INTRAVENOUS IMMUNOGLOBULIN VERSUS CORTICOSTEROID IN TREATMENT OF GRAVES OPHTHALMOPATHY

We compared the effectiveness of systemic corticosteroids with the use of high-dose intravenous immunoglobulin (IVIG) in the treatment of Gr aves' ophthalmopathy. This was performed as a prospective, nonrandomiz ed study including a blinded ophthalmological and orbital computed tom ographic (CT) evaluation. The two groups of patients were not signific antly different in relation to sex composition, age distribution, dura tion of Graves' disease, and ophthalmopathy and previous hyperthyroidi sm. All patients were followed up by endocrinologic evaluation and bli nded ophthalmological (before therapy = B, at the end of therapy = E, and 6 months after the end = 6M) and orbital CT (B and E) evaluations. Twenty-seven patients treated with IVIG were followed up after the en d of treatment for an average of 21 months (range 12 to 48 months). So ft tissue involvement (NOSPECS) improved or disappeared in 32 of 35 (9 0%) patients treated with IVIG and in 25 of 27 (92.5%) patients treate d with corticosteroids. Diplopia improved or disappeared in 22 of 29 ( 75%) patients treated with IVIG and in 16 of 20 (80%) patients treated with corticosteroids, The results observed by clinical evaluation wer e confirmed with orbital CT score in 30 IVIG patients and in the corti costeroid-treated patients; a significant reduction of extraocular mus cle thickness was observed after treatment in both groups. Proptosis i mproved or disappeared in 20 of 31 (65%) patients treated with IVIG an d in 15 of 24 (62%) patients treated with corticosteroids. Mean values of proptosis evaluated by Hertel's exophthalmometer showed a slight r eduction both in IVIG as well as in corticosteroid-treated patients. I t is interesting to observe that in 28 IVIG-treated patients in whom i t was possible to evaluate soft tissue involvement, proptosis and dipl opia in the period between the fifth and sixth month from the start of therapy, the most important part of the amelioration (if responders) was already obtained at that time. Responder patients were defined in relation to the decrease in the highest NOSPECS class or grade. Among IVIG-treated patients 26 of 34 (76%) responded; while in the corticost eroid group 18 of 27 (66%) responded to treatment. The prevalences of patients who responded to the treatments were not significantly differ ent in the two groups (Chi-square). The initial values of the subjecti ve eye score were similar in the two groups, and a significant reducti on was observed in both. Major side effects requiring discontinuation of the corticosteroid therapy were observed in two patients with hemor rhagic gastritis and in one patient with manic-depressive psychosis. A mong 15 patients submitted to the evaluation of bone mineral content b efore and after corticosteroid therapy, 4 presented signs of osteoporo sis and 3 a reduction of bone mineral content. Moderate and minor side effects were more frequently noted in steroid-treated patients than i n the IVIG group. These data suggest that IVIG is safe and effective i n reducing the eye changes in patients with Graves' ophthalmopathy.