Comment on "factors associated with severity of orbitopathy in patients with Graves' disease.

Sir,

We thank Baretić Maja et al. for their comments on the study “Factors associated with severity of orbitopathy in patients with Graves’ disease” published in Taiwan J Ophthalmol. Smoking has been consistently noted as a risk factor for Graves’ orbitopathy (GO)[1234] perhaps by causing tissue hypoxia or simply direct inflammation.[45] In our study, current smoking increased the risk of severe GO by 3.35 times.[6] Smoking predisposes to severe GO, increases the progression or de novo occurrence of GO after radioiodine treatment, delays or worsens the outcome of immunosuppressive treatment for GO. The risk is proportional to the number of cigarettes smoked per day, and former smokers have a significantly lower risk than current smokers, even after adjusting for lifetime cigarette consumption.[7] Refraining from smoking might reduce the risk of developing GO.[8]

Cigarette smoking also predisposes to Graves’ disease,[9] but also is significantly associated with relapse of Graves’ disease.[10] Smoking and the presence of GO predicted the slow disappearance of thyrotropin receptor antibody.[11]

The American Thyroid Association recommends that all clinicians advise patients with Graves’ disease to stop smoking and refer them to a structured smoking cessation program. As both firsthand and secondhand smoking increase GO risk, patients exposed to secondhand smoke should be identified and advised of its negative impact.[11] European group on Graves’ orbitopathy (EUGOGO) also recommend that all patients with Graves’ disease, to refrain from smoking, irrespective of the presence or absence of GO.[8]

Baretić Maja et al. in their online survey on “Awareness of EUGOGO guidelines and attitudes regarding smoking in Graves’ orbitopathy in Croatia” among members of Croatian national societies found that 26% of the participants were not using EUGOGO guidelines and even 30% of all participants did not recognize smoking as risk factors determining the outcome of the disease. We agree with the author that there is an urgent need for recognition among clinicians as well as sensitizing patients regarding smoking cessation in patients with Graves’ disease, as smoking is the modifiable risk factor and also to refer patients to a structured smoking cessation program.

Financial support and sponsorship

Nil.

Conflicts of interest

The authors declare that there are no conflicts of interests of this paper.