Skip to content
How It Works
Explore
Resources Ask a Question
Who It's For
Patients
Decode results, prep for appointments, weigh options.
Caregivers & advocates
Carry the research load for someone you love.
Providers & clinicians
Resources for patients in your practice.
Log In Ask a Question
PubMed This is a summary of 18 peer-reviewed journal articles Updated
Ophthalmology · Thyroid Eye Disease

Stopping the Fire: Treatments for the Active Phase

At a Glance

The active phase of Thyroid Eye Disease (TED) is a critical 1- to 3-year window for medical treatment. The primary treatments are IV steroids to reduce inflammation, and Teprotumumab (Tepezza), a targeted therapy that is often more effective for reducing eye bulging and double vision.

When your Thyroid Eye Disease (TED) is in the active phase, the goal of treatment is to “put out the fire” of inflammation as quickly as possible. This is your critical window—a period, typically lasting 1 to 3 years, where your tissues are still flexible and responsive to medication [1]. If this window is missed, the inflammation can lead to fibrosis (permanent scarring) and adipogenesis (new fat growth), which are much harder to treat without surgery [2][3].

For moderate-to-severe active disease, treatment is usually delivered via intravenous (IV) infusions at a clinic or hospital.

Option 1: The Traditional Path (IV Steroids)

The standard first-line treatment is Intravenous Methylprednisolone (IVMP). This involves receiving a dose of steroids through an IV once a week, typically for 12 weeks [4][5].

  • How it works: Steroids are powerful anti-inflammatories that reduce the swelling of the muscles and fat behind the eye, providing relief from pain and redness [4].
  • Crucial Safety Limits: Because the doses are high, your doctor will strictly cap your total cumulative dose (usually staying below 4.5 to 8 grams total for the cycle). This is a critical safety measure to prevent severe liver toxicity and adrenal failure [6][7]. Other side effects include increased blood pressure, blood sugar spikes, and potential thinning of the bones over time [8][9].

Option 2: The Modern Path (Teprotumumab)

Teprotumumab (brand name Tepezza) is a newer, targeted biological therapy. Unlike steroids, which dampen the whole immune system, this medication specifically blocks the IGF-1 receptor on the cells behind your eye [10]. It is administered via IV infusion once every three weeks for a total of 8 infusions.

  • Efficacy: Research shows it is often more effective than steroids at reducing proptosis (eye bulging) and improving diplopia (double vision) [10][11]. It may “turn off” the disease more completely for some patients [12].
  • WARNING: Fetal Harm (Teratogenicity): Teprotumumab carries a severe risk of embryo-fetal toxicity (birth defects). Women of childbearing potential must undergo pregnancy testing before starting treatment and use highly effective contraception during treatment and for several months after the final dose [10].
  • Other Side Effects: A significant and unique side effect is ototoxicity (hearing damage). Some patients experience a “muffled” feeling in their ears, ringing (tinnitus), or even permanent hearing loss [13][14]. It can also elevate blood sugar and may trigger or worsen Inflammatory Bowel Disease (IBD) [15][16].

Comparing Your Options

Feature IV Steroids (IVMP) Teprotumumab (Tepezza)
Main Goal Reduce inflammation/pain Reduce bulging and double vision
Administration 12 weekly infusions 8 infusions (every 3 weeks)
Proptosis Reduction Moderate Significant [10]
Key Risks Liver toxicity, blood sugar Fetal harm, Hearing loss, IBD

Starting treatment while your disease is still active is the best way to prevent the need for more complex surgeries later [17][18]. Discuss these major risk profiles carefully with your care team to choose the right path for your specific body and lifestyle.

