How to manage thyroiditis?

Management of Thyroiditis

Thyroiditis is typically a self-limited condition requiring conservative management with beta-blockers for symptomatic thyrotoxicosis, followed by monitoring for the transition to hypothyroidism which occurs in most patients within 1-2 months and requires levothyroxine replacement. 1

Initial Diagnostic Workup

When thyroiditis is suspected, obtain the following tests:

• TSH and free T4 to confirm thyrotoxicosis (low/normal TSH with elevated free T4) 1
• T3 levels if highly symptomatic with minimal FT4 elevation 1
• Thyroid peroxidase (TPO) antibodies to identify autoimmune etiology 1
• TSH receptor antibody (TRAb) or thyroid stimulating immunoglobulin (TSI) to rule out Graves' disease if clinical features suggest it (ophthalmopathy, persistent thyrotoxicosis >6 weeks) 1, 2
• Radioactive iodine uptake scan (RAIUS) or Technetium-99m scan if diagnosis unclear—thyroiditis shows low uptake versus high uptake in Graves' disease 1

Management Algorithm by Severity

Grade 1 (Asymptomatic or Mild Symptoms)

• Continue cancer immunotherapy if applicable 1
• Beta-blocker (atenolol or propranolol, preferably non-selective with alpha-blocking capacity) for symptomatic relief of palpitations, tremors, anxiety 1
• Monitor thyroid function every 2-3 weeks to catch transition to hypothyroidism 1
• No antithyroid drugs needed—thyroiditis is destructive, not hypersynthetic 1, 3

Grade 2 (Moderate Symptoms, Able to Perform ADL)

• Consider holding immunotherapy until symptoms return to baseline 1
• Endocrine consultation recommended 1
• Beta-blocker for symptomatic control 1
• Hydration and supportive care 1
• For persistent thyrotoxicosis >6 weeks, refer to endocrinology for additional workup and possible medical thyroid suppression 1

Grade 3-4 (Severe Symptoms, Unable to Perform ADL)

• Hold immunotherapy until symptoms resolve 1
• Mandatory endocrine consultation 1
• Beta-blocker therapy 1
• Consider hospitalization for severe cases 1
• Additional therapies may include: steroids, saturated solution of potassium iodide (SSKI), or thionamides (methimazole/propylthiouracil) under endocrine guidance 1
• Surgery in rare refractory cases 1

Subacute (DeQuervain's) Thyroiditis with Pain

For patients presenting with anterior neck pain and tenderness:

• NSAIDs or high-dose aspirin for mild to moderate pain 3, 4, 5
• Prednisone 40 mg daily for severe pain, with rapid symptom relief expected within 24-48 hours, then gradual taper over several weeks 5
• Recurrences occur in a small percentage—restore higher prednisone dose if needed 5
• Beta-blockers for adrenergic symptoms during hyperthyroid phase 3

Transition to Hypothyroidism

The thyrotoxic phase resolves within approximately 1 month, followed by hypothyroidism within 2 months of immunotherapy initiation in most patients. 1

When TSH becomes elevated and free T4 drops:

• Initiate levothyroxine at approximately 1.6 mcg/kg/day for patients <70 years without cardiac disease 6
• Start with 25-50 mcg in elderly patients or those with cardiac disease, titrating up gradually 6
• Monitor TSH every 6-8 weeks initially, then every 6-12 months once stable 6
• Most patients require lifelong thyroid hormone replacement as hypothyroidism is typically permanent 1, 3

Special Considerations and Pitfalls

Critical Timing Issue

Always start corticosteroids before levothyroxine if both adrenal insufficiency and hypothyroidism are present (as in hypophysitis) to avoid precipitating adrenal crisis 1

Distinguishing Thyroiditis from Graves' Disease

• Thyroiditis: Self-limited, low radioactive iodine uptake, typically painless, transitions to hypothyroidism 1, 3
• Graves' disease: Persistent hyperthyroidism, high radioactive iodine uptake, positive TRAb/TSI, may have ophthalmopathy or thyroid bruit, requires antithyroid drugs 1
• Physical exam findings of ophthalmopathy or thyroid bruit are diagnostic of Graves' disease and warrant early endocrine referral 1

Monitoring Strategy

• Repeat thyroid function tests every 2-3 weeks during acute phase 1
• Continue surveillance for at least 1 year as the triphasic pattern (thyrotoxicosis → hypothyroidism → recovery or permanent hypothyroidism) may take months to complete 3, 7
• Less than 1% develop permanent hypothyroidism after subacute thyroiditis, but most cases of autoimmune thyroiditis result in permanent hypothyroidism 5, 3

Drug-Induced Thyroiditis

Be aware that immune checkpoint inhibitors, amiodarone, interferon-alfa, interleukin-2, lithium, and tyrosine kinase inhibitors can all cause thyroiditis 3, 8

Postpartum Thyroiditis

Occurs within one year of delivery, miscarriage, or medical abortion and follows the same triphasic pattern 3, 4