Treatment for Thyroiditis
Treatment for thyroiditis depends entirely on the specific type and phase of disease, with most forms requiring only symptomatic management during the self-limited thyrotoxic phase, followed by thyroid hormone replacement if permanent hypothyroidism develops.
Subacute Granulomatous (De Quervain's) Thyroiditis
Thyrotoxic Phase Management
- Beta-blockers (preferably non-selective with alpha-blocking capacity) are the mainstay for symptomatic thyrotoxicosis, controlling palpitations, tremor, and anxiety without antithyroid drugs, since the hyperthyroidism results from thyroid destruction rather than overproduction 1, 2.
- Antithyroid medications (methimazole, propylthiouracil) are not indicated because the thyroid is not actively synthesizing excess hormone 2, 3.
Pain Management
- NSAIDs are first-line therapy for thyroid pain and tenderness, providing adequate relief in most cases 2, 3.
- Corticosteroids (e.g., prednisone 40 mg daily, tapered over 4-6 weeks) are reserved for severe pain unresponsive to NSAIDs 1, 2, 3.
- High-dose aspirin (acetylsalicylic acid) is an alternative anti-inflammatory option 3.
Hypothyroid Phase
- Most patients do not require levothyroxine during the transient hypothyroid phase unless symptoms are severe or TSH remains markedly elevated (>10 mIU/L) 2, 3.
- Monitor TSH every 2-3 weeks during the hypothyroid phase to detect recovery 1.
Natural History
- The condition is self-limited, with spontaneous resolution typically occurring within several months (average 1 month for thyrotoxic phase, followed by 1 month of hypothyroidism) 1, 3.
- Permanent hypothyroidism develops in only a minority of patients; recurrence is uncommon 4.
Painless (Silent) Thyroiditis and Postpartum Thyroiditis
Thyrotoxic Phase
- Conservative management with beta-blockers for symptomatic patients is sufficient, as the thyrotoxicosis is self-limiting 1, 2.
- Repeat thyroid function tests every 2-3 weeks to monitor progression 1.
Hypothyroid Phase
- Levothyroxine is indicated for:
Postpartum-Specific Considerations
- Postpartum thyroiditis occurs within one year of delivery, miscarriage, or medical abortion and follows the classic triphasic pattern 1, 2, 3.
- Women with the highest TSH levels and positive anti-thyroid peroxidase antibodies have the greatest risk of permanent hypothyroidism 1.
- Surveillance is critical: TSH and free T4 should be monitored if goiter develops or if symptoms of thyroid dysfunction appear postpartum 1.
Hashimoto's (Chronic Lymphocytic) Thyroiditis
Overt Hypothyroidism
- Lifelong levothyroxine therapy is the standard treatment for patients with elevated TSH and low free T4 2, 3.
- Dosing follows standard hypothyroidism protocols: approximately 1.6 mcg/kg/day in younger patients without cardiac disease, or 25-50 mcg/day in elderly or cardiac patients 5.
Subclinical Hypothyroidism
- Treat with levothyroxine when TSH >10 mIU/L regardless of symptoms, as this carries ~5% annual risk of progression to overt disease 5, 2.
- For TSH 4.5-10 mIU/L, treatment decisions should consider symptoms, positive anti-TPO antibodies, goiter, or pregnancy planning 5, 3.
Goiter Management
- Levothyroxine therapy may reduce goiter size in some patients with Hashimoto's thyroiditis 3.
Monitoring
- The presence of elevated thyroid peroxidase antibodies confirms the autoimmune etiology and predicts higher progression risk to overt hypothyroidism 2, 3.
Drug-Induced Thyroiditis
Immune Checkpoint Inhibitor-Induced Thyroiditis
- Thyroiditis is the most common cause of thyrotoxicosis with anti-PD1/PD-L1 drugs (6-20% incidence), presenting as painless thyroiditis 1.
- Conservative management during thyrotoxic phase: beta-blockers for symptomatic patients; no antithyroid drugs needed 1.
- Thyroid hormone replacement should be initiated at the time of hypothyroidism diagnosis (average 1 month after thyrotoxic phase, 2 months from immunotherapy start) 1.
- Immunotherapy can continue in most cases—high-dose corticosteroids are rarely required for thyroid dysfunction 1.
- Critical safety consideration: Rule out concurrent adrenal insufficiency before starting levothyroxine, as thyroid hormone can precipitate adrenal crisis in patients with hypophysitis 1, 5.
Amiodarone, Lithium, Interferon-Alfa, Interleukin-2
- Management depends on whether the drug can be discontinued and the specific pattern of thyroid dysfunction 2, 6.
- Surveillance for thyroid dysfunction is essential during treatment with these agents 2, 6.
Acute Suppurative Thyroiditis
Antibiotic Therapy
- Appropriate antibiotic treatment targeting the causative bacterial or fungal organism is curative 7, 4.
- Surgical drainage may be required for abscess formation 7, 4.
Supportive Care
- Symptomatic management of pain and fever while awaiting culture results and antibiotic response 7, 4.
Critical Pitfalls to Avoid
- Never use antithyroid drugs (methimazole, PTU) for destructive thyroiditis—the hyperthyroidism is from hormone release, not overproduction 2, 3.
- Do not assume hypothyroidism is permanent without reassessment—many patients recover normal thyroid function after the acute phase 2, 3, 4.
- Always rule out adrenal insufficiency before starting levothyroxine in patients on immunotherapy or with suspected central hypothyroidism, as this can trigger life-threatening adrenal crisis 1, 5.
- Distinguish between thyroiditis and Graves' disease: radioactive iodine uptake is low in thyroiditis but elevated in Graves' disease 6, 3, 7.
- Monitor for permanent hypothyroidism: patients with highest TSH levels and positive anti-TPO antibodies during the hypothyroid phase are at greatest risk 1, 3.
Surveillance Recommendations
In all forms of thyroiditis, ongoing clinical follow-up with serial thyroid function testing is essential to detect progression to permanent hypothyroidism or recurrence 2, 6, 3. The triphasic pattern (thyrotoxicosis → hypothyroidism → recovery) means that thyroid status can change over weeks to months, requiring vigilant monitoring rather than one-time assessment.