What is the treatment for autoimmune thyroiditis and Graves' disease?

Treatment of Autoimmune Thyroiditis and Graves' Disease

The treatment for autoimmune thyroiditis and Graves' disease should be tailored based on the specific condition and thyroid function status, with levothyroxine therapy for hypothyroidism and anti-thyroid medications, radioactive iodine, or surgery for hyperthyroidism. 1, 2

Autoimmune Thyroiditis (Hashimoto's)

Hypothyroid Phase

• For symptomatic patients with any degree of TSH elevation, initiate levothyroxine therapy 1
• For asymptomatic patients with persistent TSH levels >10 mIU/L, levothyroxine therapy is recommended 1
• Initial dosing:
  • Adults <70 years without cardiac disease: 1.6 mcg/kg/day based on ideal body weight 1
  • Adults >70 years or with cardiac disease: Start with 25-50 mcg/day and titrate gradually 1, 3
• Monitor TSH every 6-8 weeks while titrating dose to achieve TSH within reference range 1
• Once stabilized, monitor every 6-12 months or with symptom changes 1

Euthyroid Phase

• For patients with positive antibodies but normal thyroid function, monitoring without immediate treatment is recommended 1, 4
• Regular follow-up to detect progression to hypothyroidism is essential 5

Graves' Disease

Initial Management Options

• Three primary treatment approaches exist 2:
  1. Anti-thyroid medications (methimazole)
  2. Radioactive iodine ablation
  3. Surgical thyroidectomy

Medication Management

• Methimazole is indicated for patients with Graves' disease for whom surgery or radioactive iodine is not appropriate 6
• Also used to ameliorate symptoms in preparation for definitive therapy (radioactive iodine or surgery) 6
• Beta-blockers (e.g., atenolol 25-50 mg daily) provide symptomatic relief of adrenergic symptoms 3, 1

Severity-Based Management

• Grade 1 (Asymptomatic/mild): Continue immune checkpoint inhibitors if applicable, use beta-blockers for symptomatic relief 3
• Grade 2 (Moderate): Consider holding immune therapy, use beta-blockers, provide hydration and supportive care 3
• Grade 3-4 (Severe): Hold immune therapy, endocrine consultation, beta-blockers, hospitalization for severe cases 3

Definitive Treatment

• In the United States, most adult patients with Graves' disease are initially or eventually treated with radioactive iodine thyroid ablation 2
• After radioactive iodine treatment, patients often develop hypothyroidism requiring lifelong levothyroxine therapy 7

Transient Thyroiditis

Hyperthyroid Phase

• Beta-blockers for symptomatic relief 1, 4
• Monitor thyroid function every 2-3 weeks to detect transition to hypothyroidism 1
• For persistent thyrotoxicosis (>6 weeks), consider endocrine consultation 3

Hypothyroid Phase

• Short-term levothyroxine may be needed if symptomatic 4
• Most cases resolve spontaneously, but some develop permanent hypothyroidism requiring lifelong therapy 4

Special Considerations

Conversion Between Conditions

• Approximately 15-20% of patients with Graves' disease develop spontaneous hypothyroidism from chronic thyroiditis 8
• This transition may occur months to years after treatment of Graves' disease 8, 7

Monitoring

• All forms of thyroiditis require surveillance and clinical follow-up to monitor for changes in thyroid function 4
• Elevated TSH in recovery phase of thyroiditis may not require immediate treatment if FT4 is normal 1

Lifestyle Factors

• Healthy diet, appropriate supplementation of vitamins and microelements may be beneficial 5
• Regular monitoring for thyroid gland enlargement and development of nodular goiter is important 5