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Treatment strategies for Graves’ ophthalmopathy: a network meta-analysis
  1. Xiaoxin Zhou1,
  2. Dongdong Zhou2,
  3. Juan Wang1,
  4. Guangmin Chen1
  1. 1 Department of Endocrinology, University-Town Hospital of Chongqing Medical University, Chongqing, China
  2. 2 Mental Health Center, University-Town Hospital of Chongqing Medical University, Chongqing, China
  1. Correspondence to Dr Dongdong Zhou, Mental Health Center, University-Town Hospital of Chongqing Medical University, Chongqing 401331, China; zhoudongdong{at}


Purpose Various treatments have been investigated for Graves’ ophthalmopathy (GO). We aimed to provide an overall profile of the efficacy and tolerability of various interventions for active and moderate to severe GO.

Methods PubMed, Embase and the Cochrane Central Register of Controlled Trials were searched on 6 July 2018. Randomised controlled trials (RCT) investigating GO treatments were included. Two researchers independently extracted data according to a predefined form. A random effects network meta-analysis was performed using a frequentist approach. The primary outcome was efficacy, and the secondary outcome was tolerability (side effect discontinuation).

Results Thirty-three studies with 1846 patients with GO were included. Orbital radiotherapy (ORT) plus intravenous glucocorticoids (IVGC) (OR 27.11; 95% CI 4.57 to 160.92), mycophenolate mofetil (MMF) (24.40, 95% CI 5.28 to 112.67), oral glucocorticoids (OGC) plus ciclosporin (20.22, 95% CI 1.60 to 255.20), IVGC plus MMF (12.08, 95% CI 2.96 to 49.35), teprotumumab (8.92, 95% CI 2.51 to 31.77), ORT plus OGC (4.88, 95% CI 1.25 to 19.06), rituximab (RTX) (4.85, 95% CI 1.18 to 19.86), somatostatin analogues (4.23, 95% CI 1.60 to 11.16), OGC plus azathioprine (AzA) (5.77, 95% CI 1.17 to 28.47) and IVGC (4.96, 95% CI 1.96 to 12.55) showed significantly better improvement than no treatment. ORT plus IVGC ranked first, followed by MMF. High heterogeneity and significant local inconsistency were observed in the RTX studies. The results of the sensitivity analyses were similar to those of the main analysis.

Conclusion A robust recommendation regarding the best treatment cannot be made, because most evidence was rated as low or very low quality according to the Grading of Recommendations, Assessment, Development and Evaluations framework. Large RCTs and individual participant data meta-analyses are necessary to confirm these results and explore potential moderators.

PROPERO trial registration number CRD42018103029.

  • Graves’ ophthalmopathy
  • network meta-analysis
  • glucocorticoid

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  • Contributors Concept and design: DZ, XZ. Acquisition, analysis or interpretation of data: All authors. Drafting of the manuscript: DZ, XZ. Statistical analysis: DZ, XZ.

  • Funding The authors have not declared a specific grant for this research from any funding agency in the public, commercial or not-for-profit sectors.

  • Competing interests None declared.

  • Patient consent for publication Not required.

  • Provenance and peer review Not commissioned; externally peer reviewed.

  • Data availability statement Data are available upon request.

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