Abstract: Graves? orbitopathy (GO) is the most common extrathyroidal manifestation of Graves? disease (GD). Our aim was to assess the ecacy and safety of Tocilizumab (TCZ) in GO refractory to conventional therapy. This was an open-label multicenter study of glucocorticoid-resistant GO treated with TCZ. The main outcomes were the best-corrected visual acuity (BVCA), Clinical Activity Score (CAS) and intraocular pressure (IOP). These outcome variables were assessed at baseline, 1st, 3rd, 6th and 12th month after TCZ therapy onset. The severity of GO was assessed according to the European Group on Graves? Orbitopathy (EUGOGO). We studied 48 (38 women and 10 men) patients (95 eyes); mean age  standard deviation 51  11.8 years. Before TCZ and besides oral glucocorticoids, they had received IV methylprednisolone (n = 43), or selenium (n = 11). GO disease was moderate (n =29) or severe (n = 19) and dysthyroid optic neuropathy (DON) (n = 7). TCZ was used in monotherapy (n = 45) or combined (n = 3) at a dose of 8 mg/kg IV every four weeks (n = 43) or 162 mg/s.c. every week (n = 5). TCZ yielded a significant improvement in all of the main outcomes at the 1st month that was maintained at one year. Comparing the baseline with data at 1 year all of the variables improved; BCVA (0.78  0.25 vs. 0.9  0.16; p = 0.0001), CAS (4.64  1.5 vs. 1.05  1.27; p = 0.0001) and intraocular pressure (IOP) (19.05  4.1 vs. 16.73  3.4 mmHg; p = 0.007). After a mean follow-up of 16.1  2.1 months, low disease activity (CAS  3), was achieved in 88 eyes (92.6%) and TCZ was withdrawn in 29 cases due to low disease activity (n = 25) or inecacy (n = 4). No serious adverse events were observed. In conclusion, TCZ is a useful and safe therapeutic option in refractory GO treatment.

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