What are the treatment options for thyroiditis?

Treatment of Thyroiditis

Treatment of thyroiditis depends on the specific type and phase of disease, with levothyroxine replacement for hypothyroidism, beta-blockers for symptomatic thyrotoxicosis, and NSAIDs or corticosteroids for painful inflammatory thyroiditis. 1

Initial Assessment and Monitoring

Before initiating treatment, measure both TSH and free T4 to determine the phase of thyroid dysfunction and localize the disease 2, 3. This is critical because:

• Low TSH with low FT4 indicates central hypothyroidism (hypophysitis), requiring evaluation for other pituitary hormone deficiencies 3
• In patients with both adrenal insufficiency and hypothyroidism, steroids must always be started before thyroid hormone to avoid precipitating adrenal crisis 2, 3
• Thyroid receptor antibodies should be obtained if clinical features suggest Graves' disease rather than thyroiditis (ophthalmopathy, thyroid bruit, or T3 toxicosis) 3

Treatment by Thyroiditis Type and Phase

Thyrotoxic (Hyperthyroid) Phase

Beta-blockers are the mainstay of symptomatic treatment during the thyrotoxic phase, as thyroiditis is self-limited and does not require antithyroid drugs 1, 3:

• Initiate propranolol or atenolol for palpitations, tremors, heat intolerance, and other adrenergic symptoms 1
• Non-selective beta blockers with alpha receptor-blocking capacity are preferred for symptomatic patients 2
• Continue immune checkpoint inhibitors in drug-induced thyroiditis unless the patient is severely unwell with symptomatic hyperthyroidism 1
• Consider carbimazole only if anti-TSH receptor antibodies are positive, suggesting Graves' disease rather than thyroiditis 1
• Monitor thyroid function every 2-3 weeks, as the thyrotoxic phase typically resolves within 4-6 weeks 2, 3
• Refer to endocrinology if thyrotoxicosis persists beyond 6 weeks 3

Hypothyroid Phase

Levothyroxine replacement is indicated for symptomatic hypothyroidism or TSH >10 mIU/L 2, 1:

Dosing strategy:

• For patients under 70 years without cardiac disease, frailty, or multiple comorbidities: start full replacement at approximately 1.6 mcg/kg/day based on ideal body weight 2, 1
• For patients over 70 years or with cardiac disease: start low at 25-50 mcg/day and titrate gradually 1
• For drug-induced thyroiditis: start thyroxine 0.5-1.5 μg/kg 1

Monitoring and titration:

• Recheck TSH every 4-6 weeks initially while titrating to maintain TSH in the normal range 2, 3
• FT4 can help interpret ongoing abnormal TSH levels, as TSH may take longer to normalize 2
• Once stable, repeat testing every 6-12 months or with symptom changes 2
• Reduce dose or discontinue if TSH becomes suppressed, suggesting overtreatment or recovery of thyroid function 1

Consider treatment for TSH 4-10 mIU/L if:

• Patient is symptomatic 1
• Patient desires fertility 1
• In postpartum thyroiditis with these features 1

Painful Thyroiditis (Subacute Granulomatous)

NSAIDs or high-dose aspirin provide symptomatic relief for thyroid pain 1:

• Start with NSAIDs or high-dose aspirin for initial pain management 1
• For severe disease: prednisone 40 mg daily with gradual taper over several weeks 1
• Consider prednisolone 0.5 mg/kg with taper for painful drug-induced thyroiditis 1

Special Populations and Contexts

Drug-Induced Thyroiditis (Immune Checkpoint Inhibitors)

• Continue immune checkpoint inhibitor therapy in most cases 1
• Withhold immunotherapy only if patient is severely unwell with symptomatic hyperthyroidism 1
• Monitor thyroid function before every cycle for the first 3 months with anti-PD-1/PD-L1 therapy 1
• Monitor every cycle with anti-CTLA4 therapy, as late endocrine dysfunction is possible 1

Postpartum Thyroiditis

• Monitor TSH and FT4 in women who develop goiter or thyroid dysfunction symptoms within one year of delivery, miscarriage, or medical abortion 3
• Treatment approach follows the same algorithm as other thyroiditis types based on TSH levels and symptoms 1

Critical Pitfalls to Avoid

• Never start levothyroxine before hydrocortisone in patients with possible central hypothyroidism or hypophysitis, as this precipitates adrenal crisis 2, 3
• Never start high-dose levothyroxine in elderly patients or those with cardiac disease; always start low and titrate slowly 1
• Do not use antithyroid drugs for thyroiditis-induced thyrotoxicosis, as it is due to hormone release from damaged cells, not overproduction 2
• Levothyroxine is not indicated during the recovery phase of subacute thyroiditis 4
• Do not use radioactive iodine during pregnancy or breastfeeding; it is contraindicated for 4 months post-treatment 1

When to Refer to Endocrinology

Endocrinology consultation is recommended for 2, 1:

• All cases of suspected or confirmed hypophysitis
• Unusual clinical presentations
• Difficulty titrating hormone therapy
• Concern for central hypothyroidism
• Thyrotoxicosis persisting beyond 6 weeks 3

Long-Term Considerations

• Most thyroiditis cases progress from thyrotoxicosis to permanent hypothyroidism after an average of 1 month following the thyrotoxic phase 2
• Lifelong hormonal replacement is needed in most cases of hypophysitis-related hypothyroidism 2
• Monitor for progression from subclinical to overt hypothyroidism, particularly in Hashimoto's thyroiditis 1
• All patients with adrenal insufficiency should obtain and carry a medical alert bracelet 2