What is the treatment for thyroiditis?

Treatment of Thyroiditis

Treatment of thyroiditis depends on the specific type and phase of disease, with levothyroxine replacement for hypothyroidism, NSAIDs or corticosteroids for subacute thyroiditis pain, and beta-blockers for hyperthyroid symptoms. 1

Treatment by Thyroiditis Type

Hashimoto's (Lymphocytic) Thyroiditis

Levothyroxine replacement is indicated for overt hypothyroidism or symptomatic disease: 1

• Start levothyroxine 1.6 mcg/kg/day based on ideal body weight for patients under 70 years without cardiovascular disease 1, 2
• For patients over 70 years or with cardiac disease, start low at 25-50 mcg/day and titrate gradually 1, 2, 3
• Monitor TSH every 4-6 weeks initially until stable, then reduce frequency once therapeutic levels achieved 1, 2
• Reduce dose or discontinue if low TSH suggests overtreatment or recovery of thyroid function 1, 2

For subclinical hypothyroidism (TSH 4-10 mIU/L): 1

• Monitor TSH every 4-6 weeks if asymptomatic 2
• Consider treatment if symptomatic or patient desires fertility 1

For TSH >10 mIU/L, initiate levothyroxine even if asymptomatic 1, 2

Subacute (De Quervain's) Thyroiditis

This is a self-limited inflammatory condition requiring symptomatic management: 1, 4

For thyroid pain:

• NSAIDs or high-dose aspirin for mild to moderate disease 1, 4, 5
• Prednisone 40 mg daily with gradual taper over several weeks for severe disease 1, 6, 7
• Expect symptom relief within 24-48 hours with corticosteroids 6

For hyperthyroid phase symptoms:

• Beta-blockers (propranolol or atenolol) for symptomatic relief of adrenergic symptoms 1, 2, 4
• Do NOT use antithyroid drugs—hyperthyroidism is from hormone release, not overproduction 4, 5

For hypothyroid phase:

• Treatment generally not necessary unless symptomatic or TSH >10 mIU/L 1, 5
• Most patients spontaneously recover normal thyroid function after several months 2, 5

Postpartum Thyroiditis

Occurs within one year of delivery, miscarriage, or medical abortion: 4, 5

• Consider levothyroxine for TSH >10 mIU/L 1
• Also consider treatment for TSH 4-10 mIU/L if symptomatic or patient desires fertility 1, 5
• Monitor thyroid function as this may be transient or progress to permanent hypothyroidism 4, 5

Drug-Induced Thyroiditis (Immune Checkpoint Inhibitors)

For checkpoint inhibitor-induced thyroiditis: 1

• Start thyroxine 0.5-1.5 μg/kg 1
• Continue immune checkpoint inhibitor therapy in most cases 1
• Consider prednisolone 0.5 mg/kg with taper for painful thyroiditis 1
• Withhold immunotherapy ONLY if patient is unwell with symptomatic hyperthyroidism 1
• Consider carbimazole if anti-TSH receptor antibodies positive 1

Monitoring requirements:

• Check thyroid function before every cycle for first 3 months with anti-PD-1/PD-L1 1
• Monitor every cycle for anti-CTLA4 therapy 1
• Late endocrine dysfunction is possible even after treatment completion 1

Critical Pitfalls to Avoid

• Never start high-dose levothyroxine in elderly patients or those with cardiac disease—start low (25-50 mcg/day) and titrate slowly to avoid precipitating cardiac events 1, 2, 3
• Do not use radioactive iodine during pregnancy or breastfeeding—contraindicated for 4 months post-treatment 1
• Do not use levothyroxine during the recovery phase of subacute thyroiditis—it is not indicated 3
• Avoid administering levothyroxine with foods that decrease absorption (soybean-based formulas) 3
• Administer levothyroxine at least 4 hours before or after drugs that interfere with absorption 3

When to Consult Endocrinology

Consider endocrinology referral for: 1, 2

• Unusual clinical presentations
• Difficulty titrating hormone therapy
• Concern for central hypothyroidism (secondary or tertiary)
• Repeated relapses of subacute thyroiditis despite appropriate treatment 6