High dose intravenous methylprednisolone (IVMP) is the current recommended first-line treatment of active thyroid eye disease (TED) based on EUGOGO guidance. We present outcomes of an alternative management of moderate-to-severely active TED, using steroid-sparing agents (SSAs) in conjunction with IVMP. Methotrexate is used as the first-line SSA alongside ciclosporin and rituximab depending on activity.

Retrospective, 4-year, single-centre, consecutive case series of moderate-to-severe TED patients treated using the Oxford protocol. Treatment modality, TED activity (based on VISA classification) and adverse effects are reported at initial presentation, 6 and 12 month follow-up.

104 consecutive TED patients case notes were reviewed.24 patients with moderate-to-severely active disease were identified with a mean pre-treatment VISA activity score of 5.5/10 (SD=1.98;range 1-9). IVMP and SSAs was commenced in all patients. Mean total IVMP dose was 2.7g (SD=1.4;1.0-6.9). 38% of patients received 1.5g of IVMP or less. Only 2 patients required >4.5g IVMP equating to the EUGOGO protocol dose for this patient group. There was significant improvement in VISA activity score both at intermediate visit (mean score 2.7;SD=2.8;p<0.001; mean follow up 25.2 weeks) and at one year/last follow up (mean score 1.4;SD=1.5;p<0.001;mean 48.0 weeks). Methotrexate was stopped in 3 patients due to a non-specific chronic cough, deranged liver function or nausea. No serious adverse effects were reported.

The initiation of an SSA with limited adjuvant IVMP is as an effective and safe therapy for moderate-to-severely active TED, resulting in reduction of disease activity as well as the total steroid load.