Disease Awareness and Education Webinar Tuesday, July 9, 2019 - - PowerPoint PPT Presentation

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Disease Awareness and Education Webinar Tuesday, July 9, 2019 - - PowerPoint PPT Presentation

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Thyroid Eye Disease Awareness and Education Webinar Tuesday, July 9, 2019 Welcome Panelists Babak Larian, MD Raymond S. Douglas, MD, PhD Christina Seeden Assistant Clinical Professor of Surgery, Advocate Director of Orbital and Thyroid

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Thyroid Eye Disease Awareness and Education Webinar

Tuesday, July 9, 2019

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Welcome Panelists

Babak Larian, MD Assistant Clinical Professor of Surgery, Division of Head and Neck Surgery, UCLA David Geffen School of Medicine Director, Head and Neck Cancer Center and Head and Neck Tumor Board, Cedar- Sinai Medical Center Raymond S. Douglas, MD, PhD Director of Orbital and Thyroid Eye Disease Program Cedars-Sinai Medical Center in Los Angeles Christina Seeden Advocate

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Babak Larian, MD Assistant Clinical Professor of Surgery, Division of Head and Neck Surgery, UCLA David Geffen School of Medicine Director, Head and Neck Cancer Center and Head and Neck Tumor Board, Cedar-Sinai Medical Center

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Raymond S. Douglas, MD, PhD Director of Orbital and Thyroid Eye Disease Program Cedars-Sinai Medical Center in Los Angeles

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THYROID EYE DISEASE: WHAT IS IT AND

HOW TO TREAT IT..

RAYMOND S. DOUGLAS MD PHD

PROFESSOR OF SURGERY

DIVISION OF OPHTHALMOLOGY 150 NORTH ROBERSTON SUTIE 314 BEVERLY HILLS CA INFO@RAYMONDDOUGLASMD.COM

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“The speaker declares no current financial conflicts of interest”

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WHAT IS THYROID EYE DISEASE ?

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The Three Components of Graves’ Disease

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Heterogeneous disease

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Disease

Time

Ideal Immunomodulatory Therapy

Active Phase Stable Phase 18-36 months 5-7years Surgery

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Thyroid Eye Disease

Autoimmune inflammatory disease

  • ften with extensive fibrosis

Permanent Facial disfigurement No treatment to prevent disfigurement “Standard of Care” watch and wait - then surgery

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What about TED specific therapy ???

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Heterogeneous disease

Delineate the common molecular mechanisms

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Tsui et al J Immunology 181:4397 (2008)

IGF-1R Inhibition Can Attenuate TSHR Signaling

Inhibition of IGF-1R with a mAb antagonist has potential to block pathological autoantigen signaling through both IGF-1R and TSHR

Teprotumumab Phase 2 IGF-1R Antagonist

RAYMOND S. DOUGLAS MD PHD

PRINCIPAL INVESTIGATOR 22 US AND INTERNATIONAL CENTERS

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Graves’ Orbitopathy: Disease Time Course

Disease Activity

Active Phase Stable Phase

1.5 2 3 6 years

Untreated

Smith & Douglas (2011)

Teprotumumab

Efficacious therapy

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24-week randomized, double-masked, placebo- controlled treatment trial of Teprotumumab

ǂ Excluding local supportive measures and oral steroids if the maximum cumulative dose is less than 1000 mg methylprednisolone or equivalent. There must be at least 6 weeks between last administration of steroids and study

  • randomization. *No additional treatment during at least the first 3 months unless medically indicated. i.e. decompression. Elective treatments should be avoided during the first 3 months of the follow up period.

Active TED

  • 18 to 75 years
  • < 9 mo. since active TED
  • nset with no prior

treatmentǂ

  • CAS ≥ 4
  • FT4 and FT3 <50% above or

below normal limits

Teprotumumab Infusions q3w (total of 8) Placebo Infusions q3w (total of 8) Screening Randomization Off Treatme eatment Follow Up Period

Week 24 assessment was 3 weeks after last dose Week 72 assessment was 51 weeks after last dose 24 weeks 48 weeks

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Study Design

  • Less than 9 months since TED diagnosis
  • Moderate – Severe disease
  • CAS 4 or greater

Endpoints

  • Proptosis reduced by 2 mm
  • Study designed to Medically REPLACE SURGERY
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Smith TJ et al. N Engl J Med 2017;376:1748-1761

Clinical Activity Score

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Smith TJ et al. N Engl J Med 2017;376:1748-1761

Proptosis Reduction

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Individual Patient Plots (week 24)

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Smith TJ et al. N Engl J Med 2017;376:1748-1761

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Pre treatment Week 24 control

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Pre treatment Teprotumumab Week 24

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  • Teprotumumab, an antibody to the insulin-

like growth factor I receptor, led to significant responses in 69% of patients with decreased proptosis (intent to treat).

  • 79% of patients (data available) had a

decreased proptosis and response to Teprotumumab

  • Proptosis reduction was >2.5 mm
  • Worse disease bigger effect
  • May replace surgery

Results

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Single Stage Approach to Orbital Decompression

Adequate decompression can dramatically reduce need for eyelid surgery Less than 5% need lower eyelid surgery

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Aesthetic Functional Reconstruction It IS about how we Look and Feel It IS about how many surgeries and downtime Single Stage Reconstruction

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What is “aesthetic-functional” reconstruction?

Form follows function

  • Goal: Return to (Improve upon) pre disease

appearance and function

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Key Factors to Customized Surgical Planning

  • Patient Goals
  • Type of disease fat vs muscle- Risk profile
  • Disease severity
  • Presence/risk of double vision
  • Bony structure (bone available for decompression)
  • Soft tissue structure
  • Aesthetic contour of brow, eyelids, midface
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Fat + Lateral/Superior Decompression 6mm proptosis reduction, no additional surgery

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Natural lower eyelid appearance

Done by customizing decompression technique not additional surgery

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Normal Eyelid contour restored after decompression

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Fat + Lateral Decompression 3-4 mm proptosis reduction

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Fat + Lateral / Superior Decompression 6mm proptosis reduction

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Improve Cheek junction

During decompression Eyelid rectrator release Orbitomalar ligament release Midface lift / support Cheek implants

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Decompression and OML release- No eyelid surgery

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Summary

  • Orbital And Oculoplastic Surgery Service
  • Available 24/7 consults
  • Thyroid Eye Disease Program
  • Research
  • Integrated Multidisciplinary Clinical Care
  • Financial Assistance Program from philanthropy
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Christina’s Thyroid Eye Disease Journey

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Christina’s TED Journey

October 2006 Diagnosed with Graves August 2007 August 2011 Before RAI August 2012

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Christina’s TED Journey

Before TED 2011 Active TED 2012 Active TED 2012 1 month after surgery

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Christina’s TED Journey

February 2013 Befo fore surger gery August 2013 3.5 months nths after ter surge gery ry

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Christina’s TED Journey

February 2013 Now

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Thank You Panelists

Babak Larian, MD Assistant Clinical Professor of Surgery, Division of Head and Neck Surgery, UCLA David Geffen School of Medicine Director, Head and Neck Cancer Center and Head and Neck Tumor Board, Cedar- Sinai Medical Center Raymond S. Douglas, MD, PhD Director of Orbital and Thyroid Eye Disease Program Cedars-Sinai Medical Center in Los Angeles Christina Seeden Advocate