broadwww.gogo.com

EditorialTheEUGOGOConsensusStatementontheManagementofGraves'Orbitopathy:EquallyApplicabletoNorthAmericanCliniciansandPatientsTheEuropeangrouponGraves'orbitopathy(EUGOGO;www.
eugogo.
org)isamultidisciplinaryconsortiumofclinicianscommittedtoimprovingtheman-agementofpatientswiththeocularcomplicationsofGraves'disease.
ThegroupdevelopedaconsensusstatementonthemanagementofGraves'orbitopathy(GO)thatwasunveiledattheannualmeetingoftheEuropeanThyroidAssociationinLeipzig,Germany,inSeptember2007,andsimultane-ouslyappearsinthisissueofThyroidandintheEuropeanJournalofEndocrinology(1).
EUGOGOistobecommendedfortheireffortsthatreectaremarkabledegreeofinterna-tionalcooperationbyacademicendocrinologistsandoph-thalmologists.
Theauthorsrefertothedocumentasa''consensusstate-ment''byexpertsintheeld,ratherthanapracticeguideline.
Thisseemsappropriate,becausewhiletheEUGOGOgroupcanbecreditedwithhavingperformedthemajorityofran-domizedcontrolledtrials(RCTs)inthisarea,theyarenotofsufcientscopetosupportformalpracticeguidelines.
De-spitethis,thedocumentistimelyandshouldproveusefultoclinicianswhomanageGOpatients.
Theauthorsrightlyanticipatethatthedocumentwill''provideafocusforauditandresearch''andaidintheidenticationoftopicsforfutureRCTs.
Theconsensusstatementisscholarlyandconcise,andtherecommendationsaregenerallyapplicabletoNorthAmeri-can,aswellasEuropean,cliniciansandpatients.
Thegradedrecommendationsareappendedinthedocument,andtheevidencesupportingeachisdiscussedindetailinthebodyofthetext.
TheapplicationoftherecommendationsrequiresthatcliniciansmustrstsegregatetheirGOpatientsinto''mild,''''moderatetosevere,''or''sight-threatening''categories,anddeterminewhetherornotthediseaseisactive.
Sufcientde-tailsareprovidedwithinthetextregardingtheassessmentofdiseaseseverityandactivitytoallowclassicationintothesebroadcategories.
EUGOGOdoesnotadvocateusinganyde-tailedgradingorscoringsystemotherthantherelativelysimple''clinicalactivityscore''andspecicocularmeasure-mentstoassesstheseverityofthedisease.
Whilethisapproachmaynotideallycaptureallfeaturesofthedisease,ithasbeenvalidatedbythegroupinnumerousclinicalstudiesandshouldserveasthegoldstandardagainstwhichotherGOclassica-tionsystemsaremeasured.
ThedocumentwillserveasanespeciallyusefultoolforclinicianswhoalreadyhavesomeexpertiseinmanagingGOpatients.
OthersnotsoexperiencedbutencounterGOpa-tientsintheirpracticeareadvisedto''referpatientswithGO,exceptforthemildestcases,tocombinedthyroid–eyeclinicsforfurtherassessmentandmanagement.
''Whichreferralsshouldbemadeurgentlyandwhicharenonurgentiscare-fullyoutlinedinthetext.
TheproblematicaspectofthisrecommendationforcliniciansinNorthAmerica,however,isthatregionalGOconsultantsarefrequentlyophthalmolo-gistswhodonotworkincombinedthyroid–eyeclinics.
OneofthemanypositiveresultsstemmingfromtheinceptionofEUGOGOhasbeenthemandatoryestablishmentofacom-binedthyroid–eyeclinicwithineachoftheEuropeanmedicalcenterwishingtoparticipateintheconsortium.
OnlythroughthistypeofcooperationcanGOpatientsbenetfromthefullrangeofexpertiseneededtounderstandandmanageallaspectsofthisperplexingdisease.
Whilethevastmajorityoftherecommendationsseemtometobequitereasonableandbasedtotheextentpossibleonpertinentliterature,Idotakeissuewiththestatementthat''thetreatmentofchoiceformoderatetosevereandactiveGOispulsesofintravenousglucocorticoids(GCs).
