Treatment algorithm

Please note that formulations/routes and doses may differ between drug names and brands, drug formularies, or locations. Treatment recommendations are specific to patient groups: see disclaimer

ACUTE

hyperthyroid (thyrotoxic) phase

1st line – supportive care

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ACUTE
|
hyperthyroid (thyrotoxic) phase
1st line – 

supportive care

Not all patients require treatment, as symptoms may be mild and/or subsiding by the time the diagnosis is made. During this phase, treatment is supportive because symptoms are due to the release of preformed thyroid hormone, so antithyroid medications that inhibit new hormone synthesis are ineffective. Some patients do not require analgesics if the discomfort does not interfere with daily activities.

Plus – analgesic or corticosteroid

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ACUTE
|
hyperthyroid (thyrotoxic) phase
|
with thyroid pain and tenderness
Plus – 

analgesic or corticosteroid

Treatment recommended for ALL patients in selected patient group

If needed, generally, the thyroid pain improves with initiation of a non-steroidal anti-inflammatory drug (NSAID). Analgesics may be needed for several weeks. Aspirin should be avoided, as at high doses it causes thyroid hormone to be displaced from serum plasma proteins, effectively increasing the bioactive or free pool of thyroid hormone.

If the thyroid pain prevents patients from swallowing or sleeping, moderate doses of opioid analgesics can be used before meals and at bedtime.

Corticosteroids can be used for severe pain unrelieved by NSAIDs and opioid analgesics. Pain relief can be dramatic within a few days. High-dose corticosteroids (e.g., 40 mg/day of prednisolone) are usually required for several weeks, followed by a 4- to 6-week taper depending on the clinical course.[36]​ Some data suggest that a lower dose of prednisolone (e.g., 15 mg/day) may be effective for pain control.[37][38]​​ If pain recurs during the tapering down, the corticosteroids should be used for an additional 2 weeks before tapering down again.

Primary options

ibuprofen: 300-400 mg orally every 6-8 hours when required, maximum 2400 mg/day

OR

naproxen: 250-500 mg orally twice daily when required, maximum 1250 mg/day

OR

indometacin: 25-50 mg orally three times daily when required

Secondary options

paracetamol: 500-1000 mg orally every 4-6 hours when required, maximum 4000 mg/day

-- AND --

codeine phosphate: 15-60 mg orally every 4-6 hours when required, maximum 240 mg/day

or

oxycodone: 2.5 to 10 mg orally every 4-6 hours when required

Tertiary options

prednisolone: 40-60 mg orally once daily for several weeks then taper over 4-6 weeks depending on clinical course

Plus – beta-blocker or calcium-channel blocker

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ACUTE
|
hyperthyroid (thyrotoxic) phase
|
with tachycardia or anxiety or tremor
Plus – 

beta-blocker or calcium-channel blocker

Treatment recommended for ALL patients in selected patient group

Many patients have only mild symptoms of hyperthyroidism that do not require treatment. However, if thyrotoxic symptoms are troublesome, then beta-blockers or calcium-channel blockers can be beneficial.[15]

Propranolol is lipid soluble and is thought to improve thyrotoxic central nervous system symptoms better than other agents.

In patients with reactive airway disease, beta-blockers may worsen wheezing; calcium-channel blockers may be used to reduce heart rate.

Patients should be adequately hydrated before using a beta-blocker to prevent heart rate reduction resulting in hypotension. Patients are often volume depleted from heat intolerance and reduced oral intake due to thyroid pain.

Primary options

propranolol: 20-40 mg orally (immediate-release) every 4-6 hours

OR

atenolol: 50-100 mg orally once daily

Secondary options

verapamil: 80 mg orally (immediate-release) three times daily

OR

diltiazem: 30-60 mg orally (immediate-release) three to four times daily

Plus – potassium iodide plus prednisolone

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ACUTE
|
hyperthyroid (thyrotoxic) phase
|
with severe thyrotoxicosis
Plus – 

potassium iodide plus prednisolone

Treatment recommended for ALL patients in selected patient group

Because thyrotoxicosis is due to release of preformed thyroid hormone, there is no direct treatment to reduce thyroid release of hormones. However, the degree of thyrotoxicosis can be reduced by preventing the main circulating thyroid hormone (T4) from being deiodinated and converted to the more bioactive T3.

Conversion of T4 to T3 can be reduced by a high level of iodine, usually achieved by giving a saturated solution of potassium iodide or iopanoic acid along with high doses of corticosteroids such as oral prednisolone.

Primary options

potassium iodide: 250 mg orally three times daily

and

prednisolone: 40 mg orally once daily for 2-3 weeks then taper over 4-6 weeks

hypothyroid phase

1st line – observation and regular reassessment

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ACUTE
|
hypothyroid phase
|
mild (TSH <10-15 mIU/L)
1st line – 

observation and regular reassessment

Many patients with mild hypothyroidism (TSH <10-15 mIU/L) do not require levothyroxine therapy, unless the patient is actively trying to conceive or is already pregnant, given the importance of normal thyroid hormone levels for the fetus.[40]​ If the patient's energy levels do not interfere with the activities of daily living and there are no other symptoms, no therapy is offered, and thyroid function (TSH level and free thyroxine index) is regularly rechecked every 4 to 6 weeks, when symptoms can also be reassessed. If with subsequent testing, the TSH rises, levothyroxine therapy should be reconsidered.

Consider – levothyroxine

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ACUTE
|
hypothyroid phase
|
mild (TSH <10-15 mIU/L)
Consider – 

levothyroxine

Additional treatment recommended for SOME patients in selected patient group

If the patient is adversely affected by the hypothyroidism, including the presence of fatigue that may interfere with daily activities, levothyroxine can be given for up to several months and then stopped without a taper. TSH should be checked every 4 to 6 weeks during treatment with levothyroxine, and the dose adjusted to maintain a normal TSH level. Most patients (85% to 90%) return to normal thyroid function and will not need long-term levothyroxine therapy. Treatment should be withdrawn after 6 months to determine if endogenous function has returned to normal. TSH level should be checked 4 to 6 weeks after stopping. If normal, no further therapy is necessary. If elevated, re-institute levothyroxine for permanent hypothyroidism.[1][2][34]

Primary options

levothyroxine: 50 micrograms orally once daily initially, adjust dose according to thyroid function tests

1st line – levothyroxine

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ACUTE
|
hypothyroid phase
|
moderate (TSH >15 mIU/L)
1st line – 

levothyroxine

Patients who have moderate deficiency (TSH >15 mIU/L) should be treated with levothyroxine to normalise the TSH. This dose of levothyroxine can be maintained for several months and then stopped without a taper. During treatment, TSH should be checked every 4 to 6 weeks. Generally, the hypothyroid phase of subacute thyroiditis is resolved by this time. Thyroid function tests should be checked 4-6 weeks after stopping the levothyroxine, to confirm normal thyroid function.

Primary options

levothyroxine: 75-125 micrograms orally once daily initially, adjust dose according to thyroid function tests

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Please note that formulations/routes and doses may differ between drug names and brands, drug formularies, or locations. Treatment recommendations are specific to patient groups. See disclaimer

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