Table 4.

A summary of the posology, advantages, and disadvantages of current immunosuppressive and glucocorticoids used to treat thyroid eye disease.

Treatment	Posology	Advantages	Disadvantages	References
First-line treatments
Intravenous Methylprednisolone (IVMP)	EUGOGO Regimen ▪6 weekly infusions of 500 mg ▪In moderate to severe disease, an additional 6 weekly infusions of 250 mg ▪Doses can be adjusted between 4.5 and 7.5 g/cycle according to severity	▪Gold standard: effectively controls disease activity. ▪Induces rapid anti-inflammatory response ▪Higher response rates compared to oral prednisone ▪Well tolerated with fewer reported serious adverse effects compared to oral steroids	▪IV administration ▪Safety concerns with cumulative high doses (>8 g per cycle) ▪Monitoring for adverse events, including arrhythmias, hyperglycemia, infections, etc. ▪Requires gastric and bone protection	[97,98,99,100,101]
Oral Prednisone	▪0.5 to 1 mg/kg/day tapered based on response ▪Lowest effective dose over prolonged periods	▪Oral administration ▪Effective in mild to moderate TED	▪Slower onset of action ▪Higher risk of systemic adverse effects than IVMP	[102]
Second-line treatments
Azathioprine	▪Initial dose of 1 to 2 mg/kg/day orally, in combination with radiotherapy or corticosteroids	▪Can reduce risk of relapse following steroid taper ▪Beneficial outcomes in combination with glucocorticoids	▪Only effective as a combination therapy ▪Adverse effects: bone marrow suppression, nausea, vomiting	[103,104,105]
Cyclosporine	▪2 to 5 mg/kg/day orally in combination with prednisone	▪Fast onset of action ▪Effective in combination therapy with prednisone	▪Narrow therapeutic index requiring therapeutic drug monitoring ▪Serious adverse effects: nephrotoxicity, hypertension, neurotoxicity	[106,107,108]
Mycophenolate	▪Mycophenolate mofetil 1 g daily orally or mycophenolate sodium 0.72 g daily orally for 24 weeks in combination with IVMP	▪Improved clinical outcomes when used in combination with IVMP ▪Less severe adverse effects than corticosteroids	▪Requires monitoring for gastrointestinal disturbances and systemic adverse effects ▪Lack of long-term data	[2]
Sirolimus	▪2 mg orally on Day 1 followed by 0.5 mg/day for 12 weeks	▪Superior response rate compared to IVMP in moderate-to-severe TED ▪Anti-fibrotic properties in renal and pulmonary transplant patients	▪Significant adverse effect profile requiring careful monitoring	[109]
Methotrexate	▪Typically initiated at 7.5 to 10 mg orally weekly	▪Effective in reducing inflammation by suppressing lymphocytes ▪Promising results in combination with glucocorticoids for sight-threatening TED	▪Lack of robust randomized controlled trials (RCTs) limits evidence of efficacy ▪Potential adverse effects include fatigue, nausea, and hair loss	[110,111,112]