How do you stop a Hashimoto's (thyroiditis) attack?

Managing Hashimoto's Thyroiditis Flares

There is no specific treatment to "stop" a Hashimoto's attack or flare, as the autoimmune inflammation is self-limited and resolves on its own—management focuses on symptom control during the thyrotoxic phase and thyroid hormone replacement if hypothyroidism develops. 1

Understanding the Disease Pattern

Hashimoto's thyroiditis follows a triphasic pattern that cannot be interrupted but must be managed through each phase 1:

• Initial thyrotoxic phase: Preformed thyroid hormone is released from damaged thyroid cells, causing temporary hyperthyroidism 1
• Hypothyroid phase: Thyroid hormone stores become depleted 1
• Recovery or permanent hypothyroidism: Some patients return to normal function, while others develop permanent hypothyroidism requiring lifelong treatment 1

Acute Symptom Management During Thyrotoxic Phase

For Hyperthyroid Symptoms (Palpitations, Tremor, Anxiety)

Beta-blockers are the primary treatment for symptomatic relief during the thyrotoxic phase 2:

• Use atenolol or propranolol to control adrenergic symptoms (tachycardia, tremor, heat intolerance) 2
• Continue monitoring thyroid function every 2-3 weeks to catch the transition to hypothyroidism 2
• Provide hydration and supportive care 2

Important Distinction from True Hyperthyroidism

• Do NOT use antithyroid medications (methimazole, propylthiouracil) for Hashimoto's thyroiditis, as this is destructive thyroiditis with hormone release, not increased hormone production 2, 1
• Antithyroid drugs are only indicated for Graves' disease or toxic nodular disease 2
• The thyrotoxic phase is self-limited and typically resolves within weeks 2

Monitoring and Transition to Hypothyroidism

Close surveillance is critical because most patients transition to hypothyroidism 2, 1:

• Check TSH and free T4 every 2-3 weeks during the acute phase 2
• Watch for elevated TSH with low free T4, indicating transition to hypothyroidism 2
• Initiate levothyroxine when TSH persistently exceeds 10 mIU/L or for symptomatic patients with any degree of TSH elevation 3

Long-Term Thyroid Hormone Replacement

When to Start Treatment

Begin levothyroxine therapy when 3, 4:

• TSH >10 mIU/L regardless of symptoms 3
• TSH 4.5-10 mIU/L with clear hypothyroid symptoms (fatigue, weight gain, cold intolerance, constipation) 3
• Positive TPO antibodies with TSH elevation, as this indicates higher progression risk (4.3% per year vs 2.6% in antibody-negative patients) 3

Dosing Strategy

For patients <70 years without cardiac disease: Start with full replacement dose of approximately 1.6 mcg/kg/day 3

For patients >70 years or with cardiac disease: Start with 25-50 mcg/day and titrate gradually to avoid cardiac complications 3

Monitoring During Treatment

• Recheck TSH and free T4 every 6-8 weeks while adjusting dose 3
• Target TSH within reference range (0.5-4.5 mIU/L) with normal free T4 3
• Once stable, monitor every 6-12 months or if symptoms change 3

Special Considerations for Malabsorption

Patients with Hashimoto's frequently have gastrointestinal disorders affecting levothyroxine absorption 5:

• Consider levothyroxine sodium oral solution (Tirosint-SOL) if standard tablets fail to normalize TSH despite dose escalation 5
• This formulation contains only levothyroxine, water, and glycerol, avoiding excipients that may trigger sensitivities 5
• Particularly useful in patients with gastroparesis, small intestinal bacterial overgrowth (SIBO), or multiple food/medication sensitivities 5

Nutritional Support (Adjunctive, Not Primary Treatment)

While supplementation cannot stop an acute flare, addressing deficiencies may support overall thyroid health 6:

• Selenium supplementation has shown benefits in reducing TPO antibody levels 6
• Vitamin D supplementation may help in deficient patients 6
• Ensure adequate iodine, magnesium, iron, and vitamin B12, as deficiencies are common 6
• Consider anti-inflammatory diet rich in vitamins and minerals, low in animal foods 6

Critical Pitfalls to Avoid

Never use antithyroid medications for Hashimoto's thyroiditis, as this represents destructive thyroiditis, not hormone overproduction 2, 1

Do not treat based on a single elevated TSH value—30-60% normalize on repeat testing 3

Never start thyroid hormone before ruling out adrenal insufficiency in patients with suspected central hypothyroidism, as this can precipitate adrenal crisis 3

Avoid overtreatment with levothyroxine, which occurs in 14-21% of treated patients and increases risk for atrial fibrillation, osteoporosis, and fractures 3

Prognosis and Remission Potential

Some patients, particularly children and adolescents, may experience remission of Hashimoto's thyroiditis 7:

• Thyroid ultrasound changes can parallel functional improvement 7
• Serial monitoring may reveal restoration of normal thyroid architecture 7
• However, most adult patients require lifelong thyroid hormone therapy 4