''WhilesevereGOmaywarrantthisapproach,IremainreluctanttorecommendivGCstopatientswithonlymoderatedisease(i.
e.
,thosehavingonlyasinglefeaturethatwouldplacetheminthe''moderatetosevere''category,orafewfeaturesmeasuringjustabovemild).
MyconcernstemsbothfromreportsoffatalacuteliverfailureinfourGOpatientsduringorfollowingcompletionofivGCtreatment(2,3),andfromthenaturalhistoryofthediseaseshowingimprovementinthemajorityof(albeitunselected)patientswithinayears'time.
Fortunately,thefrequencyofhepatotoxicityappearstobeverylow;7ofapproximately800GOpatientstreatedinItalywithivGCssufferedsevereliverdamage,ofwhom3died(3).
BecausenocaseofliverfailurehasbeenreportedinGOpatientsreceiving<8gmethylprednisolone,thecon-sensusstatementindicatesthatthecumulativedoseinonecourseshouldbelessthanthisamountandspeciesthativGCsshouldonlybeadministeredincentersexperiencedinthistherapy.
Despitethis,therisk–benetratioforivGCsinpatientswithactivediseaseofonlymoderateseveritywhomightdoequallywellwithoralsteroidsorevencarefulTHYROIDVolume18,Number3,2008MaryAnnLiebert,Inc.
DOI:10.
1089=thy.
2008.
0034281observationandfrequentreassessmentseemstometobeweightedtowardthesideofunacceptablerisk.
Insummary,theconsensusstatementbyEUGOGOisatimelyandusefuldocumentthatcanbeupdatedasadditio-nalevidencefromfutureRCTsbecomesavailable.
TheEu-ropeangroupisproceedingwithmulticentertrialsthatwillallowrecruitmentoflargenumbersofpatientsintothesestudies.
Thisconsensusstatementbringstotheforeashort-cominginthecareofGOpatientsintheUnitedStates,namely,thatmanypatientsarenotcaredforinjointthyroid–eyeclinics.
Inaddition,endocrinologists,ophthalmologists,andotherswhoseeGOpatientsinthiscountryarenotyetorganizedtoperformmulticenterRCTs.
Thereis,how-ever,activityunderwaytoincreasecooperationbetweenthesegroupsandtoestablishtheimportantinfrastructureneededtoperformlargemulticenterGOtrialsinNorthAmerica.
Finally,whileevidence-basedguidelinesorconsensusstatementscanfacilitatedecisionmaking,managementmustbeultimatelyindividualizedandfocusedontheneedsanddesiresofthepatient.
Thisrequirestheapplicationofboththeartandscienceofmedicine,anddemandsthatthecli-nicianactivelylistenstoGOpatients,manyofwhomareunderstandablyapprehensiveandfrightened.
Compassio-natecounselingofpatientshouldincludewiderangingdis-cussionsonthenatureoftheconditionanditsnaturalhistory,aswellascustomizedtreatmentoptions.
Suchanapproachislikelytoimproveoutcomesofwhatisoftenahighlydistressingdisease.
References1.
BartalenaL,BaldeschiL,DickensonA,EcksteinA,Kendall-TaylorP,MarcocciC,etal.
2007ConsensusstatementoftheEuropeanGrouponGraves'Orbitopathy(EUGOGO)onthemanagementofGraves'orbitopathy.
Thyroid18:333–346.
2.
WeisselM,HauffW2000Acuteandfatalliverfailureafterhigh-doseglucocorticoidpulsetherapyinapatientswithsevereeyedisease.
Thyroid10:521.
3.
MarinoM,MorabitoBrunetteMR,BartalenaL,PincheraA,MarcocciC2004AcuteandsevereliverdamageassociatedwithintravenousglucocorticoidpulsetherapyinpatientswithGraves'ophthalmopathy.
Thyroid14:403–406.
—RebeccaBahn,M.
D.
President,AmericanThyroidAssociationConsultantinEndocrinology,MayoClinic282BAHN