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Thyroid Eye Disease — RACP Adult Medicine MCQ

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ModerateEndocrinology & DiabetesThyroid Eye DiseaseRACP Adult Medicine

A 38-year-old woman with known Graves' disease develops acute proptosis, chemosis, and diplopia. Her thyroid function is controlled on carbimazole. Her clinical activity score (CAS) for thyroid eye disease is 5/7 (active). What is the first-line treatment for moderate-to-severe active thyroid eye disease?

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Correct answer: A — IV methylprednisolone pulse therapy

Active moderate-to-severe thyroid eye disease (Graves' ophthalmopathy) with a CAS ≥3/7 is treated with IV methylprednisolone pulse therapy (typically 500 mg weekly for 6 weeks, then 250 mg weekly for 6 weeks – EUGOGO protocol). This is more effective and better tolerated than oral prednisolone. Teprotumumab (anti-IGF-1R antibody) has shown remarkable efficacy in clinical trials (OPTIC trial) and is emerging as a potential first-line or second-line option. Radioactive iodine can WORSEN thyroid eye disease and should be used cautiously (with steroid cover) or avoided in active TED. Smoking cessation is essential.

Reference: eTG – 2025 – Endocrinology; EUGOGO – 2021 – Thyroid Eye Disease Guidelines