For decades, corticosteroids were considered the primary medical treatment for moderate-to-severe thyroid eye disease (TED) 1. While steroids remain an important part of treatment in certain situations, the approval of Tepezza® (teprotumumab) has fundamentally changed how physicians approach this complex autoimmune condition (2). Because patients now have more treatment options for TED it is important for patients to understand how Tepezza compares with traditional steroid therapy and whether one treatment is “better” than the other.
Although both therapies aim to reduce the underlying inflammation associated with TED, they work through different mechanisms and may be used at different stages of disease management or for different patient needs. (3) Understanding these differences can help patients have informed conversations with their physicians and better understand why one treatment may be recommended over another.
Understanding the Role of Steroids in Thyroid Eye Disease
Before targeted biologic therapies became available, intravenous corticosteroids, most commonly intravenous methylprednisolone (IVMP), were considered the first-line treatment for active, moderate-to-severe TED. Steroids work by broadly suppressing the immune system, reducing inflammation throughout the body. In TED, this helps decrease inflammatory swelling within the orbit, leading to improvements in pain, redness, eyelid swelling, and other signs of active disease.
However, this broad immunosuppressive effect of steroids has important limitations. Although steroids effectively control inflammation, they have limited ability to reverse proptosis (eye bulging) or cause lasting change. They are better for short-term treatment than long-term. Many patients treated with steroids ultimately require additional medications or surgery to address persistent proptosis and/or double vision (5).
How Tepezza is Different
While both steroids and Tepezza are intended to reduce the inflammation and orbital changes caused by TED, they work differently. Steroids provide broad immune suppression to quickly reduce inflammation, while Tepezza specifically targets IGF-1R, a pathway involved in orbital tissue expansion, inflammation, and fibrosis.
Unlike corticosteroids, Tepezza is a monoclonal antibody and targeted biologic therapy. Rather than broadly suppressing the immune system, Tepezza specifically blocks the insulin-like growth factor-1 receptor (IGF-1R), disrupting a key signaling pathway involved in the autoimmune process that drives TED. Activation of the IGF-1 receptor contributes to the expansion of orbital fat, enlargement of the eye muscles, inflammation, and excess production of hyaluronic acid, all of which result in tissue remodeling that pushes the eye forward. By interrupting this pathway, Tepezza targets a specific pathway involved in the inflammation, tissue expansion, and remodeling associated with TED. This targeted mechanism helps explain why Tepezza produces improvements in eye bulging that were rarely achievable with steroids alone (6).
Comparing Effectiveness
The greatest difference between the two therapies lies in their effects on proptosis. Multiple clinical studies have demonstrated that Tepezza produces significantly greater reductions in eye bulging than intravenous steroids. Clinical studies have consistently shown that patients treated with teprotumumab experience greater improvements in both proptosis and double vision than those treated with intravenous methylprednisolone (7). In many patients, the reduction in proptosis with TEPEZZA approaches those historically achieved only with orbital decompression surgery. In contrast, steroids, while effective at reducing inflammation, generally produce more modest improvements in proptosis.
Long-Term Treatment Needs
Another important consideration is whether either treatment reduces the need for additional therapies. A recent retrospective study comparing patients treated with intravenous steroids and Tepezza found that overall rates of additional TED-related interventions were similar, but there were important differences in the types of treatments that followed. Patients initially treated with steroids were more likely to require multiple additional medications over time, whereas patients treated with Tepezza generally followed a simpler treatment course with fewer subsequent medical interventions. Although neither treatment completely eliminated the possibility of future interventions, Tepezza reduced the overall complexity of long-term disease management.
These differences reflect the distinct ways the two therapies work. Steroids are particularly effective for rapidly reducing inflammation-related symptoms such as eyelid swelling, redness, and pain. Tepezza also reduces inflammation while targeting the IGF-1R pathway involved in orbital tissue changes, which may lead to greater improvements in proptosis and double vision for appropriate patients.
Different Safety Profiles
Another major difference lies in the side effects. Because steroids produce broad nonspecific immunosuppression, they may cause weight gain, elevated blood sugar, high blood pressure, mood changes, insomnia, osteoporosis, increased infection risk and liver toxicity (particularly with high cumulative IV doses). These risks become greater with prolonged or repeated treatment (1).
Tepezza has a different side-effect profile because it targets a specific receptor rather than suppressing the immune system as a whole (8). Reported side effects include muscle cramps, hearing changes, elevated blood sugar, hair thinning, diarrhea, fatigue and changes in taste. Although hearing-related side effects have received increasing attention, many cases improve after treatment ends, particularly when patients undergo appropriate baseline and follow-up hearing monitoring.
As with any medication, neither therapy is free from risk, making individualized treatment decisions essential.
Mode of Administration
Intravenous steroids are typically administered over several weeks, with dosing schedules depending on disease severity and physician preference. Tepezza follows a standardized protocol consisting of eight intravenous infusions administered every three weeks, completing treatment over approximately five months. Although the infusion schedule is longer, it also allows physicians to monitor response and side effects throughout treatment.
