Comparison of the 2021 EUGOGO guidelines and the 2022 ATA/ETA consensus statement for the management of Graves’ orbitopathy

The two documents show a high degree of concordance as to classification, assessment, and prevention, as well as treatment of mild GO, moderate-to-severe and inactive GO, and sight-threatening GO. The major disagreement regards treatment of moderate-to-severe and active GO. The EUGOGO guidelines, written when teprotumumab was not available outside the USA, indicate intravenous glucocorticoids (IVGC) (with/without mycophenolate) as the first-line treatment, whereas the ATA/ETA consensus statement indicates teprotumumab as the first-line treatment for virtually all phenotypes of moderate-to-severe and active GO, particularly when exophthalmos is predominant. However, also in the ATA/ETA consensus statement, IVGC are the preferred treatment when the goal is GO inactivation and resolution of inflammation, and among the preferred treatments (in combination with orbital radiotherapy) when the goals are inactivation and correction of eye dysmotility. Recent developments to be considered in future revisions of the guidelines/consensus statement include the possible use of biologicals (teprotumumab and tocilizumab) for dysthyroid optic neuropathy, treatment of longstanding inactive GO with teprotumumab, reconsideration of the cautious use of radioactive iodine in patients with moderate-to-severe and active GO concomitantly treated with IVGC (with/without orbital radiotherapy), and use of statins as an adjunct therapy.