What is the recommended dose of steroid, specifically prednisone (corticosteroid), in thyroiditis?

Steroid Dosing for Thyroiditis

Direct Recommendation

For immune checkpoint inhibitor-related thyroiditis with severe symptoms or gland inflammation, start prednisone 1 mg/kg/day orally and taper based on clinical recovery; for subacute (de Quervain's) thyroiditis, initiate prednisone 30-40 mg daily with gradual taper over several weeks. 1, 2

Context-Specific Dosing Algorithms

Immune Checkpoint Inhibitor-Related Thyroiditis

Symptomatic thyrotoxicosis (Grade 2-4):

• Do NOT routinely use steroids - thyroiditis is self-limiting and transitions to hypothyroidism 3
• Use beta-blockers (atenolol 25-50 mg daily) for symptomatic relief instead 3
• Hold checkpoint inhibitor therapy until symptoms resolve to baseline 3, 1
• Monitor thyroid function every 2-3 weeks to catch transition to hypothyroidism 3

Exception - Severe gland inflammation with pain:

• Start prednisone 1 mg/kg/day orally 1
• Taper based on recovery of clinical symptoms 1
• Consider interrupting immunotherapy for symptomatic cases 1

Subacute (De Quervain's) Thyroiditis

Mild-to-moderate symptoms:

• NSAIDs (salicylates or loxoprofen 180 mg/day) are first-line 2, 4
• Expect symptom resolution in 21 days (14-32 days) with NSAIDs 4

Moderate-to-severe symptoms (preferred approach):

• Start prednisone 40 mg daily 2
• Expect dramatic symptom relief within 24-48 hours 2
• Gradually reduce dosage over several weeks 2
• Typical duration: 6-8 weeks total 2

Alternative lower-dose regimen (equally effective):

• Start prednisone 30 mg daily for 1 week 5
• Followed by 1 week of NSAIDs 5
• This achieves similar efficacy with fewer side effects (lower parathyroid hormone suppression, lower blood pressure elevation) 5

Even lower-dose option (for resource-limited settings):

• Start prednisone 20 mg daily 6
• Taper over 4 weeks 6
• 94% pain relief by 2 weeks 6
• Can drastically taper after 2 weeks 6

Critical Pitfalls to Avoid

Recurrence management:

• Small percentage of patients experience recurrence during taper 2
• Restore higher dose temporarily, then resume taper 2
• Repeat exacerbations are uncommon 2

Avoid excessive dosing:

• Increasing prednisone above 50-75 mg daily does NOT improve outcomes in steroid-resistant cases 7
• If no response after 1-2 months at 50-75 mg daily, consider thyroidectomy rather than further dose escalation 7

Distinguish from painful Hashimoto's thyroiditis:

• Painful Hashimoto's may be steroid-resistant 7
• Check anti-thyroid antibodies (TPOAb, TGAb) 7
• If resistant to conventional doses, thyroidectomy may be necessary 7

Comparative Effectiveness

Prednisone vs NSAIDs:

• Time to symptom resolution: 7 days (prednisone) vs 21 days (NSAIDs) 4
• Time to thyroid function normalization: 25 days vs 32 days (not significantly different) 4
• Prednisone provides faster symptom relief but similar thyroid function recovery 4

Long-Term Outcomes

• Recovery is almost universal 2
• Less than 1% develop permanent hypothyroidism 2
• During transient hypothyroidism phase, levothyroxine may be provided but can usually be discontinued 2
• Thyroidectomy should be reserved only for the very small minority with repeated relapses despite appropriate treatment 2