What is the treatment for Hashimoto's thyroiditis?

From the Guidelines

The primary treatment for Hashimoto's thyroiditis is levothyroxine (T4), a synthetic thyroid hormone replacement medication. Treatment typically begins when the condition causes hypothyroidism, with starting doses usually between 25-125 mcg daily depending on the patient's age, weight, cardiac status, and severity of hypothyroidism, as stated in the USPSTF recommendation statement 1. The medication should be taken on an empty stomach, 30-60 minutes before breakfast or 3-4 hours after the last meal of the day. Dose adjustments are made based on thyroid-stimulating hormone (TSH) levels, which should be checked 6-8 weeks after starting treatment or changing doses, with the goal of maintaining TSH within normal range (typically 0.5-4.5 mIU/L) 1. Levothyroxine is a lifelong treatment, as Hashimoto's causes permanent thyroid damage. Regular monitoring is essential, with thyroid function tests recommended annually once stable. Certain medications and supplements (including calcium, iron, and antacids) can interfere with levothyroxine absorption, so they should be taken at least 4 hours apart. Treatment is necessary because the autoimmune attack in Hashimoto's progressively destroys thyroid tissue, reducing the gland's ability to produce essential hormones that regulate metabolism, energy, and numerous bodily functions.

Some key points to consider when treating Hashimoto's thyroiditis include:

• The principal treatment for hypothyroidism is oral T4 monotherapy (levothyroxine sodium) 1
• Hyperthyroidism is treated with antithyroid medications (such as methimazole) or nonreversible thyroid ablation therapy (for example, radioactive iodine or surgery) 1
• The USPSTF found no direct evidence that treatment of thyroid dysfunction based on risk level alters final health outcomes 1
• The serum TSH test is the primary screening test for thyroid dysfunction, and multiple tests should be done over a 3- to 6-month interval to confirm or rule out abnormal findings 1
• Follow-up testing of serum T4 levels in persons with persistently abnormal TSH levels can differentiate between subclinical (normal T4 levels) and “overt” (abnormal T4 levels) thyroid dysfunction 1
• The optimal screening interval for thyroid dysfunction (if one exists) is unknown 1
• Research Needs and Gaps: Although detection and treatment of abnormal TSH levels (with or without abnormal T4 levels) in asymptomatic persons is common practice, evidence that this clinical approach improves important health outcomes is lacking 1

From the FDA Drug Label

The general aim of therapy is to normalize the serum TSH level In adult patients with primary hypothyroidism, monitor serum TSH levels after an interval of 6 to 8 weeks after any change in dosage. The recommended daily dosage of levothyroxine sodium tablets in pregnant patients is described in Table 3. TSH Suppression in Well-differentiated Thyroid Cancer in Adult and Pediatric Patients The levothyroxine sodium dosage is based on the target level of TSH suppression for the stage and clinical status of thyroid cancer.

The treatment for Hashimoto's thyroiditis, which is a form of primary hypothyroidism, is levothyroxine sodium therapy, with the goal of normalizing the serum TSH level. The dosage is adjusted based on the patient's response, with monitoring of serum TSH levels every 6 to 8 weeks after any change in dosage in adults, and every 3 to 12 months in pediatric patients after dosage stabilization 2.

From the Research

Treatment Options for Hashimoto's Thyroiditis

The treatment for Hashimoto's thyroiditis depends on the clinical presentation and the degree of thyroid dysfunction.

• For patients with hypothyroidism, thyroid hormone replacement therapy is the primary treatment, typically with levothyroxine (LT4) 3, 4, 5.
• The dose of LT4 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.
• In some cases, patients may require a different formulation of LT4, such as an oral solution, due to malabsorption or other gastrointestinal issues 4.
• For patients with thyrotoxicosis, symptoms are usually controlled with β-blockers 3.
• Euthyroidism requires periodical thyroid stimulating hormone measurements to assess for progression to hypothyroidism 3.

Surgical Treatment

Surgical treatment may be necessary for some patients with Hashimoto's thyroiditis, including those with:

• Thyromegaly with compression symptoms, non-responding to L-thyroxin treatment 6.
• Nodular form of HT with dominant thyroid nodul over 2 cm in size 6.
• Suspicion for neoplasm or an unsightly neck appearance due to a large goiter 6.

Combinatorial Treatment

Combinatorial treatment with warming and invigorating drugs and levothyroxine may be effective for hypothyroidism caused by Hashimoto disease, although further evidence is needed to confirm this 7.

• This treatment approach may improve FT3, FT4, TSH, TPOAb, and TGAb levels more than levothyroxine alone 7.

Special Considerations

Patients with immune checkpoint inhibitor-associated hypothyroidism may require a different LT4 dose than those with Hashimoto's thyroiditis, with a recommended initial dose of 1.45 mcg/[kg·day] 5.