Ophthalmology

Cooling the Fire: Medical Treatments for Active Disease

At a Glance

Treatment for active euthyroid Graves orbitopathy focuses on calming inflammation and protecting vision. Depending on disease severity and eye findings, specialists may use IV steroids with mycophenolate, Tepezza, or orbital radiotherapy, while monitoring for serious effects and avoiding smoking.

When Euthyroid Graves Orbitopathy (EGO) is in its active phase, the goal of medical treatment is to “cool down” the inflammation, reduce swelling, and prevent permanent damage to your vision. Because your thyroid levels are currently normal, these treatments focus entirely on the immune system’s attack on the tissues behind your eyes. It is important to never self-start steroids or immunosuppressive medications without direct clinician guidance.

The most critical first step in any treatment plan is addressing risk factors. Smoking cessation is the single most important lifestyle change you can make, as smoking makes medical treatments less effective and increases the risk of the disease worsening ^[1].

First-Line Therapy: IV Steroids and Mycophenolate

The 2021 international guidelines (EUGOGO) recommend a combination of intravenous (IV) methylprednisolone and mycophenolate as an option for moderate-to-severe active disease ^[1]^[2].

IV steroids are often preferred over oral tablets for selected moderate-to-severe disease because they are more effective at reducing inflammation, but they carry serious dose-related risks rather than being inherently safer ^[1]. A highly individualized course by your specialist often involves up to 12 weekly infusions ^[3].

Important Risks and Monitoring:

Liver Injury: While rare, high-dose IV steroids can cause severe liver inflammation. Your doctor must check your liver enzymes and test for hepatitis before you start ^[4]^[5].
Blood Sugar and Pressure: Steroids can cause sudden spikes in blood sugar (hyperglycemia) and blood pressure. Frequent monitoring is required, especially if you have diabetes ^[6].
Psychiatric Changes: Some patients experience “steroid psychosis,” which can include severe anxiety, insomnia, or mood swings ^[6].
Mycophenolate Risks: This medication helps suppress the immune system but requires appropriate blood-count and organ-function monitoring, infection precautions, and vaccine advice. It also carries a severe risk of fetal harm. Patients who could become pregnant must undergo strict pregnancy testing and prevention ^[7]^[8].

Targeted Biologic Therapy: Teprotumumab (Tepezza)

In the United States, 2022 guidelines (ATA) often favor teprotumumab (Tepezza) as a first-line option for active moderate-to-severe disease, particularly when eye bulging (proptosis) is a major concern ^[9]. This is a targeted biologic that blocks the IGF-1 receptor, which plays a key role in the eye swelling process.

Tepezza is highly effective at reducing proptosis—by a study average of 2.46 mm—and can also improve double vision, though individual results vary ^[10]^[11].

Important Risks and Monitoring:

Hearing Loss and Tinnitus: About 10% or more of patients may experience hearing changes or ringing in the ears (tinnitus). While often temporary, some hearing loss can be permanent. You should have a baseline hearing test (audiometry) and repeat it periodically during and after treatment ^[12]^[13].
IBD Flares: Tepezza can cause new or worsening Inflammatory Bowel Disease (IBD). If you have a history of Crohn’s or ulcerative colitis, this drug may be risky ^[14]^[15].
Fetal Harm and Hyperglycemia: Tepezza poses severe risks to a fetus requiring strict pregnancy prevention and testing. Thorough baseline screening and periodic monitoring for blood sugar spikes are also essential.
Muscle Spasms: Many patients experience temporary, sometimes painful muscle cramps during the course of treatment ^[11].

Orbital Radiotherapy

Orbital radiotherapy uses low-dose X-rays targeted at the tissues behind the eye to reduce inflammation. It is often used in combination with steroids, particularly when the main problem is restricted eye movement or double vision (diplopia) ^[16]^[17].

Radiotherapy is generally not effective for reducing eye bulging and is reserved for patients who are still in the active phase of the disease ^[18].

Important Risks and Cautions:

Diabetic Retinopathy: This treatment is usually avoided in patients with diabetes who already have damage to their retina (diabetic retinopathy), as radiation can worsen this condition ^[19]^[20].
Late Risks: There is a very small, long-term risk of developing cataracts or, even more rarely, secondary tumors in the treated area ^[21]^[22].

Choosing the right treatment involves weighing these serious risks against the goal of stabilizing your vision and appearance during the active window of the disease.

Common questions in this guide

What treatments are used for active euthyroid Graves orbitopathy?

Treatment is chosen according to disease activity, severity, eye bulging, and double vision. Options for moderate-to-severe active disease include IV methylprednisolone with mycophenolate, teprotumumab (Tepezza), or orbital radiotherapy in selected cases. A specialist should weigh the expected benefit against each option’s monitoring needs and risks.

