Life-threatening complications of high doses of intravenous methylprednisolone for treatment of Graves’ orbitopathy

BACKGROUND: Treatment of moderate to severe Graves’ orbitopathy (GO) is based mainly on intravenous pulses of methylprednisolone. High doses of methylprednisolone can exert several adverse effects, some of which might be life-threatening. The objective of this study is to describe the most severe complications associated with intravenous administration of high doses of glucocorticoids, and to develop the patient examination standards prior to their qualification for the therapy. MAIN BODY: In this paper, we describe the most severe, life-threatening complications of intravenous methylprednisolone and address their possible underlying mechanism. We also present recommendations and precautions which should be taken prior to initiation of intravenous pulses of methylprednisolone treatment for GO. To address risk of hepatic complications, we recommend regular monitoring of biochemical parameters of hepatic function. Additionally, assessment of the risk of cardiovascular events should be undertaken based on medical history, estimation of risk factors, and investigations, such as determination of thyroid hormones and thyroid-stimulating hormone levels, electrolyte and glucose concentrations, electrocardiogram examination and measurements of blood pressure. CONCLUSIONS: An individualized safe and effective dose of intravenous methylprednisolone should be established for each patient with GO based on the vascular risk factors, comorbidities, and concomitant drugs. According to the European Group on Graves’ Orbitopathy (EUGOGO) guidelines, cumulative doses of intravenous methylprednisolone should not exceed 8 g.