FIG. 5.

Overview of the management of TED. An individualized approach to the management of TED, based on disease activity, severity, duration, trend across time, impact of the disease on daily living, treatment goals, patient age, and comorbidities, as well as the availability and relative costs of therapies, must be advised. Wherever possible, the task force members ranked therapeutic approaches as either “preferred,” “acceptable,” or “may be considered” (see Section 2.1. for definitions). ¹See Figure 1. ²Except for the mildest cases improving with local measures. ³See Table 8. ⁴In most patients with mild TED, a “watchful monitoring” strategy is sufficient (it includes simple measures, see Section 5.1 and Fig. 1). Selected cases (with a significant decrease in QOL) may be treated as moderate-to-severe TED. ⁵In patients with symptomatic inflammatory soft tissue involvement or if radioactive iodine is used (oral glucocorticoids prophylaxis). ⁶Particularly in countries that are selenium insufficient. ⁷Standard treatment—IVGC (cumulative dose 4.5 g). ⁸In selected patients, a higher cumulative dose of methylprednisolone (7.5 g) may be considered. ⁹In patients with prominent soft tissue involvement and diplopia. ¹⁰In patients with a short duration of TED (< 9 months). ¹¹In patients who are intolerant or resistant to IVGC. ¹²In selected patients with moderate-to-severe TED, a “watchful monitoring” strategy may be acceptable. ¹³See Section 7.3.2, and Supplementary Figure S2a, b. ¹⁴If there is coexistent active disease, then medical treatment as for moderate-to-severe disease is indicated in parallel with surgical treatment. ¹⁵High doses of IVGC (500–1000 mg of methylprednisolone) for 3 consecutive days or on alternate days during the first week. IVGC, intravenous glucocorticoid.