Common questions in this guide

Why is it important to treat Thyroid Eye Disease during the active phase?
Treating TED during the active phase helps reduce inflammation before it causes permanent scarring (fibrosis) or new fat growth behind the eye. Treating the disease during this critical 1- to 3-year window can help prevent the need for complex surgeries later.
What is the difference between IV steroids and Tepezza for TED?
IV steroids work by broadly reducing inflammation to relieve pain and swelling behind the eye. Tepezza is a targeted biological therapy that blocks a specific receptor, making it generally more effective at reducing severe eye bulging and double vision.
What are the side effects and risks of Tepezza?
Tepezza carries severe risks of birth defects, so women of childbearing age must use highly effective contraception during treatment. It can also cause hearing damage (ototoxicity), elevate blood sugar, and potentially trigger or worsen Inflammatory Bowel Disease.
How many IV infusions will I need for my TED treatment?
If you receive IV steroids, the standard protocol is typically one infusion per week for 12 weeks. If you take Tepezza, the treatment involves one infusion every three weeks for a total of eight doses.
Should I get a hearing test before starting Tepezza?
Yes. Because Tepezza carries a risk of hearing damage, tinnitus, or a muffled feeling in the ears, it is important to have a baseline hearing test with an audiologist before you begin the infusions.

Questions to Ask Your Doctor

Curated prompts to bring to your next appointment.

  1. 1.Am I a candidate for teprotumumab (Tepezza), and how does its success rate for proptosis reduction compare to IV steroids in my specific case?
  2. 2.If I am a woman of childbearing age taking teprotumumab, what specific contraception protocols do I need to follow?
  3. 3.Will you be coordinating with an audiologist to perform a baseline hearing test before I start teprotumumab?
  4. 4.If we choose the weekly steroid protocol (IVMP), what is the total cumulative dose you've planned to prevent liver toxicity?
  5. 5.Since I have [diabetes/IBD/high blood pressure], how will we manage the potential for these treatments to worsen those conditions?

Questions For You

Tap a prompt to share your answer — we'll use it plus this page's context to start a tailored conversation.

References

References (18)
  1. 1

    Pathophysiology of thyroid-associated orbitopathy.

    Lee ACH, Kahaly GJ

    Best practice & research. Clinical endocrinology & metabolism 2023; (37(2)):101620 doi:10.1016/j.beem.2022.101620.

    PMID: 35181241
  2. 2

    Interleukin-27 is a multitarget regulator of fibroblast remodeling in thyroid-associated ophthalmopathy.

    Zhang P, Wang X, Lu N, et al.

    iScience 2025; (28(12)):113982 doi:10.1016/j.isci.2025.113982.

    PMID: 41362621
  3. 3

    Orbital decompression surgery for the treatment of Graves' ophthalmopathy: comparison of different techniques and long-term results.

    Cubuk MO, Konuk O, Unal M

    International journal of ophthalmology 2018; (11(8)):1363-1370 doi:10.18240/ijo.2018.08.18.

    PMID: 30140642
  4. 4

    Factors associated with the efficacy of intravenous methylprednisolone in moderate-to-severe and active thyroid-associated ophthalmopathy: A single-centre retrospective study.

    Hu S, Wang Y, He M, et al.

    Clinical endocrinology 2019; (90(1)):175-183 doi:10.1111/cen.13855.

    PMID: 30229982
  5. 5

    Treatment with Intravenous Methylprednisolone in Patients with Graves' Orbitopathy Significantly Affects Adrenal Function: Assessment of Serum, Salivary Cortisol and Serum Dehydroepiandrosterone Sulfate.

    Pelewicz K, Szewczyk S, Miśkiewicz P

    Journal of clinical medicine 2020; (9(10)) doi:10.3390/jcm9103233.

    PMID: 33050327
  6. 6

    Can combination of glucocorticoids with other immunosoppressive drugs reduce the cumulative dose of glucocorticoids for moderate-to-severe and active Graves' orbitopathy?

    Tanda ML, Piantanida E, Masiello E, et al.

    Journal of endocrinological investigation 2019; (42(3)):351-352 doi:10.1007/s40618-019-01015-8.

    PMID: 30719623
  7. 7

    Liver Dysfunction Associated with Intravenous Methylprednisolone Pulse Therapy in Patients with Graves' Orbitopathy.

    Eguchi H, Tani J, Hirao S, et al.

    International journal of endocrinology 2015; (2015()):835979 doi:10.1155/2015/835979.

