What is the treatment for thyroiditis?

Treatment of Thyroiditis

Treatment of thyroiditis depends on the specific type and phase of disease, but most commonly involves symptomatic management with beta-blockers during hyperthyroid phases, levothyroxine replacement for hypothyroidism, and NSAIDs or corticosteroids for painful inflammatory forms.

Treatment Approach by Thyroiditis Type

Hashimoto's (Lymphocytic) Thyroiditis

Levothyroxine replacement is the cornerstone of treatment for patients with overt hypothyroidism or symptomatic disease. 1

• Initiate levothyroxine for:

  • Symptomatic patients with any TSH elevation 1
  • Asymptomatic patients with TSH >10 mIU/L 1
  • Consider treatment for TSH 4.5-10 mIU/L if symptomatic 1

• Dosing strategy:

  • For patients <70 years without cardiovascular disease: start 1.6 mcg/kg/day based on ideal body weight 1
  • For patients >70 years or with cardiac disease: start low at 25-50 mcg/day and titrate gradually 1
  • Monitor TSH every 4-6 weeks initially until stable 1

• Long-term management:

  • Most patients require lifelong thyroid hormone therapy 2
  • Reduce dose or discontinue if low TSH suggests overtreatment or recovery of thyroid function 1

Subacute (DeQuervain's) Thyroiditis

Treatment focuses on symptomatic relief of pain and managing the triphasic thyroid dysfunction pattern. 2, 3

• For thyroid pain:

  • Mild to moderate disease: NSAIDs or high-dose aspirin 3, 4
  • Severe disease: Prednisone 40 mg daily with gradual taper over several weeks 4, 5
  • Corticosteroids typically provide rapid symptom relief within 24-48 hours 4
  • Recurrences occur in a small percentage; restore higher dose if needed 4

• For hyperthyroid phase:

  • Beta-blockers (propranolol or atenolol) for symptomatic relief of adrenergic symptoms 6, 2
  • Antithyroid drugs are NOT indicated as this is destructive thyrotoxicosis, not increased hormone production 2

• For hypothyroid phase:

  • Generally not necessary to treat as most cases are transient 2
  • Consider levothyroxine if symptomatic or TSH significantly elevated 2
  • Can usually be discontinued after recovery 4

• Prognosis:

  • Self-limited disease with spontaneous resolution in most cases 3, 4
  • Less than 1% develop permanent hypothyroidism 4

Postpartum Thyroiditis

Management is similar to subacute thyroiditis but without the pain component. 6

• Hyperthyroid phase:

  • Beta-blockers for symptomatic relief 3
  • Monitor thyroid function as this phase is typically transient 3

• Hypothyroid phase:

  • Consider levothyroxine for TSH >10 mIU/L 3
  • Also consider treatment for TSH 4-10 mIU/L if symptomatic or patient desires fertility 3
  • Treatment may be transient or permanent depending on recovery 6

• Monitoring:

  • Evaluate TSH and free T4 levels in women who develop goiter or symptoms postpartum 6
  • Risk of permanent hypothyroidism is greatest with highest TSH levels and elevated antithyroid peroxidase antibodies 6

Drug-Induced Thyroiditis (Immune Checkpoint Inhibitors)

Continue immunotherapy in most cases while managing thyroid dysfunction. 6

• For hypothyroidism:

  • Start thyroxine 0.5-1.5 μg/kg (start low in elderly or those with cardiac history) 6
  • Continue immune checkpoint inhibitor therapy 6
  • For painful thyroiditis: consider prednisolone 0.5 mg/kg with taper 6

• For hyperthyroidism:

  • Beta-blockers (propranolol or atenolol) for symptoms 6
  • Consider carbimazole if anti-TSH receptor antibodies positive 6
  • Withhold immunotherapy only if patient is unwell with symptomatic hyperthyroidism 6

• Monitoring:

  • Check thyroid function tests before every cycle for first 3 months with anti-PD-1/PD-L1 6
  • Every cycle monitoring for anti-CTLA4 therapy 6
  • Late endocrine dysfunction can occur 6

Common Pitfalls to Avoid

• Do not use antithyroid drugs for destructive thyroiditis (subacute, postpartum) as hyperthyroidism results from hormone release, not overproduction 2
• Do not delay corticosteroid treatment in severe subacute thyroiditis waiting for symptom resolution with NSAIDs alone 4, 5
• Do not assume all thyroiditis is permanent—many forms are self-limited and require surveillance rather than lifelong treatment 2, 4
• Do not start high-dose levothyroxine in elderly patients or those with cardiac disease; start low and titrate slowly 1
• Do not use radioactive iodine during pregnancy or breastfeeding (contraindicated for 4 months posttreatment) 6

Follow-Up and Surveillance

• All forms of thyroiditis require ongoing monitoring for changes in thyroid function 2
• Consider endocrinology consultation for unusual presentations, difficulty titrating therapy, or concern for central hypothyroidism 1
• Monitor for progression from subclinical to overt hypothyroidism, particularly in Hashimoto's thyroiditis 1