What is the dose of steroids, specifically prednisone (corticosteroid), in the treatment of thyroiditis?

Steroid Dosing for Thyroiditis

For inflammatory thyroiditis (subacute/De Quervain's thyroiditis), initiate prednisone at 20-40 mg daily orally, with lower doses (15-20 mg daily) being sufficient for most patients and higher doses (40 mg daily) reserved for severe cases, tapered over 2-6 weeks based on clinical response.

Context-Specific Dosing

Immune Checkpoint Inhibitor-Related Thyroiditis

• Start prednisone 1 mg/kg orally daily when inflammation of the thyroid gland is present with symptomatic disease 1
• Taper based on recovery of clinical symptoms 1
• Consider interrupting checkpoint inhibitor therapy when symptomatic 1

Subacute (De Quervain's) Thyroiditis

Mild to Moderate Disease:

• Initial dose of 15-20 mg prednisone daily is sufficient for most patients 2, 3
• A Japanese study demonstrated that 15 mg/day with tapering by 5 mg every 2 weeks was effective and safe, with 51.6% of patients recovering within 6 weeks 3
• Another study from Nepal showed 20 mg/day tapered over 4 weeks provided complete pain relief in 94% of patients by 2 weeks 2

Moderate to Severe Disease:

• Initiate prednisone 30-40 mg daily for more severe symptoms 4, 5
• The traditional approach uses 40 mg daily with gradual reduction over several weeks 4
• Recent evidence supports shorter courses: 30 mg/day for 1 week followed by NSAIDs showed similar efficacy to 6-week conventional therapy with fewer side effects 5

Tapering Protocols

Standard Taper:

• Reduce by 5 mg every 2 weeks after initial symptom control 3
• Total duration typically 4-6 weeks for most patients 2, 4
• Dramatic pain relief should occur within 24-48 hours if steroids are effective 4

Accelerated Taper:

• For patients responding well, dose can be drastically tapered after 2 weeks 2
• Short-term therapy (1 week at 30 mg followed by NSAIDs) is an alternative with better safety profile 5

Monitoring and Recurrence Management

• Recurrences occur in a small percentage of patients (approximately 20% need >8 weeks of therapy) 4, 3
• When recurrence occurs, restore higher dose temporarily 4
• Repeat exacerbations are uncommon 4

Critical Pitfalls to Avoid

Steroid-Resistant Cases:

• Increasing prednisone above conventional maximal dosages (40-50 mg daily) may not be beneficial in truly resistant cases 6
• If no response after prolonged high-dose therapy (50-75 mg daily for 1-2 months), consider thyroidectomy rather than further dose escalation 6
• Both painful Hashimoto's thyroiditis and rarely subacute thyroiditis can show steroid resistance 6

Inadequate Initial Dosing:

• NSAIDs alone are less effective than steroids, with slower and less dramatic response 2, 4
• Reserve NSAIDs for mild cases or as step-down therapy after initial steroid course 5

Premature Discontinuation:

• Ensure adequate treatment duration to prevent recurrence 4, 3
• Monitor clinical symptoms and inflammatory markers (ESR, CRP) during taper 2

Special Considerations

• Less than 1% of patients develop permanent hypothyroidism 4
• During transient hypothyroidism phase, levothyroxine may be provided but can usually be discontinued subsequently 4
• Thyroidectomy should only be considered in the very small minority with repeated relapses despite appropriate treatment 6, 4