Editorial [Hot Topic : Graves' Orbitopathy - A Therapeutic Challenge (Guest Editor: John H. Lazarus)]

Graves' orbitopathy occurs in around 30&percnt of patients with Graves' disease and ranges in clinical severity from mild to severe. Even mild disease can affect quality of life significantly while severe disease can be sight threatening. This issue of Immunology, Endocrine and metabolic Agents in Medicinal Chemistry explores the therapy of this condition. Before considering therapy however, the pathogenesis must be appreciated. Draman and Ludgate update our understanding in this regard as well as indicating where our knowledge is deficient. While the clinical presentation of this condition may be obvious to some clinicians the experience from The European Group on Graves' Orbitopathy (EUGOGO) has reported that many patients are diagnosed late as the early signs may be mistaken for other conditions. Heggie and Petros Perros, the current chairman of EUGOGO, review the clinical features of the condition as well as commenting on the psychosocial aspects. It is important to note that The Amsterdam Declaration (2009) seeks to achieve greater access of patients to centres of excellence. Until recently the treatment of Graves' orbitopathy has included symptomatic measures, immunosuppression and surgical intervention.. Steroids have been the mainstay of immunosuppressive therapy; Zang and Kahaly review this modality concentrating on the immunological action as well as the mode of administration. Developments in our understanding of the immune system have given rise to new possibilities in therapy for autoimmune diseases. Rituximab, which depletes memory CD20+ B cells has been used with success in rheumatoid arthritis: Salvi and colleagues report their experience with this targeted immune modulator in Graves' orbitopathy. Further discussion of potential targets for immunotherapy is presented by Smith who explores different facets of the immune system in this regard. One of the features of this issue was that it should incorporate a communication from the pharmaceutical industry on which we depend for drug development. The review by van Maurik and colleagues illustrates the wide variety of new immune modulators that are currently available; it is to be hoped that at least some of them will be studied in the management of orbitopathy in the near future. I would like to thank sincerely all the contributors to this volume for their work and patience. I believe the end result amply justifies the effort.