Intravenous steroids remain appropriate for patients with active inflammatory disease, individuals requiring rapid control of inflammation and certain patients with contraindications to biologic therapy. Tepezza may be particularly valuable for patients with moderate-to-severe active TED, significant proptosis, progressive double vision, poor response to steroids and a desire to reduce the likelihood of needing decompression surgery
Regardless of the treatment selected, patient-specific factors including disease activity, duration, medical history, diabetes status, hearing health, and treatment goals all holistically influence the decision.
The choice between steroids and Tepezza depends on several factors, including disease severity, how quickly inflammation needs to be controlled, symptoms affecting vision, medical history, and treatment availability. Steroids may be preferred when rapid inflammation control is needed, while Tepezza may be considered for patients with moderate-to-severe active TED who have significant proptosis, double vision, or other symptoms related to orbital tissue changes.
Despite the strong efficacy of Tepezza, corticosteroids continue to play an important role in the management of TED. They are still commonly used for urgent cases involving vision-threatening optic neuropathy, as a temporary treatment while other therapies are arranged, or when biologic treatments are not available or appropriate. Rather than replacing corticosteroids, Tepezza has expanded the therapeutic options available to physicians managing TED.
The Importance of Individualized Care
As mentioned above, the decision between steroids and Tepezza is rarely one-size-fits-all. Factors that influence treatment selection include disease severity, Clinical Activity Scores (CAS), degree of proptosis, presence of optic nerve compression, double vision, medical comorbidities, previous treatments and also patient preference. An experienced TED specialist considers all of these variables before deciding the course of therapy.
The Bottom Line
Both corticosteroids and Tepezza remain valuable treatment options for TED, but they differ in how they target the disease and when they may be most appropriate. Steroids are highly effective at rapidly reducing inflammation and remain an important option for many patients. However, they have a limited ability to reverse eye bulging and often require additional therapies over time.
Tepezza represents a different approach by targeting one of the key biological pathways responsible for TED. Studies suggest it provides greater improvements in proptosis and double vision while simplifying the long-term treatment pathway for many patients.
Working with an experienced TED specialist allows treatment to be tailored to an individual’s disease activity, symptoms, and long-term goals, maximizing outcomes while minimizing unnecessary risks. If you are interested in learning more about your treatment options, schedule an appointment with Dr. Raymond Douglas without delay.
References
- Eid KT, Kally PM, Kahana A. Orbital corticosteroid injections for the treatment of active thyroid eye disease. Front Ophthalmol (Lausanne). 2023;3:1296092. Epub 20240104. doi: 10.3389/fopht.2023.1296092. PubMed PMID: 38983036; PMCID: PMC11182274.
- Couch SM. Teprotumumab (Tepezza) for Thyroid Eye Disease. Mo Med. 2022;119(1):36-41. PubMed PMID: 36033157; PMCID: PMC9312457.
- Fox T, Kossler AL, Dosiou C. Thyroid Eye Disease: Management, Advances, and Future Opportunities. Endocr Pract. 2025;31(10):1319-28. Epub 20250617. doi: 10.1016/j.eprac.2025.06.011. PubMed PMID: 40553958.
- Butt S, Patel BC. Exophthalmos. StatPearls. Treasure Island (FL)2025.
- Rootman DB. Orbital decompression for thyroid eye disease. Surv Ophthalmol. 2018;63(1):86-104. Epub 20170324. doi: 10.1016/j.survophthal.2017.03.007. PubMed PMID: 28343872.
- Shabto JM, Stevens S, Gregerson C, Kazim M. Transformation of Thyroid Eye Disease Phenotype Following Teprotumumab Treatment. Ophthalmic Plast Reconstr Surg. 2025. Epub 20251106. doi: 10.1097/IOP.0000000000003110. PubMed PMID: 41196136.
- Douglas RS, Kahaly GJ, Ugradar S, Elflein H, Ponto KA, Fowler BT, Dailey R, Harris GJ, Schiffman J, Tang R, Wester S, Jain AP, Marcocci C, Marino M, Antonelli A, Eckstein A, Fuhrer-Sakel D, Salvi M, Sile S, Francis-Sedlak M, Holt RJ, Smith TJ. Teprotumumab Efficacy, Safety, and Durability in Longer-Duration Thyroid Eye Disease and Re-treatment: OPTIC-X Study. Ophthalmology. 2022;129(4):438-49. Epub 20211021. doi: 10.1016/j.ophtha.2021.10.017. PubMed PMID: 34688699.
- Mukit FA, Manley A, Patel AB, Hashemi M, Laplant JF, Fleming JC, Fowler BT. Side Effects and Adverse Events After Treatment With Teprotumumab for Thyroid Eye Disease: A Retrospective Observational Case Series. Cureus. 2024;16(4):e58585. Epub 20240419. doi: 10.7759/cureus.58585. PubMed PMID: 38765324; PMCID: PMC11102658.
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