Approach

The goal of treatment in the thyrotoxic (hyperthyroid) phase should be to ameliorate thyrotoxic symptoms and prevent thyrotoxic complications.[27] During the hypothyroid phase treatment should target hypothyroid symptoms and limit hypothyroid complications. Patients should be closely monitored during the transition between the thyrotoxic and hypothyroid phases.

Increased metabolism during the thyrotoxic phase may alter effectiveness of medications and require dosing adjustments (e.g., accelerated metabolism of vitamin K-dependent clotting factors may require a reduction in warfarin dose).[36] Conversely, during the hypothyroid phase the metabolism of many drugs is slowed, which may result in toxicity, while warfarin requirements for sufficient anticoagulation may increase.

Antithyroid drugs that work through interfering with thyroid hormone synthesis (e.g., methimazole or propylthiouracil) have no role in the treatment of this condition.[27] Similarly, absent radioiodine uptake precludes the use of radioiodine treatment.

There is no consensus on whether causative drugs such as immunomodulatory drugs, amiodarone, or lithium should be discontinued when painless thyroiditis develops. Because the disease is self-limiting, it is usually not necessary to stop treatment.

Thyrotoxic (hyperthyroid) phase

Mild: in a young patient with no cardiovascular disease and who is asymptomatic or has only minimal symptoms, treatment may not be necessary. Thyroid function should be monitored every 4 to 6 weeks until the euthyroid state has been re-established. In older patients and those with pre-existing cardiovascular disease, beta-blockers should be given to limit complications such as atrial fibrillation.

Moderate: in patients with symptomatic thyrotoxicosis, beta-blockers will ameliorate the tachycardia and tremulousness.[27][37] Older patients and those with underlying cardiovascular disease may be at risk of atrial fibrillation, and should be treated with beta-blockers even if asymptomatic. If beta-blockers are contraindicated or not tolerated, a calcium-channel blocker may provide some symptomatic benefit and protection from atrial arrhythmias. Addition of systemic corticosteroids may be considered in some patients with moderate thyrotoxicosis who cannot tolerate symptoms.

Severe: in patients who are not tolerating thyrotoxic symptoms and are not responding to conventional therapy and/or have thyrotoxic complications, systemic corticosteroids should be given. Systemic corticosteroids may shorten the course and reduce the severity of thyrotoxic symptoms.[27]

Hypothyroid phase

Mild: if thyroid-stimulating hormone (TSH) is <10 microunits/mL and the patient has absent or minimal symptoms, treatment may be deferred. Monitoring is recommended in this group.[38]

Moderate to severe: levothyroxine is given to normalize serum TSH concentrations.[21] The initial dose should be slightly less than average replacement doses of levothyroxine with dose adjustments at 6-week intervals until TSH is normal. While the hypothyroid phase may last only a few months, it is occasionally more prolonged. In one study, 54% of women who developed postpartum thyroiditis were hypothyroid 12 months' postpartum.[39] Instead of trying to discontinue levothyroxine periodically, a simple approach is to wait 6 months before stopping or tapering the levothyroxine to determine whether thyroid function has returned to normal.

Permanent hypothyroidism: if TSH becomes elevated after stopping levothyroxine treatment, levothyroxine should be restarted and continued indefinitely (as for Hasmimoto’s thyroiditis). Patients with very high titers of thyroid peroxidase antibodies are at an increased risk of remaining permanently hypothyroid.

Recurrent thyroiditis

Women who experience postpartum thyroiditis have a high risk of developing recurrent postpartum thyroiditis in subsequent pregnancies (69%).[18]

Up to 11% of patients with sporadic painless thyroiditis will have recurrent thyroiditis.[40] Although it is rarely done, such patients may elect to have their thyroid gland ablated with radioiodine or surgically removed between episodes when they are euthyroid.[41][42]

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