Why is stopping smoking important during treatment?

Smoking can make Graves orbitopathy more likely to worsen and can make medical treatments less effective. Stopping smoking is the most important lifestyle change described for improving the chance that treatment will work.

What monitoring is needed with IV steroids and mycophenolate?

Before and during IV steroid treatment, clinicians may check liver enzymes, hepatitis status, blood pressure, blood sugar, and mood-related symptoms. Mycophenolate requires blood-count and organ-function monitoring, infection precautions, and guidance about vaccines. It also requires strict pregnancy testing and prevention because it can seriously harm a fetus.

What should I know about Tepezza for active eye disease?

Tepezza, also called teprotumumab, can reduce eye bulging and may improve double vision, but results vary. Treatment can cause hearing changes or ringing in the ears, inflammatory bowel disease flares, blood sugar increases, muscle spasms, and severe fetal harm. A baseline and repeat hearing tests, along with blood sugar and pregnancy safety monitoring, are important.

When is orbital radiotherapy used for Graves orbitopathy?

Orbital radiotherapy is generally reserved for active disease, especially when restricted eye movement or double vision is a major problem. It is usually not effective for reducing eye bulging. Doctors may avoid it in people with diabetic retinopathy because radiation can worsen retinal damage.

Get notified when new evidence is published on Euthyroid Graves orbitopathy.

We monitor PubMed for new peer-reviewed studies on this topic and email a short summary when something meaningful changes.

Key takeaways

Smoking cessation is the most important lifestyle change because smoking can worsen Graves orbitopathy and reduce the effectiveness of medical treatments.
For moderate-to-severe active disease, IV methylprednisolone combined with mycophenolate is a guideline-supported treatment option.
Teprotumumab (Tepezza) can reduce eye bulging and improve double vision, but requires hearing and blood sugar monitoring and careful assessment of bowel disease and pregnancy risks.
Orbital radiotherapy can help restricted eye movement or double vision during active disease but generally does not reduce eye bulging and may be unsuitable with diabetic retinopathy.
Steroids and immune-suppressing medicines should only be started under clinician guidance because they can affect the liver, blood sugar, blood pressure, mood, infection risk, and pregnancy.

References (22)

