What is the treatment for thyroiditis?

Treatment of Thyroiditis

The treatment of thyroiditis depends on the specific type, with levothyroxine being the standard treatment for hypothyroidism caused by Hashimoto's thyroiditis, while subacute thyroiditis requires anti-inflammatory medications with steroids being more effective than NSAIDs. 1, 2

Types of Thyroiditis and Their Treatment

Hashimoto's Thyroiditis

• First-line treatment: Levothyroxine replacement therapy 1, 3
• Dosing considerations:
  • Adults under 70 without cardiac disease: 1.6 mcg/kg/day (target TSH: 0.5-2.0 mIU/L)
  • Elderly patients or those with cardiac conditions: 25-50 mcg/day (target TSH: 1.0-4.0 mIU/L)
  • Pregnant women: Dose adjusted to maintain trimester-specific TSH reference range 1
• Monitoring: Check thyroid function (TSH and free T4) 4-6 weeks after starting therapy and adjust dose to maintain TSH within target range 1
• Long-term follow-up: Monitor TSH and free T4 levels every 6-12 months or if symptoms change 1

Subacute Thyroiditis

• Treatment focuses on symptom management through the triphasic disease pattern (hyperthyroidism → hypothyroidism → normal function) 2

• Anti-inflammatory options:

  1. Corticosteroids (preferred): Methylprednisolone provides faster symptomatic relief within 2 weeks 4

     • Initial dose: Prednisone 40 mg daily with gradual reduction over several weeks 5
     • More effective than NSAIDs for early clinical remission 4
     • Associated with lower risk of permanent hypothyroidism (6.6% vs 22.8% with NSAIDs) 4

  2. NSAIDs: Ibuprofen 1800 mg daily 4

     • Less effective than steroids (59.5% of patients require switching to steroids) 4
     • Higher risk of permanent hypothyroidism, especially in anti-TPO positive patients 4

• Hyperthyroid phase management: Beta-blockers (propranolol or atenolol) for adrenergic symptoms like tachycardia and palpitations 1, 2

• Hypothyroid phase management:

  • Temporary hypothyroidism often resolves without treatment
  • Consider levothyroxine for symptomatic patients or if TSH >10 mIU/L 2, 6
  • Monitor for permanent hypothyroidism (occurs in 6.6-22.8% of patients) 4

Postpartum Thyroiditis

• Occurs within one year of delivery, miscarriage, or medical abortion 2
• Management:
  • Monitor for changes in thyroid function 6
  • Beta-blockers for hyperthyroid symptoms 6
  • Levothyroxine for hypothyroid phase if TSH >10 mIU/L or if symptomatic with TSH 4-10 mIU/L 6
  • Consider levothyroxine in women desiring fertility 6

Special Considerations

• Risk factors for permanent hypothyroidism:

  • Treatment with NSAIDs only (rather than steroids) 4
  • Positive thyroid peroxidase antibody (anti-TPO) 4

• Thyroid storm (severe thyrotoxicosis):

  • Medical emergency requiring:
    • Propylthiouracil or methimazole
    • Saturated solution of potassium iodide or sodium iodide
    • Dexamethasone
    • Supportive care (oxygen, antipyretics, monitoring) 7
  • Propylthiouracil is preferred in thyroid storm 1

• Medication warnings:

  • Levothyroxine should not be used for weight loss or obesity treatment 3
  • Administer levothyroxine as a single daily dose on an empty stomach, 30-60 minutes before breakfast 3
  • Take levothyroxine at least 4 hours before or after medications that interfere with absorption 3

Treatment Algorithm

1. Identify thyroiditis type based on clinical presentation, thyroid function tests, and antibodies
2. For Hashimoto's thyroiditis with hypothyroidism: Start levothyroxine based on age and cardiac status
3. For subacute thyroiditis:
   • If mild to moderate symptoms: Trial of NSAIDs
   • If severe symptoms or inadequate response to NSAIDs: Switch to corticosteroids
   • Add beta-blockers for hyperthyroid symptoms
   • Monitor for transition to hypothyroid phase and treat if symptomatic
4. For postpartum thyroiditis: Monitor thyroid function and treat symptomatically through phases

Regular monitoring of thyroid function is essential for all types of thyroiditis to assess treatment response and detect permanent hypothyroidism.