What is the initial treatment approach for thyroiditis?

Initial Treatment Approach for Thyroiditis

The initial treatment for thyroiditis depends on the type and phase of thyroiditis, with beta-blockers being the first-line treatment for symptomatic relief during the thyrotoxic phase, while conservative management is sufficient for most cases of thyroiditis as it is generally a self-limiting process. 1

Diagnostic Evaluation

• Check TSH and Free T4 levels for case detection in symptomatic patients; T3 can be helpful in highly symptomatic patients with minimal FT4 elevations 1
• Consider TSH receptor antibody testing if there are clinical features and suspicion of Graves' disease (e.g., ophthalmopathy and T3 toxicosis) 1
• Thyroid peroxidase (TPO) antibody testing is warranted if hypothyroidism is confirmed 1

Treatment Based on Clinical Phase

Thyrotoxic Phase (Initial hyperthyroidism)

• For asymptomatic or mild symptoms (Grade 1):

  • Continue immune checkpoint inhibitor therapy if applicable 1
  • Beta-blockers (e.g., atenolol or propranolol) for symptomatic relief of adrenergic symptoms such as palpitations, tremors, and fever 1, 2
  • Close monitoring of thyroid function every 2-3 weeks to detect transition to hypothyroidism 1, 2

• For moderate symptoms (Grade 2):

  • Consider holding immune checkpoint inhibitor therapy until symptoms return to baseline 1
  • Consider endocrine consultation 1
  • Beta-blockers for symptomatic relief 1
  • Hydration and supportive care 1
  • For persistent thyrotoxicosis (>6 weeks), refer to endocrinology for additional workup and possible medical thyroid suppression 1

• For severe symptoms (Grade 3-4):

  • Hold immune checkpoint inhibitor therapy until symptoms resolve 1
  • Endocrine consultation for all patients 1
  • Beta-blockers for symptom management 1
  • Hospitalization in severe cases with inpatient endocrine consultation 1
  • Additional medical therapies may include steroids, SSKI, or thionamide (methimazole or propylthiouracil) 1

For Painful Thyroiditis (Subacute Thyroiditis)

• Non-selective beta blockers for symptomatic relief 1
• NSAIDs or high-dose acetylsalicylic acid for relief of thyroid pain 3, 4
• For severe symptoms or high fever, systemic glucocorticoids are recommended 2
• Continuation of NSAID monotherapy for longer than 1 month is inappropriate for patients with persistent fever 2

Hypothyroid Phase (Following thyrotoxic phase)

• Thyroid hormone replacement (levothyroxine) should be initiated at the time of hypothyroidism diagnosis 1
• Important: Levothyroxine sodium tablets are not indicated for treatment of hypothyroidism during the recovery phase of subacute thyroiditis 5
• For patients with TSH persistently >10 mIU/L or symptomatic patients with TSH 4-10 mIU/L, thyroid hormone supplementation is recommended 1
• For patients without risk factors (<70 years old, not frail, without cardiac disease), full replacement can be estimated using ideal body weight for a dose of approximately 1.6 mcg/kg/day 1
• For older patients (>70 years) or frail patients with comorbidities, start with a lower dose of 25-50 mg and titrate up 1

Monitoring and Follow-up

• Monitor thyroid function every 2-3 weeks during the initial phase 1, 2
• For patients on thyroid hormone replacement, monitor TSH every 6-8 weeks while titrating hormone replacement to goal of TSH within the reference range 1
• Thyroiditis is self-limited and the initial hyperthyroidism generally resolves in weeks with supportive care, most often transitioning to primary hypothyroidism or occasionally returning to normal 1

When to Refer to Endocrinology

• An endocrinology consultation is recommended in all cases of suspected or confirmed hypophysitis, primary hypothyroidism, hyperthyroidism, thyroiditis, and type 1 DM 1
• For persistent thyrotoxicosis (>6 weeks) 1
• Physical examination findings of ophthalmopathy or thyroid bruit (diagnostic of Graves' disease) should prompt early endocrine referral 1

Special Considerations

• In the presence of both adrenal insufficiency and hypothyroidism, steroids should always be started prior to thyroid hormone to avoid an adrenal crisis 1
• Thyroiditis is a self-limiting process and leads to permanent hypothyroidism after an average of 1 month after the thyrotoxic phase and 2 months from initiation of immunotherapy 1
• Most cases of subacute thyroiditis follow an upper respiratory viral illness, which is thought to trigger inflammatory destruction of thyroid follicles 3