Published in Oculoplastics

Talking, Testing, Tepezza: Preparing Patients for TED Treatment

Madhura Tamhankar, MD

Madhura Tamhankar, MD

Preeya K. Gupta, MD

Preeya K. Gupta, MD

This is editorially independent content supported by advertising by Amgen
7 min read
Join Preeya K. Gupta, MD, and Madhura Tamhankar, MD, to review how ophthalmologists can discuss thyroid eye disease (TED) and TEPEZZA with patients.
On this episode of Interventional Mindset, Preeya K. Gupta, MD, sits down with Madhura Tamhankar, MD, to discuss how to test patients for thyroid eye disease (TED), review TED treatments with patients, and identify optimal candidates for TEPEZZA (teprotumumab-trbw, Amgen).
Dr. Tamhankar is a neuro-ophthalmologist and associate professor of ophthalmology at the University of Pennsylvania in Philadelphia, Pennsylvania.

Testing patients for thyroid eye disease

TED is a rare autoimmune condition caused by the activation of orbital fibroblasts by autoantibodies directed against thyroid receptors that can lead to enlargement of the extraocular muscles (EOMs) and fatty and connective tissue.1
In a previous episode, Dr. Gupta spoke with Prem Subramanian, MD, PhD, to review symptoms that ophthalmologists can consider potentially suspicious for TED, such as:2
  • Chronic red or dry eye that is unresponsive to standard therapies
  • Palpebral fissure
  • Proptosis
  • Difficulty with or incomplete lid closure (ex., lagophthalmos)
  • Diplopia
With this in mind, testing for patients with symptoms of TED is generally divided into two parts: a laboratory workup and neuroimaging, explained Dr. Tamhankar. She added that neuroimaging (i.e., a CT scan or MRI) is not always necessary, but it is critical for patients with moderate to severe proptosis or double vision to check for enlargement of the EOMs, orbital fat hypertrophy in the retrobulbar area, and signs of compressive optic neuropathy.1
A laboratory workup for TED can consist of basic thyroid function tests and thyroid antibody tests, such as:
  • Thyroid function tests
    • Triiodothyronine (T3)
    • Thyroxine (T4)
    • Thyroid-stimulating hormone (TSH)
  • Thyroid antibody tests
    • Thyroid-stimulating immunoglobulin (TSI)
    • Thyroid peroxidase (TPO)
    • Thyrotropin receptor antibody (TRAb)
While the results from these tests alone are not diagnostic for TED, they can provide helpful insights when paired with clinical observations.1
For a deeper dive into the clinical trial results of TEPEZZA, check out the article, Thyroid Eye Disease: Unpacking Symptoms & Durable Treatments!

Discussing TEPEZZA with patients

Until recently, the main treatment approach for TED was intravenous corticosteroids and/or orbital radiation to address the active inflammatory phase and surgical correction during inactive phases of the disease.1
In January 2020, TEPEZZA became the first FDA-approved drug for the treatment of TED, with a typical treatment course of eight infusions over 6 months. Of note, teprotumumab is a monoclonal antibody directed against the insulin-like growth factor-1 receptor (IGF-1R) to block its activation and signaling.1
As there has been a direct-to-consumer marketing campaign for TEPEZZA, there are now more patients who have researched it and may come to appointments with questions or concerns, noted Dr. Tamhankar.
However, in her experience, most patients tend to feel overwhelmed after being presented with information about TEPEZZA because there is a lot to understand, many of them already feel distressed by the appearance of their eye, and some may be receiving a double diagnosis of TED in addition to a thyroid condition.
Consequently, if it is not an emergent case, after discussing the medication and potential side effects and addressing any patient questions, Dr. Tamhankar provides them with a brochure and recommends that they read it and call her if they have additional questions and come back in 2 weeks.
She will also call her patients to check that they have had time to absorb the information and recommends they come in for a follow-up appointment to follow up on the trajectory of the disease course.

Identifying optimal candidates for TEPEZZA

For patients who decide to move forward with TEPEZZA, Dr. Tamhankar orders audiology testing prior to initiating the therapy to establish a baseline and may repeat if necessary, such as if patients have any symptoms of hearing dysfunction during therapy with teprotumumab. One study found that teprotumumab influences hearing function most significantly at higher frequencies and in older patients.3
She explained that in her experience, the patients who tend to respond best to TEPEZZA are those with similar symptoms to the patients from the phase 3 clinical trial (OPTIC, NCT03298867), meaning those in an active stage of the disease who have significant diplopia and proptosis and a high clinical activity score (CAS).4
Further, Dr. Tamhankar was the first author of a recent literature review that evaluated the efficacy of teprotumumab in patients with dysthyroid optic neuropathy (DON).5 The study found that teprotumumab was an effective treatment for DON in published cases wherein treatment with steroids, surgery, or orbital radiation was unsuccessful. However, it is worth noting that these findings have yet to be validated in clinical trials.

To learn more about how to discuss the potential risks and side effects of teprotumumab with patients, watch the full interview!

What is the risk of TED recurrence after treatment with teprotumumab?

