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Comment on: ‘Thyroid eye disease and steroid therapy: risk stratification for bone health’

Eye (2026)Cite this article

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We read with interest the article ‘Mind the bone: a protocol for osteoporosis prophylaxis in patients with thyroid eye disease on intravenous methylprednisolone’ by Kanda et al. [1]. It raises a valid point about the missed opportunities of timely initiation of bisphosphonate therapy for primary prevention of osteoporosis in patients receiving intravenous steroids for thyroid eye disease (TED).

This approach would certainly also be applicable to a larger number of patients who are managed with oral prednisolone for TED [2]. Within hyperthyroidism management, there are several clinical scenarios that need oral steroids. Patients with severe hyperthyroidism (with or without TED) may be prescribed oral prednisolone alongside anti-thyroid medications to reduce peripheral conversion of T4 to T3. Prophylactic prednisolone is often prescribed in patients undergoing radioactive iodine therapy with stable TED or with retrosternal goitre to prevent relapse of TED and preventing thyroiditis respectively. Steroid courses are also used during management of thyroiditis, where the duration of treatment could be protracted based on the speed of recovery. It is also important to recognise that some patients may require short but multiple courses of steroids, and cumulative steroid exposure also contributes to loss of bone mineral density [3]. The current osteoporosis guidelines recommend considering anti-resorptive therapy if prednisolone ≥7.5 mg/day or equivalent is used for 3 months [4].

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References

  1. Kanda M, Nghiem AZ, Jawad A, Uddin J. Mind the bone: a protocol for osteoporosis prophylaxis in patients with thyroid eye disease on intravenous methylprednisolone. Eye. 2025;39:2733–5.

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  2. Vekinis JS, Clarke K, Lee V, Moledina M, Khan SR, Naik M, et al. Low risk of thyroid eye disease (TED) following radioiodine (RAI) therapy in a multidisciplinary setting: a retrospective cohort study. Thyroid Res. 2025;18:41–2.

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Authors and Affiliations

  1. Institute of Ophthalmology, University College London, London, UK

    Maria S. Varughese

  2. University of Sheffield Medical School, Royal Hallamshire Hospital, Sheffield, UK

    Maria S. Varughese

  3. University Hospitals of North Midlands NHS Trust, Stoke-on-Trent, North Staffordshire, UK

    Ananth U. Nayak & Lakshminarayanan Varadhan

  4. School of Medicine, Faculty of Health, Keele University, North Staffordshire, UK

    Ananth U. Nayak & Lakshminarayanan Varadhan

Authors
  1. Maria S. Varughese
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  2. Ananth U. Nayak
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  3. Lakshminarayanan Varadhan
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Contributions

MSV, AUN and LV reviewed the published article. MSV conducted the literature review. AUN examined the evidence base and contributed to the comments and discussion. LV and MSV wrote the article. MSV, AUN and LV contributed equally to this COMMENT.

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Correspondence to Lakshminarayanan Varadhan.

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Varughese, M.S., Nayak, A.U. & Varadhan, L. Comment on: ‘Thyroid eye disease and steroid therapy: risk stratification for bone health’. Eye (2026). https://doi.org/10.1038/s41433-025-04195-1

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