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Graves Ophthalmopathy (GO) is a complex condition with the potential for significant visual disability. The EUGOGO consensus for first line treatment in active moderate/severe disease is 12 once weekly course of intravenous steroids (IVMP). Although this has good efficacy (improvement seen in up to 63%) sustaining the treatment response and avoiding relapse over the disease course has proven challenging. The MINGO study has shown promise for mycophenolate (MMF) as a second line agent.

Retrospective review of 19 patients with moderate to severe GO treated in an MDT thyroid eye clinic and started on MMF post IVMP. Data collection included reported symptoms, clinical findings and clinical activity score (CAS score) before and after treatment, side effects, adverse events and the need for re-treatment with steroids.

Our analysis included 8 males and 11 females with a median age of 53, 11 of whom had DON. A mean reduction in the CAS score of 2.13 (range 0 to 6) was found following initiation of MMF (p<0.0001). Follow up duration ranged from 1 to 10 months and the dose of MMF ranged from 500mg to 2g daily. Most patients have reported improvement in pain with over 80% reporting an improvement in diplopia and a third showing improvement in periorbital swelling. Only one patient required maintenance with concurrent oral prednisolone. One was refractory to MMF and was switched to ciclosporin. One discontinued due to muscle cramps, and another was excluded due to incomplete data. No significant adverse events were reported.

Our experience shows promise for the role of MMF as a second line agent. We have seen an encouraging improvement in disease activity with a safety profile comparable if not superior to steroids.