    PMID: 26221141
  8. 8

    Decrease in Bone Formation and Bone Resorption during Intravenous Methylprednisolone Pulse Therapy in Patients with Graves' Orbitopathy.

    Rymuza J, Gutowska K, Kurpios-Piec D, et al.

    Journal of clinical medicine 2022; (11(17)) doi:10.3390/jcm11175005.

    PMID: 36078937
  9. 9

    Acute bilateral cerebral infarction in the presence of neuromyelitis optica spectrum disorder: A case report.

    Wang ZY, Wang M, Guo JJ, et al.

    Medicine 2020; (99(40)):e22616 doi:10.1097/MD.0000000000022616.

    PMID: 33019482
  10. 10

    Thyroid eye disease (Graves' orbitopathy): clinical presentation, epidemiology, pathogenesis, and management.

    Wiersinga WM, Eckstein AK, Žarković M

    The lancet. Diabetes & endocrinology 2025; (13(7)):600-614 doi:10.1016/S2213-8587(25)00066-X.

    PMID: 40324443
  11. 11

    Proptosis and Diplopia Response With Teprotumumab and Placebo vs the Recommended Treatment Regimen With Intravenous Methylprednisolone in Moderate to Severe Thyroid Eye Disease: A Meta-analysis and Matching-Adjusted Indirect Comparison.

    Douglas RS, Dailey R, Subramanian PS, et al.

    JAMA ophthalmology 2022; (140(4)):328-335 doi:10.1001/jamaophthalmol.2021.6284.

    PMID: 35175308
  12. 12

    Teprotumumab for treating active thyroid eye disease: A meta-analysis.

    Cong X, Pei L, Hu H

    Medicine 2025; (104(26)):e42966 doi:10.1097/MD.0000000000042966.

    PMID: 40587732
  13. 13

    Risk of audiologic side effects with teprotumumab treatment for thyroid eye disease: propensity matched analysis.

    Markle JC, Johanis A, Shaia JK, et al.

    Eye (London, England) 2025; (39(6)):1107-1114 doi:10.1038/s41433-024-03531-1.

    PMID: 39668181
  14. 14

    Prospective Assessment of Otologic Adverse Events due to Teprotumumab: Preliminary Results.

    Kay-Rivest E, Belinsky I, Kozlova A, et al.

    Otolaryngology--head and neck surgery : official journal of American Academy of Otolaryngology-Head and Neck Surgery 2023; (168(5)):1164-1169 doi:10.1002/ohn.174.

    PMID: 36939482
  15. 15

    New-Onset of Inflammatory Bowel Disease in a Patient Treated With Teprotumumab for Thyroid Associated Ophthalmopathy.

    Ashraf DC, Jankovic I, El-Nachef N, et al.

    Ophthalmic plastic and reconstructive surgery 2021; (37(5)):e160-e164 doi:10.1097/IOP.0000000000001943.

    PMID: 33710035
  16. 16

    Efficacy and Safety of Teprotumumab in Thyroid Eye Disease.

    Teo HM, Smith TJ, Joseph SS

    Therapeutics and clinical risk management 2021; (17()):1219-1230 doi:10.2147/TCRM.S303057.

    PMID: 34858025
  17. 17

    Tocilizumab for the Management of Thyroid-Associated Orbitopathy.

    Smith LD, Moscato EE, Seiff SR

    Ophthalmic plastic and reconstructive surgery 2022; (38(2)):188-192 doi:10.1097/IOP.0000000000002027.

    PMID: 34293786
  18. 18

    Efficacy and Safety of Teprotumumab in Thyroid Eye Disease: A Systematic Review and Meta-Analysis.

    Huang W, Ou X, Lin S, et al.

    Endocrine practice : official journal of the American College of Endocrinology and the American Association of Clinical Endocrinologists 2025; (31(5)):640-649 doi:10.1016/j.eprac.2025.01.012.

    PMID: 39952471

This page provides educational information about treatments for the active phase of Thyroid Eye Disease (TED). It does not replace professional medical advice from your ophthalmologist or endocrinologist regarding your specific treatment plan.

Get notified when new evidence is published on thyrotoxic exophthalmos.

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