From the Guidelines
Hashimoto's thyroiditis should be treated with daily synthetic thyroid hormone replacement, most commonly levothyroxine, to improve morbidity, mortality, and quality of life outcomes. The primary screening test for thyroid dysfunction is the serum TSH test, and multiple tests should be done over a 3- to 6-month interval to confirm or rule out abnormal findings 1. The principal treatment for hypothyroidism is oral T4 monotherapy (levothyroxine sodium), and treatment is generally recommended for patients with a TSH level that is undetectable or less than 0.1 mIU/L, particularly those with overt Graves disease or nodular thyroid disease 2.
Some key points to consider in the management of Hashimoto's thyroiditis include:
- Regular blood tests to monitor TSH levels are necessary, with adjustments made every 6-8 weeks until optimal levels are achieved
- Most patients require lifelong treatment
- Beyond medication, some patients benefit from a gluten-free diet, selenium supplementation (200 mcg daily), and vitamin D if deficient
- The condition occurs when antibodies mistakenly target thyroid peroxidase (TPO) and thyroglobulin, causing gradual destruction of thyroid tissue
- While the exact cause remains unknown, genetic factors play a significant role, with women being 5-10 times more likely to develop the condition than men
- Regular monitoring is essential as Hashimoto's patients have a slightly increased risk of developing other autoimmune conditions.
It is essential to note that the USPSTF found no direct evidence that treatment of thyroid dysfunction based on risk level alters final health outcomes 1, but treatment is still recommended to improve symptoms and quality of life.
From the Research
Hashimoto's Disease Overview
- Hashimoto's disease is a common autoimmune disorder that affects women 7-10 times more often than men 3
- The disease develops due to genetic susceptibility, X-chromosome inactivation patterns modulated by environmental factors, and microbiome composition, leading to an imbalance in self-tolerance mechanisms 3
- The consequential thyroid infiltration by lymphocytes, potentiated by antibody-mediated autoimmune response, leads to a destruction of thyrocytes 3
Clinical Presentation and Diagnosis
- The clinical presentation of Hashimoto's thyroiditis includes thyrotoxicosis, euthyroidism, and hypothyroidism 3
- The presence of thyroid peroxidase antibodies (TPOAbs) is associated with a 2 to 4-fold increase in the risk of recurrent miscarriages and preterm birth in pregnant women 3
- The management of Hashitoxicosis is based on symptoms control, usually with β-blockers, while euthyroidism requires periodical thyroid-stimulating hormone measurements to assess for progression to hypothyroidism 3
Treatment Options
- Hypothyroidism is treated with thyroid hormone replacement therapy, with the dose of levothyroxine (LT4) used for treatment based on the degree of preserved thyroid functionality and lean body mass 3
- The dose of LT4 usually ranges from 1.4 to 1.8 mcg/kg/day 3
- For patients who remain symptomatic on LT4 therapy, clinical guidelines recommend, on a trial basis, therapy with LT4+LT3 4
- Levothyroxine sodium oral solution can be an effective treatment option for patients with Hashimoto's disease and comorbid gastrointestinal conditions, such as gastroparesis and small intestinal bacterial overgrowth (SIBO) 5
Special Considerations
- There is insufficient evidence to recommend for or against therapy with triiodothyronine (T3), apart from in pregnancy when only levothyroxine is indicated 3
- Hashimoto's thyroiditis is associated with a higher risk of papillary thyroid cancer and thyroid lymphoma than in the general population 3
- Treatment of subclinical hypothyroidism should be confirmed by repeat thyroid function tests, and treatment is not necessary unless the TSH exceeds 7.0-10 mIU/L 6