1
The 2021 European Group on Graves' orbitopathy (EUGOGO) clinical practice guidelines for the medical management of Graves' orbitopathy.
Bartalena L, Kahaly GJ, Baldeschi L, et al.
European journal of endocrinology 2021; (185(4)):G43-G67.
PMID: 34297684
2
[Optimization of the treatment of moderate to severe and active thyroid orbitopathy considering the recommendations of the European Group on Graves' Orbitopathy (EUGOGO) [Optymalizacja leczenia umiarkowanej do ciężkiej i aktywnej orbitopatii tarczycowej z uwzględnieniem zaleceń European Group on Graves' Orbitopathy (EUGOGO)]].
Nowak M, Marek B, Kos-Kudła B, et al.
Endokrynologia Polska 2022; (73(4)):756-777 doi:10.5603/EP.a2022.0040.
PMID: 36059167
3
Adrenal axis integrity after IV methylprednisolone therapy for thyroid eye disease: a retrospective cohort study.
Effraimidis G, Kasotas A, Bargiota A
European journal of endocrinology 2026; (194(5)):653-662 doi:10.1093/ejendo/lvag077.
PMID: 42139516
4
Acute liver damage following intravenous glucocorticoid treatment for Graves' ophthalmopathy.
Moleti M, Giuffrida G, Sturniolo G, et al.
Endocrine 2016; (54(1)):259-268 doi:10.1007/s12020-016-0928-3.
PMID: 27003434
5
Safety profile of intravenous methylprednisolone therapy for thyroid eye disease: a multicenter retrospective study.
Higashida T, Tagami M, Kinari G, et al.
Japanese journal of ophthalmology 2026; doi:10.1007/s10384-026-01413-5.
PMID: 42690508
6
Characteristics of adverse drug reactions and risk management strategies for methylprednisolone sodium succinate in the treatment of idiopathic sudden sensorineural hearing loss: a clinical study of 1026 patients.
Wu T, Tang Y, Yan S, et al.
Frontiers in medicine 2025; (12()):1589531 doi:10.3389/fmed.2025.1589531.
PMID: 40568206
7
Systemic safety analysis of mycophenolate in Graves' orbitopathy.
Lee ACH, Riedl M, Frommer L, et al.
Journal of endocrinological investigation 2020; (43(6)):767-777 doi:10.1007/s40618-019-01161-z.
PMID: 31834613
8
Mycophenolate plus methylprednisolone versus methylprednisolone alone in active, moderate-to-severe Graves' orbitopathy (MINGO): a randomised, observer-masked, multicentre trial.
Kahaly GJ, Riedl M, König J, et al.
The lancet. Diabetes & endocrinology 2018; (6(4)):287-298 doi:10.1016/S2213-8587(18)30020-2.
PMID: 29396246
9
Comparison of the 2021 EUGOGO guidelines and the 2022 ATA/ETA consensus statement for the management of Graves' orbitopathy.
Bartalena L, Gallo D, Kahaly GJ, et al.
European thyroid journal 2025; (14(6)).
PMID: 41283777
10
Teprotumumab for the Treatment of Active Thyroid Eye Disease.
Douglas RS, Kahaly GJ, Patel A, et al.
The New England journal of medicine 2020; (382(4)):341-352 doi:10.1056/NEJMoa1910434.
PMID: 31971679
11
Teprotumumab for patients with active thyroid eye disease: a pooled data analysis, subgroup analyses, and off-treatment follow-up results from two randomised, double-masked, placebo-controlled, multicentre trials.
Kahaly GJ, Douglas RS, Holt RJ, et al.
The lancet. Diabetes & endocrinology 2021; (9(6)):360-372 doi:10.1016/S2213-8587(21)00056-5.
PMID: 33865501
12
Hearing Dysfunction After Treatment With Teprotumumab for Thyroid Eye Disease.
Sears CM, Azad AD, Amarikwa L, et al.
American journal of ophthalmology 2022; (240()):1-13 doi:10.1016/j.ajo.2022.02.015.
PMID: 35227694
13
Audiologic Assessment and Management of Teprotumumab-Associated Ototoxicity: An Updated Narrative Review.
Williams J, Elkins A, Sarigul A, et al.
Audiology research 2026; (16(3)) doi:10.3390/audiolres16030092.
PMID: 42345631
14
Teprotumumab in Clinical Practice: Recommendations and Considerations From the OPTIC Trial Investigators.
Douglas RS, Wang Y, Dailey RA, et al.
Journal of neuro-ophthalmology : the official journal of the North American Neuro-Ophthalmology Society 2021; (41(4)):461-468 doi:10.1097/WNO.0000000000001134.
PMID: 33417417
15
A case of ulcerative colitis associated with teprotumumab treatment for thyroid eye disease.
Safo MB, Silkiss RZ
American journal of ophthalmology case reports 2021; (22()):101069 doi:10.1016/j.ajoc.2021.101069.
PMID: 33817409
16
Radiotherapy for Active Thyroid Eye Disease.
Godfrey KJ, Kazim M
Ophthalmic plastic and reconstructive surgery 2018; (34(4S Suppl 1)):S98-S104 doi:10.1097/IOP.0000000000001074.
PMID: 29771752
17
Orbital Radiation Therapy in Thyroid Eye Disease.
Chundury RV, Weber AC, Perry JD
Ophthalmic plastic and reconstructive surgery 2016; (32(2)):83-9 doi:10.1097/IOP.0000000000000544.
PMID: 26325378
18
Orbital Radiation for Thyroid Eye Disease: A Report by the American Academy of Ophthalmology.
Sobel RK, Aakalu VK, Vagefi MR, et al.
Ophthalmology 2022; (129(4)):450-455 doi:10.1016/j.ophtha.2021.10.025.
PMID: 34895729
19
No retinopathy after orbital irradiation in patients with thyroid eye disease - a follow up study.
Makhoul S, Aranyosi JK, Csiki E, et al.
Frontiers in endocrinology 2025; (16()):1720650 doi:10.3389/fendo.2025.1720650.
PMID: 41450582
20
Thyroid Eye Disease and Its Association With Diabetes Mellitus: A Major Review.
Gupta R, Kalra P, Ramamurthy LB, Rath S
Ophthalmic plastic and reconstructive surgery 2023; (39(6S)):S51-S64 doi:10.1097/IOP.0000000000002449.
PMID: 38054986
21
Contour Variability in Thyroid Eye Disease with Compressive Optic Neuropathy Treated with Radiation Therapy.
Nanda T, Sanchez A, Purswani J, et al.
Advances in radiation oncology 2020; (5(5)):804-808 doi:10.1016/j.adro.2020.02.005.
PMID: 33089016
22
Secondary malignancy following radiotherapy for thyroid eye disease.
Gillis CC, Chang EH, Al-Kharazi K, Pickles T
Reports of practical oncology and radiotherapy : journal of Greatpoland Cancer Center in Poznan and Polish Society of Radiation Oncology 2016; (21(3)):156-61 doi:10.1016/j.rpor.2016.01.001.
PMID: 27601944

This page explains treatment and monitoring options for active euthyroid Graves orbitopathy for informational purposes only and does not replace medical advice. Discuss steroid, immune-suppressing, biologic, or radiation treatment with your eye and medical specialists.