TED Immunosuppression advice during Covid-19
Every TED patient needs to be managed on a case by case basis. These recommendations are not prescriptive but based on collective multidisciplinary experience.
Intravenous methyl prednisolone therapy is generally not recommended for treating moderate to severe thyroid eye disease during the COVID19 pandemic. These patients will be at risk of severe suppression of their immune system and it is vital to avoid unnecessary hospital visits for this vulnerable group.
Where feasible patients who, under normal circumstances, would have had intravenous methylprednisolone should be switched to oral prednisolone in order to adequately shield them. The recommended dose of oral prednisolone is greater than 20mg/day for longer than 4 weeks in unilateral / bilateral sight threatening disease. Bloods can be done at the GP surgery within the shielding protocol.
Whilst oral prednisolone may be required, it has been shown in peer reviewed literature that oral prednisolone is less effective and more likely to cause side effects and thus should only be considered for severe (e.g. severe constant diplopia) or sight threatening disease and avoided in moderate disease.
Home administration of 3 cycles of IVMP in line with strict shielding protocols, subject to availability of this service.
To identify a ‘safe’ unit within the hospital where IVMP can be administered.
The use of local orbital steroids can be considered as sole treatment or in conjunction with other therapeutic agents in moderate to severe disease
Ongoing review by regular virtual consultations and documented review of their blood results is recommended.
Urgent decompression surgery should be available for sight threatening disease. In these patients, consider decompressing lateral wall instead of medial wall to limit aerosol exposure.
Orbital Radiotherapy (OR) for patients with severe / sight threatening disease and no contra-indications should be considered as the first choice second line treatment (depending on time frame and OR availability)
Management of moderate thyroid eye disease;
Steroid therapy should be delayed by commencing second line treatment as per local protocols and patients followed up by regular virtual review.
Patients already on second line immune suppression should continue on their current dose, as long as there are no concurrent symptoms of infection; sudden cessation may result in a relapse which will be difficult to treat.
If the patient’s medication needs to be revised due to changes in the clinical status or abnormal blood results, then regular virtual review should be undertaken.
In the event that any patients develop symptoms of COVID, we would suggest the patient:
- Follows the standard COVID guidance
- Stops second line immunosuppression with immediate effect
- Carry the name of their immunosuppressant drug on a card with them at all times.
- Takes all possible measures to boost their immune system.
- Takes all precautions, self – isolate and maintain social distancing as recommended.
Patients should be warned of the usual red flag signs and if these develop phone the emergency number and ask for advice.
Patients should be made aware where they can safely have their regular blood tests, at a site which allows minimal exposure.