Are steroids indicated in Hashimoto's Thyroiditis?

Steroids in Hashimoto's Thyroiditis

Steroids are not indicated in the routine management of Hashimoto's thyroiditis and should be reserved only for specific rare complications or variants of the disease.

Standard Management of Hashimoto's Thyroiditis

Hashimoto's thyroiditis is an autoimmune disorder characterized by thyroid-specific autoantibodies (thyroid peroxidase and thyroglobulin) that typically leads to hypothyroidism. The standard treatment approach focuses on:

• Thyroid hormone replacement therapy (levothyroxine) for patients with overt hypothyroidism 1
• Clinical monitoring for patients with subclinical disease or normal thyroid function

When Steroids Might Be Considered

Steroids are only considered in specific, uncommon presentations of Hashimoto's thyroiditis:

1. Painful variant of Hashimoto's thyroiditis:

   • This is an uncommon presentation where patients experience thyroid tenderness
   • However, research shows that corticosteroid therapy is often unsuccessful in treating painful Hashimoto's thyroiditis 2
   • L-thyroxine and aspirin have shown better success rates for pain management in these cases

2. Hashimoto's encephalopathy:

   • A rare neurological complication associated with Hashimoto's thyroiditis
   • Presents with seizures, stroke-like episodes, cognitive decline, or psychiatric symptoms
   • Steroids may be indicated in this specific complication

Risks of Steroid Therapy

Using steroids for Hashimoto's thyroiditis carries significant risks:

• Hypothalamic-pituitary-adrenal (HPA) axis suppression 3
• Risk of adrenal crisis with abrupt discontinuation
• Suppression may persist for up to 12 months after stopping therapy
• Common side effects including weight gain, hypertension, gastric irritation, mood changes, and immunosuppression
• Osteopenia with long-term use
• Increased risk of infections

Evidence Against Routine Steroid Use

The current medical literature does not support the use of steroids as a standard treatment for Hashimoto's thyroiditis:

• No evidence that steroids alter the natural course of the disease
• Steroids do not provide long-term benefits for thyroid function
• One small study from 1989 suggested that prednisolone treatment in a patient with Hashimoto's thyroiditis (who also had SLE and Sjögren's syndrome) affected antibody titers, but this was a single case with multiple autoimmune conditions 4
• Recent research (2024) shows that thyroid antibodies in Hashimoto's thyroiditis are associated with inflammation and multiple symptoms, but this doesn't translate to steroid therapy being beneficial 5

Treatment Algorithm for Hashimoto's Thyroiditis

1. Diagnosis confirmation:

   • Elevated thyroid peroxidase (TPO) and/or thyroglobulin (TG) antibodies
   • Clinical assessment for signs of hypothyroidism
   • Thyroid function tests (TSH, free T4)

2. For patients with overt hypothyroidism:

   • Initiate levothyroxine replacement therapy
   • Titrate dose based on TSH levels

3. For patients with subclinical hypothyroidism:

   • Consider levothyroxine if TSH >10 mIU/L or if symptomatic
   • Monitor thyroid function regularly if not treating

4. For euthyroid patients with positive antibodies:

   • Regular monitoring of thyroid function
   • No specific treatment required

5. For painful variant:

   • Consider L-thyroxine and NSAIDs for pain management
   • Surgical intervention (thyroidectomy) may be considered for intractable pain
   • Steroids are generally not effective 2

Conclusion

Based on current evidence, steroids should not be routinely used in the management of Hashimoto's thyroiditis. The mainstay of treatment remains thyroid hormone replacement therapy for hypothyroidism. Steroids carry significant risks of adverse effects and HPA axis suppression that outweigh any potential benefits in typical cases of Hashimoto's thyroiditis.