What is the treatment for subacute thyroiditis?

Treatment of Subacute Thyroiditis

The treatment of subacute thyroiditis should focus on symptom management with beta-blockers for symptomatic relief during the thyrotoxic phase, and corticosteroids for patients with moderate to severe pain, as steroids provide more rapid and effective relief than NSAIDs. 1

Clinical Presentation and Diagnosis

• Subacute thyroiditis typically presents with anterior neck pain, tender thyroid on palpation, and elevated inflammatory markers (ESR >30mm/h) 2, 3
• The disease usually follows a triphasic pattern: initial hyperthyroidism (thyrotoxicosis), followed by hypothyroidism, and eventual restoration of normal thyroid function in most cases 3
• Laboratory evaluation should include TSH, free T4, and inflammatory markers; T3 can be helpful in highly symptomatic patients with minimal FT4 elevations 1

Treatment Algorithm Based on Symptom Severity

Mild Symptoms (Grade 1)

• Beta-blockers (e.g., atenolol or propranolol) for symptomatic relief of adrenergic symptoms such as palpitations, tremors, and fever 1
• Close monitoring of thyroid function every 2-3 weeks to detect transition to hypothyroidism 1
• NSAIDs may be considered for mild pain relief, though they are less effective than steroids 4, 5

Moderate to Severe Symptoms (Grade 2-4)

• Corticosteroid therapy is recommended as first-line treatment for patients with moderate to severe pain 6, 4
• Prednisone starting at 40 mg daily with gradual tapering over several weeks provides rapid relief of symptoms within 24-48 hours 5
• Lower initial doses (20 mg/day tapered over four weeks) may be effective in some patients 2
• Consider hospitalization for patients with severe symptoms affecting daily activities 7

Management of Thyroid Dysfunction

Thyrotoxic Phase

• Beta-blockers for symptomatic relief 1
• Hydration and supportive care 1
• For persistent thyrotoxicosis (>6 weeks), refer to endocrinology for additional workup 1

Hypothyroid Phase

• Monitor for development of hypothyroidism, which commonly follows the thyrotoxic phase 1
• Treat transition to elevated TSH and low FT4 as primary hypothyroidism with levothyroxine 1
• For patients without risk factors (<70 years old, not frail, without cardiac disease), full replacement can be estimated using ideal body weight (approximately 1.6 mcg/kg/day) 1
• For older patients (>70 years) or those with comorbidities, start with lower doses (25-50 mcg) 1

Important Clinical Considerations

• Thyroiditis is self-limited, with the initial hyperthyroidism generally resolving in weeks with supportive care 1
• Steroid treatment appears to be protective against permanent hypothyroidism compared to NSAID treatment alone 4
• Recurrences occur in approximately 20% of patients and are more frequent in those receiving only steroid therapy compared to NSAIDs alone (23% vs. 10.5%) 4
• Persistent hypothyroidism develops in about 22.8% of patients treated only with NSAIDs versus 6.6% of patients treated with steroids only 4
• Risk factors for permanent hypothyroidism include NSAID-only treatment and positive thyroid peroxidase antibody (anti-TPO) 4

Follow-up and Monitoring

• Monitor thyroid function every 2-3 weeks during the initial phase 1, 7
• For persistent thyrotoxicosis (>6 weeks), endocrinology consultation is recommended 1
• In asymptomatic patients with elevated TSH but FT4 within reference range during recovery phase, consider monitoring before treating to determine if there is recovery to normal within 3-4 weeks 1
• Development of low TSH on therapy suggests overtreatment or recovery of thyroid function; dose should be reduced or discontinued with close follow-up 1