Based on the data that has been published so far, around one in four patients experience a recurrence of TED at an average of 10 to 12 months after the first series of infusions, noted Dr. Tamhankar.6
As such, during consultations, she tells patients that there is a chance they may relapse, and there is a higher risk of recurrence in patients with highly fluctuating thyroid function or smokers. If a patient smokes, she emphasizes the fact that smoking cessation is a significant factor in decreasing the risk and severity of TED.7

Conclusion

Thyroid eye disease can be a challenging condition for both doctors and patients, though with the approval and implementation of TEPEZZA, ophthalmologists have an additional effective treatment in their armamentarium.
Key takeaways on TED treatment:
  • Symptoms of thyroid eye disease include:
    • Chronic red or dry eye that is unresponsive to standard therapies
    • Palpebral fissure
    • Proptosis
    • Difficulty with or incomplete lid closure (ex., lagophthalmos)
    • Diplopia
  • Testing is generally divided into a laboratory workup and imaging, such as:
    • Basic thyroid function and thyroid antibody tests
    • Neuroimaging if there is significant proptosis and diplopia
  • When discussing TED treatments, provide patients with educational brochures and mention the risk of recurrence and factors that may contribute (i.e., fluctuating thyroid function and smoking status)
  • Optimal candidates for TEPEZZA include those with:
    • Active TED
    • Significant diplopia and proptosis
    • High CAS

Watch the interview to hear more insights into treatment recommendations for TEPEZZA!

  1. Boyd K. What is thyroid eye disease (TED) or Graves’ eye disease?. American Academy of Ophthalmology. Published September 30, 2024. Accessed December 4, 2024. https://www.aao.org/eye-health/diseases/what-is-graves-disease.
  2. Burkat CN, Epley KD, Phelps PO, et al. Thyroid eye disease. EyeWiki. July 9, 2024. Accessed December 4, 2024. https://eyewiki.org/Thyroid_Eye_Disease.
  3. Keen JA, Correa T, Pham C, et al. Frequency and patterns of hearing dysfunction in patients treated with teprotumumab. Ophthalmology. 2024;131(1):30-36. doi: 10.1016/j.ophtha.2023.08.001
  4. Treatment of Graves’ orbitopathy (thyroid eye disease) to reduce proptosis with teprotumumab infusions in a randomized, placebo-controlled, clinical study (OPTIC). ClinicalTrials.gov. July 11, 2024. Accessed December 5, 2024. https://clinicaltrials.gov/study/NCT03298867.
  5. Tamhankar MA, Pradeep T, Chen Y, Briceño CA. Real-world experience with teprotumumab in patients with dysthyroid optic neuropathy. J Neuroophthalmol. 2024;44(1):74-79. doi:10.1097/WNO.0000000000001994
  6. Monostra M. Few adults with thyroid eye disease receiving teprotumumab require second course. Healio. October 24, 2022. Accessed December 5, 2024. https://www.healio.com/news/endocrinology/20221024/few-adults-with-thyroid-eye-disease-receiving-teprotumumab-require-second-course.
  7. O’Dell JM, Mussatto CC, Chu RL, et al. Effects of smoking on outcomes of thyroid eye disease treated with teprotumumab: A retrospective cohort study. Kans J Med. 2023;16:62-64. doi: 10.17161/kjm.vol16.18940
Madhura Tamhankar, MD
About Madhura Tamhankar, MD

Madhura Tamhankar, MD, is a neuro-ophthalmologist who practices at the University of Pennsylvania and Penn Presbyterian Medical Center in Philadelphia, Pennsylvania. She attended medical school at Lokmanya Tilak Municipal Medical College, Maharashtra University of Health Sciences in Mumbai, India.

She completed residencies at Nair Hospital, Topiwala National Medical College in Mumbai, India, St. Mary's Hospital in Philadelphia, Pennsylvania, and the Hospital of the University of Pennsylvania in Philadelphia, Pennsylvania. In addition, she completed an ophthalmology fellowship at the University of Pennsylvania.

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Preeya K. Gupta, MD
About Preeya K. Gupta, MD

Dr. Gupta earned her medical degree at Northwestern University’s Feinberg School of Medicine in Chicago, and graduated with Alpha Omega Alpha honors. She fulfilled her residency in ophthalmology at Duke University Eye Center in Durham, North Carolina, where she earned the K. Alexander Dastgheib Surgical Excellence Award, and then completed a fellowship in Cornea and Refractive Surgery at Minnesota Eye Consultants in Minneapolis. She served on the faculty at Duke University Eye Center in Durham, North Carolina as a Tenured Associate Professor of Ophthalmology from 2011-2021.

Dr. Gupta has authored many articles in the peer-reviewed literature and serves as an invited reviewer to journals such as Ophthalmology, American Journal of Ophthalmology, and Journal of Refractive Surgery. She has also written several book chapters about corneal disease and ophthalmic surgery, as well as served as an editor of the well-known series, Curbside Consultation in Cataract Surgery. She also holds several editorial board positions.

Dr. Gupta serves as an elected member of the American Society of Cataract and Refractive Surgery (ASCRS) Refractive Surgery clinical committee, and is also is the Past-President of the Vanguard Ophthalmology Society. She gives presentations both nationally and internationally, and has been awarded the National Millennial Eye Outstanding Female in Ophthalmology Award, American Academy of Ophthalmology (AAO) Achievement Award, and selected to the Ophthalmologist Power List.

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