What is the treatment for thyroiditis?

Treatment of Thyroiditis

Treatment of thyroiditis depends on the specific type and phase of disease, with most cases requiring conservative management during the thyrotoxic phase followed by levothyroxine replacement if hypothyroidism develops, while subacute thyroiditis requires NSAIDs or corticosteroids for pain control. 1

Treatment by Thyroiditis Type

Hashimoto's Thyroiditis (Chronic Autoimmune)

Levothyroxine replacement is indicated for patients with overt hypothyroidism or symptomatic disease. 1

Dosing strategy:

• Patients under 70 years without cardiovascular disease: Start levothyroxine 1.6 mcg/kg/day based on ideal body weight 1
• Patients over 70 years or with cardiac disease: Start low at 25-50 mcg/day and titrate gradually to avoid cardiac complications 1
• Monitor TSH every 4-6 weeks initially until stable, then reduce frequency once therapeutic levels achieved 1

Subacute (De Quervain's) Thyroiditis

For pain control, NSAIDs or high-dose aspirin are first-line for mild-to-moderate disease, while corticosteroids are reserved for severe cases. 1, 2

Specific treatment approach:

• Mild-to-moderate pain: NSAIDs (ibuprofen 1800 mg daily) or high-dose aspirin 1, 3
• Severe disease: Prednisone 40 mg daily with gradual taper over several weeks 1, 4
• Hyperthyroid phase: Beta-blockers (propranolol or atenolol) for symptomatic relief of palpitations, tremors, and adrenergic symptoms 1, 2

Important caveat: Research shows that steroid treatment achieves symptomatic remission within two weeks in all patients, while 59.5% of patients treated with ibuprofen alone fail to achieve adequate clinical response and require switching to steroids within 9.5 days. 3 Additionally, steroid treatment appears protective against permanent hypothyroidism (6.6% vs 22.8% with NSAIDs alone), particularly in anti-TPO positive patients. 3

Monitor thyroid function every 2-3 weeks during the initial phase to detect transition to hypothyroidism, which typically occurs 1-2 months after the thyrotoxic phase. 2, 5

Postpartum Thyroiditis

Treatment depends on TSH level and symptom severity: 1

• TSH >10 mIU/L: Start levothyroxine replacement 1
• TSH 4-10 mIU/L: Consider treatment if symptomatic or patient desires fertility 1
• Hyperthyroid phase: Beta-blockers for symptomatic relief; avoid antithyroid drugs as this is a destructive process, not true hyperthyroidism 5

Monitor for permanent hypothyroidism, which develops in approximately 20-30% of cases. 5

Drug-Induced Thyroiditis (Immune Checkpoint Inhibitors)

Conservative management during the thyrotoxic phase is sufficient, as this is a self-limiting process. 6

Specific management approach:

• Continue immune checkpoint inhibitor therapy in most cases 1
• Symptomatic thyrotoxicosis: Non-selective beta-blockers, preferably with alpha receptor-blocking capacity 6
• Painful thyroiditis: Consider prednisolone 0.5 mg/kg with taper 1
• Withhold immunotherapy only if patient is severely unwell with symptomatic hyperthyroidism 1
• When hypothyroidism develops: Start thyroxine 0.5-1.5 μg/kg 1

Thyroiditis from checkpoint inhibitors leads to permanent hypothyroidism after an average of 1 month after the thyrotoxic phase and 2 months from initiation of immunotherapy, requiring lifelong replacement. 6

Monitoring schedule: Check thyroid function before every cycle for first 3 months with anti-PD-1/PD-L1, and every cycle for anti-CTLA-4 therapy. 1

Critical Pitfalls to Avoid

• Never start high-dose levothyroxine in elderly patients or those with cardiac disease—this can precipitate myocardial infarction or arrhythmias; always start low (25-50 mcg) and titrate slowly 1
• Do not use antithyroid drugs (methimazole, propylthiouracil) for thyroiditis-induced thyrotoxicosis—this is a destructive process with release of preformed hormone, not increased synthesis 2, 5
• Avoid continuing NSAID monotherapy beyond 1 month in subacute thyroiditis with persistent symptoms—this indicates inadequate response and requires escalation to corticosteroids 7
• In patients with both adrenal insufficiency and hypothyroidism (hypophysitis), always start steroids before thyroid hormone to avoid precipitating adrenal crisis 6

When to Refer to Endocrinology

Endocrinology consultation is recommended in all cases of suspected or confirmed thyroiditis, particularly for: 6

• Unusual presentations or difficulty titrating therapy 1
• Concern for central (secondary/tertiary) hypothyroidism 1
• Drug-induced thyroiditis from checkpoint inhibitors 6
• Recurrent subacute thyroiditis despite appropriate treatment 4

Monitoring and Long-Term Management

For secondary or tertiary hypothyroidism, serum TSH is unreliable—use serum free-T4 to titrate dosing until the patient is clinically euthyroid and free-T4 is in the upper half of normal range. 8

The peak therapeutic effect of levothyroxine may not be attained for 4-6 weeks, so avoid premature dose adjustments. 8

Permanent hypothyroidism develops in less than 1% of subacute thyroiditis cases but is more common in Hashimoto's and postpartum thyroiditis, necessitating long-term surveillance. 4, 5