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Endokrine Orbitopathie aus internistischer Sicht

Graves’ ophthalmopathy from the internist’s perspective

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Zusammenfassung

Die endokrine Orbitopathie (EO) ist die häufigste extrathyreoidale Manifestation des M. Basedow und tritt bei bis zu 40% der Patienten mit M. Basedow auf. Bei fast allen Patienten mit EO lassen sich TSH-Rezeptor-Antikörper (TRAK) nachweisen, die pathognomonisch für den M. Basedow sind und auch pathophysiologisch an der Entstehung der EO beteiligt sind. Diagnostiziert wird der M. Basedow bei klinischen Zeichen der Hyperthyreose durch die laborchemische Konstellation der primären Hyperthyreose (supprimiertes TSH, erhöhtes fT3 und/oder fT4) sowie den Nachweis von TRAKs. Bei allen Patienten mit M. Basedow muss regelmäßig nach extrathyreoidalen Manifestationen, insbesondere einer EO gefahndet werden. Die Verifizierung und Klassifizierung durch den Ophthalmologen ist obligat. Therapeutisch muss schnellstmöglich eine Euthyreose, primär mittels thyreostatischer Therapie, erreicht werden, da bereits hierdurch eine Besserung der EO erzielt werden kann. Alle Patienten sollten dazu angehalten werden, das Rauchen aufzugeben. Die EO per se wird stadiengerecht durch Ophthalmologen behandelt. Bei unzureichender Kontrolle der Hyperthyreose bzw. Rezidiv des M. Basedow muss eine definitive Therapie der Schilddrüsenerkrankung erfolgen. Zur Verfügung stehen die Radiojodtherapie oder die Schilddrüsenoperation. Die Betreuung von Patienten mit M. Basedow und EO stellt eine komplexe Herausforderung dar und sollte in interdisziplinärer Zusammenarbeit von Internisten/Endokrinologen, Ophthalmologen, Nuklearmedizinern, Chirurgen und Strahlentherapeuten erfolgen.

Abstract

Graves’ orbitopathy (GO) is the most frequently observed extrathyroidal manifestation of Graves’ disease occurring in up to 40% of patients. Most patients with Graves’ orbitopathy are tested positive for TSH receptor autoantibodies (TRAb), which are pathognomonic for Graves’ disease and also play a central pathogenetic role in the development of GO. For the diagnosis of Graves’ disease, symptoms of hyperthyroidism, low TSH and high fT3 and/or fT4 levels and positive TRAbs are typical. All patients with Graves’ disease must be regularly examined for extrathyroidal manifestations, especially for Graves’ orbitopathy. For hyperthyroidism, treatment with antithyroidal drugs, such as thiamazole or propylthiouracil is initiated to quickly restore euthyroidism, which also frequently leads to improvement of Graves’ orbitopathy. Smoking cessation is also heavily mandated. In cases of relapse or ineffective antithyroidal treatment, radioiodine therapy or thyroid surgery is a further definitive therapeutic option to treat hyperthyroidism. The management of Graves’ orbitopathy remains clinically challenging and demands involvement of a multidisciplinary team including endocrinologists, ophthalmologists, surgeons, radiotherapists and nuclear medicine specialists.

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Correspondence to J. Seufert FRCPE.

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Laubner, K., Weber, W. & Seufert, J. Endokrine Orbitopathie aus internistischer Sicht. Ophthalmologe 108, 410–416 (2011). https://doi.org/10.1007/s00347-010-2185-9

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