Management of Subacute Thyroiditis

Beta-blockers are the first-line treatment for symptomatic relief in subacute thyroiditis, with additional therapies based on symptom severity. 1

Initial Treatment Approach

Beta-blockers (such as propranolol or atenolol) should be initiated for symptomatic relief of adrenergic symptoms including palpitations, tremors, and fever during the thyrotoxic phase 1, 2
For patients with mild pain, nonsteroidal anti-inflammatory drugs (NSAIDs) are recommended for pain management 3, 4
Monitor thyroid function every 2-3 weeks to detect transition to hypothyroidism, which is the most common outcome 1, 2

For patients with severe symptoms or significant pain, systemic glucocorticoids are recommended as they provide more rapid and effective relief 4, 5
Prednisone may be initiated at 40 mg daily with gradual tapering over several weeks 4
Corticosteroids typically provide symptomatic relief within 24-48 hours 4
NSAIDs alone are often inadequate for severe symptoms, with studies showing that 59.5% of patients treated with ibuprofen alone required a change to steroid therapy 5

Subacute thyroiditis typically follows a triphasic pattern:

Beta-blockers for symptomatic control of adrenergic symptoms 2, 1
Pain management with NSAIDs or corticosteroids based on symptom severity 4, 5
Avoid antithyroid drugs as the thyrotoxicosis is due to release of preformed thyroid hormone, not increased production 3

Monitor for development of hypothyroidism, which occurs in many patients as thyroid stores are depleted 3, 6
Consider levothyroxine therapy if symptomatic hypothyroidism develops or if TSH > 10 mIU/L 7
Most patients will recover normal thyroid function within 6-12 months 6

Most patients (>90%) will return to normal thyroid function 4
Permanent hypothyroidism develops in approximately 5-15% of patients, with higher risk in those with positive thyroid peroxidase antibodies 5

Patients with positive thyroid peroxidase antibodies have a higher risk of developing permanent hypothyroidism and may benefit from early steroid treatment 5
Recurrence rates are approximately 20%, with higher rates observed in patients treated with steroids alone (23%) compared to NSAIDs alone (10.5%) 5
For elderly patients or those with cardiac disease, use lower starting doses of beta-blockers and thyroid replacement if hypothyroidism develops 1

Thyroid function tests should be performed every 2-3 weeks during the initial phase 1, 2
For persistent thyrotoxicosis beyond 6 weeks, endocrinology consultation is recommended 2, 1
Long-term monitoring is necessary as permanent hypothyroidism may develop in some patients, particularly those with positive thyroid antibodies 5

Steroid treatment has been shown to be more effective than NSAIDs for achieving early clinical remission 5
Studies indicate that steroid treatment may be protective against permanent hypothyroidism compared to NSAID treatment alone (6.6% vs 22.8%) 5