What is the treatment for Hashimoto's thyroiditis?

From the Guidelines

The primary treatment for Hashimoto's thyroiditis is thyroid hormone replacement therapy, typically with levothyroxine (synthetic T4). Start with a low dose, usually 25-50 mcg daily, and adjust based on thyroid function tests every 6-8 weeks until levels normalize. The goal is to achieve a TSH level within the normal range, usually between 0.5-2.5 mIU/L, as recommended by the USPSTF 1.

In addition to medication, patients should:

• Have regular thyroid function tests (at least annually once stable)
• Maintain adequate iodine intake through diet or supplements
• Consider selenium supplementation (200 mcg daily) to potentially reduce antibodies
• Adopt a gluten-free diet if celiac disease is present (more common in Hashimoto's patients)

Levothyroxine works by replacing the thyroid hormone that the body is unable to produce due to the autoimmune attack on the thyroid gland. This helps alleviate symptoms such as fatigue, weight gain, and depression. The medication is typically taken for life, as Hashimoto's is a chronic condition. It's crucial to take levothyroxine on an empty stomach, at least 30-60 minutes before eating or drinking anything other than water, to ensure proper absorption. Certain medications and supplements can interfere with absorption, so discuss all medications with your healthcare provider.

The USPSTF found no direct evidence that treatment of thyroid dysfunction based on risk level alters final health outcomes 1. However, treatment is generally recommended for patients with a TSH level that is undetectable or less than 0.1 mIU/L, particularly those with overt Graves disease or nodular thyroid disease. Treatment is typically not recommended for patients with TSH levels between 0.1 and 0.45 mIU/L or when thyroiditis is the cause 1.

Long-term randomized, blinded, controlled trials of screening for thyroid dysfunction would provide the most direct evidence on any potential benefits of this widespread practice 1. Important clinical outcomes include cardiovascular- and cancer-related morbidity and mortality, as well as falls, fractures, functional status, and quality of life.

From the FDA Drug Label

Thyroid hormone drugs are indicated: As replacement or supplemental therapy in patients with hypothyroidism of any etiology, except transient hypothyroidism during the recovery phase of subacute thyroiditis... As pituitary thyroid-stimulating hormone (TSH) suppressants, in the treatment or prevention of various types of euthyroid goiters, including thyroid nodules, subacute or chronic lymphocytic thyroiditis (Hashimoto's) and multinodular goiter The treatment for Hashimoto's thyroiditis is:

• Replacement or supplemental therapy with thyroid hormone drugs, such as liothyronine, for patients with hypothyroidism resulting from Hashimoto's thyroiditis
• TSH suppressants to treat or prevent euthyroid goiters associated with Hashimoto's thyroiditis 2

From the Research

Treatment Options for Hashimoto's Thyroiditis

• The primary treatment for Hashimoto's thyroiditis is levothyroxine (LT4) replacement therapy, which is usually lifelong 3, 4, 5.
• The dose of LT4 used for treatment is based on the degree of preserved thyroid functionality and lean body mass, and usually ranges from 1.4 to 1.8 mcg/kg/day 3.
• Photobiomodulation (PBM) has been shown to be effective in increasing T3/T4 ratio and decreasing thyroid peroxidase antibody (TPO Ab) levels and weekly dosages of LT4 replacement therapy 6.
• Selenium supplementation has been found to be useful as an adjunctive therapy to LT4 in the treatment of Hashimoto's thyroiditis, with a significant decrease in TPOab titers and improvement in mood and/or general well-being 7.

Management of Hashitoxicosis

• The management of Hashitoxicosis is based on symptoms control, usually with β-blockers 3.
• Euthyroidism requires periodical thyroid stimulating hormone measurements to assess for progression to hypothyroidism 3.
• Hypothyroidism is treated with thyroid hormone replacement therapy, with the dose of LT4 adjusted based on the degree of preserved thyroid functionality and lean body mass 3, 5.

Special Considerations

• Patients with immune checkpoint inhibitor-associated hypothyroidism may require a different dose of LT4 than patients with Hashimoto's thyroiditis, with a recommended initial weight-based dose of 1.45 mcg/[kg·day] 5.
• Pregnant women with Hashimoto's thyroiditis require special consideration, with only levothyroxine indicated for treatment due to the insufficient evidence for the use of triiodothyronine (T3) 3.