden and mitigate treatment-related hyperglycemia. Khachikian emphasizes close coordination with ophthalmology in patients with early optic neuropathy or significant orbitopathy to balance therapeutic benefit and risk.