Approach
Treatment is focused on providing pain relief and treating any manifestations of hyper- or hypothyroidism that may be present. Not all patients require treatment, as symptoms may be mild and/or subsiding by the time the diagnosis is made.
Hyperthyroid (thyrotoxic) phase
During this phase, treatment is supportive, as symptoms are due to the release of preformed thyroid hormone, and antithyroid medications that inhibit new hormone synthesis are ineffective.
Nonsteroidal anti-inflammatory drugs (NSAIDs) and corticosteroids may be used to treat the hyperthyroid symptoms, but they do not alter the clinical course of the disease.[35][36]
For pain, most cases are treated initially with NSAIDs. 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. Thyroid pain may prevent patients from swallowing or sleeping. In these cases, moderate doses of opioid analgesics can be used before meals and at bedtime. Analgesics are given until the pain resolves, which may be several weeks.
Severe pain or pain unresponsive to analgesics may be treated with corticosteroids.[35][36] If pain does not respond to corticosteroid therapy in 1 to 2 days, the diagnosis should be reconsidered. High-dose corticosteroids (e.g., 40 mg/day of prednisone) are usually required for several weeks, followed by a 4- to 6-week taper depending on the clinical course.[37] Some data suggest that a lower dose of prednisone (e.g., 15 mg/day) may be effective for pain control.[38][39] If corticosteroids are stopped too early, the pain will return. Occasionally the pain will recur some time after 6 weeks, and in this situation the corticosteroids should be used for an additional 2 weeks before tapering down again.
Symptoms of hyperthyroidism in most patients are mild and do not require treatment. However, if thyrotoxic symptoms such as tachycardia, anxiety, and/or tremor are troublesome, patients can benefit from treatment with a beta-blocker or calcium-channel blocker.[15] Beta-blocker therapy is the drug of choice for sinus tachycardia. Calcium-channel blockers can be used when beta-blockers are contraindicated such as in patients with bronchospasm and asthma. Beta-blockers are the preferred therapy for tachycardia, as the action is primarily directed to the sinoatrial node and less on the atrioventricular node, resulting in less hypotension.
Patients with severe symptoms of thyrotoxicosis may require medication that inhibits the conversion of T4 to T3. The rationale for this approach is that T3 is 20 to 50 times more bioactive than T4. 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 prednisone.[40] The iodinated contrast agents iopanoic acid and ipodate are available in Europe but not in the US.
Hypothyroid phase
The treatment is supportive in mild cases (TSH <10-15 mIU/L). Generally, patients with this degree of hypothyroidism do not require thyroid hormone therapy, unless the patient is actively trying to conceive or is already pregnant, given the importance of normal thyroid hormone levels for the fetus.[33] If the patient is adversely affected by the hypothyroidism, or if the hypothyroidism is moderate to severe biochemically and/or accompanied by fatigue that interferes with daily activities, a low to moderate dose of 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, reinstitute levothyroxine for permanent hypothyroidism.[1][2][35]
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