What is the management and treatment of thyroiditis?

From the Guidelines

Thyroiditis is a serious condition that requires prompt management and treatment to prevent long-term complications and improve quality of life. The management and treatment of thyroiditis depend on the specific type and symptoms present.

Types of Thyroiditis and Treatment

• For painful subacute thyroiditis, NSAIDs like ibuprofen (400-800mg three times daily) are first-line treatment, with prednisone (40mg daily, tapered over 2-4 weeks) reserved for severe cases 1.
• Hashimoto's thyroiditis typically requires lifelong levothyroxine replacement therapy, starting at 1.6 mcg/kg/day and adjusted based on TSH levels.
• Postpartum thyroiditis often resolves spontaneously but may require beta-blockers like propranolol (10-40mg three times daily) for hyperthyroid symptoms or temporary levothyroxine for hypothyroid phase.
• Silent thyroiditis generally needs only symptomatic treatment.
• Suppurative thyroiditis requires antibiotics targeting the causative organism and possible surgical drainage.
• Radiation-induced thyroiditis may respond to NSAIDs and beta-blockers.

Monitoring and Treatment Approach

Regular monitoring of thyroid function is essential for all types, as some patients may transition from transient to permanent hypothyroidism 1. Treatment aims to manage inflammation, control symptoms, and restore normal thyroid function, with the approach tailored to the underlying cause, severity of symptoms, and thyroid hormone status. For patients with immune-related adverse events, such as those treated with immune checkpoint inhibitor therapy, guidelines recommend monitoring TSH and FT4 levels every 4-6 weeks, with management based on grading of symptoms 1. In severe cases, hospitalization and endocrine consultation may be necessary to manage life-threatening consequences. Overall, a comprehensive approach to managing thyroiditis is crucial to preventing long-term morbidity and mortality, and improving quality of life.

From the FDA Drug Label

Limitations of Use: • Levothyroxine sodium tablets are not indicated for suppression of benign thyroid nodules and nontoxic diffuse goiter in iodine-sufficient patients • Levothyroxine sodium tablets are not indicated for treatment of hypothyroidism during the recovery phase of subacute thyroiditis.

The management and treatment of thyroiditis is not directly addressed in the provided drug labels, except that levothyroxine sodium tablets are not indicated for treatment of hypothyroidism during the recovery phase of subacute thyroiditis.

• The labels do provide information on the treatment of hypothyroidism, but this is not the same as thyroiditis.
• Thyroiditis can have different causes and manifestations, and its treatment may vary depending on the specific condition.
• The labels do not provide information on the seriousness of thyroiditis. 2 2

From the Research

Overview of Thyroiditis

• Thyroiditis is a general term for inflammation of the thyroid gland, with the most common forms being Hashimoto, postpartum, and subacute thyroiditis 3, 4, 5.
• The disease pattern of thyroid dysfunction in thyroiditis is often triphasic, consisting of an initial phase of hyperthyroidism, followed by hypothyroidism, and eventual restoration of normal thyroid function 3, 4.

Management and Treatment of Thyroiditis

• Treatment of thyroiditis focuses on symptomatic relief, with beta blockers used to treat adrenergic symptoms in the hyperthyroid phase and levothyroxine used in the hypothyroid phase 3, 4.
• Nonsteroidal anti-inflammatory drugs (NSAIDs) and corticosteroids are indicated for the treatment of thyroid pain 3, 4, 6, 7.
• In cases of subacute thyroiditis, steroid treatment may be considered, especially in patients with positive thyroid peroxidase antibody (anti-TPO) or high-level acute phase reactants 6.
• Low-dose prednisolone (15 mg/day) has been shown to be an effective and safe treatment method for patients with subacute thyroiditis who are unresponsive to NSAID therapy 7.

Specific Considerations for Different Forms of Thyroiditis

• Hashimoto thyroiditis is an autoimmune disorder that presents with or without signs or symptoms of hypothyroidism, often with a painless goiter, and is associated with elevated thyroid peroxidase antibodies 3, 4, 5.
• Postpartum thyroiditis occurs within one year of delivery, miscarriage, or medical abortion, and patients should be monitored for changes in thyroid function 3, 4.
• Subacute thyroiditis is a self-limited inflammatory disease characterized by anterior neck pain, and treatment should focus on symptoms, with NSAIDs or corticosteroids used to relieve pain and control the inflammatory process 3, 4, 6, 7.

Risk Factors and Complications

• Certain drugs, such as amiodarone, immune checkpoint inhibitors, interleukin-2, interferon-alfa, lithium, and tyrosine kinase inhibitors, may induce thyroiditis 3.
• Treatment with only ibuprofen and positive thyroid peroxidase antibody (anti-TPO) have been determined as the main risk factors for permanent hypothyroidism 6.
• Subacute thyroiditis can cause significant deterioration in quality of life and sleep, but low-dose steroid treatment has been shown to be effective in improving these parameters 7.