Tocilizumab use for optic nerve compression in thyroid eye disease: a prospective longitudinal cohort.

PURPOSE: To assess the effectiveness of tocilizumab in reverting the signs and symptoms of dysthyroid optic neuropathy (DON) in thyroid eye disease and the need for emergency orbital decompression. The secondary outcomes are to identify the optimal number of tocilizumab cycles to achieve the primary outcome, to analyze the association between thyroid stimulating immunoglobulin (TSI), clinical activity score (CAS) and proptosis in response to the treatment and the need for rehabilitative orbital decompression. METHODS: Prospective longitudinal cohort study that included 13 patients who had unilateral or bilateral dysthyroid optic neuropathy (DON) due to severe and progressive sight-threatening thyroid eye disease based on the CAS system. Patients were seen in this facility starting from July 2017, and all had received intravenous tocilizumab. RESULTS: Initial visual acuity mean was 0.52 ± 0.38 and the final were 0.93 ± 0.11 with a mean difference of 0.41 and P < 0.00245. The mean CAS prior to the initiation of the treatment was 7.92 ± 0.66 and the final was 2.85 ± 1.03 with mean difference of 5.07 and P < 0.00001. Initial mean proptosis was 24.85 ± 2.31 and the final was 21.78 ± 2.18 with a mean difference of 3.07 and P < 0.000497. No emergency orbital decompression was performed. TSI was high initially in all cases with a wide range of 2.4 to 40 IU/L and with a mean of 10.70 ± 13.40. The final TSI mean was 2.90 ± 3.90 with a mean difference of 7.81 and significant P value (P < 0.0272). CONCLUSION: Tocilizumab use in optic nerve compression showed promising results as it can be the primary or an alternative treatment option.

A 46-Year-Old Woman with a 4-Year History of Graves Disease, with Severe Corticosteroid-Unresponsive Thyroid Eye Disease, Successfully Treated with Tocilizumab.

BACKGROUND Tocilizumab is a therapeutic biologic antagonist of the interleukin-6 (IL-6) receptor that has been approved to treat some autoimmune and chronic inflammatory diseases. This report is of a patient with a history of Graves disease and severe corticosteroid-unresponsive thyroid eye disease that included edema of the optic nerve and choroid, which was successfully treated with tocilizumab. CASE REPORT A 46-year-old woman with a 4-year history of Graves disease presented with acutely progressive bilateral severe optic nerve compression, severe bilateral optic nerve edema, bilateral restriction of eye movement, and bilateral choroidal folds. The patient was managed with an initial high dose of systemic steroid without any success. She then underwent bilateral orbital wall decompression without any noticeable amelioration. She subsequently received 4 doses of a tocilizumab (8 mg/kg) infusion. This resulted in a considerable decrease in inflammatory signs and improvement in optic nerve function, thereby improving her quality of life. The patient did not have any adverse reactions to the tocilizumab. CONCLUSIONS The findings from this case support recent case reports and clinical trials indicating that tocilizumab may be effective in corticosteroid-resistant thyroid eye disease associated with autoimmune hyperthyroidism.

Tocilizumab use in pediatric thyroid eye disease: First documented case.

PURPOSE: To report the first case of Tocilizumab treatment for progressive pediatric thyroid eye disease (TED) in a 9-year-old female. OBSERVATIONS: A 9-year-old female with a history of hyperthyroidism for 4 months presented with bilateral proptosis (more in the right eye) associated with retrobulbar pain, tearing, and conjunctival and caruncular redness. The exophthalmometry reading on presentation was 21mm OD and 17 mm OS. The patient was managed with observation and control of hyperthyroidism in the beginning. However, on a subsequent visit 3 months later it was observed that the symptoms and clinical findings were rapidly worsening. The exophthalmometry reading upon subsequent follow-up was 22 OD and 22 OS. After multidisciplinary team (MDT) discussions it was decided to treat the patient with four doses of 8mg/kg Tocilizumab injection on monthly basis. Notable improvement of proptosis and resolution of pain, conjunctival and caruncular redness was observed. The exophthalmometry reading 4 months after treatment was 20 OD and 19 OS. CONCLUSION AND IMPORTANCE: This case report opens an important gateway for the use of Tocilizumab in progressive TED in pediatric age groups.

Global burden of psoriasis - comparison of regional and global epidemiology, 1990 to 2017.

BACKGROUND: Psoriasis is a common disease that has not only cutaneous manifestations but also causes significant systemic illness and disability. Most epidemiological studies on the burden of psoriasis that are available in literature are regional, and thus a detailed description of the worldwide burden of psoriasis is warranted. METHODS: We analyzed the prevalence, incidence, disability adjusted life years (DALY), and years lived with disability (YLD) related to psoriasis for the period 1990 to 2017, from the Global Burden of Disease dataset (developed by the Institute of Health Metrics, University of Washington). We also searched the PubMed MEDLINE for quality of life and economic burden of psoriasis for a comprehensive evaluation of the burden of psoriasis. RESULTS: In 2017, the global age-standardized prevalence rate of psoriasis was 811 per 100,000 population, approximating to 0.84% of world population or about 64.6 million individuals. The incidence of new cases increased from 92 per 100,000 in 1990 to 99 in 2017. The highest rates were recorded in North America and Western Europe, while the lowest rates were found in Asia and Western Pacific regions. The age distribution shows a rising rate of incidence from the second decade, peaking at 55-60 years. Women are slightly more likely to be affected. CONCLUSIONS: The global incidence of psoriasis has been rising over the last three decades. The burden of the economic and psychosocial suffering caused by psoriasis calls for resource allocation and a multidisciplinary approach to address this common medical condition. KEY MESSAGE: The prevalence, incidence, and the burden of suffering caused by psoriasis have been rising over the past 17 years, despite efforts at improving diagnosis and treatment.