eMedicine Specialties > Endocrinology > Thyroid

Hashimoto Thyroiditis: Treatment & Medication

Author: Stephanie L Lee, MD, PhD, Fellow, Association of Clinical Endocrinology; Director of Thyroid Nodule and Cancer Center, Associate Chief, Section of Endocrinology, Diabetes and Nutrition, Boston Medical Center; Associate Professor, Department of Medicine, Boston University School of Medicine
Coauthor(s): Sylvester Odeke, MD, FACE, Clinical Assistant Professor of Medicine, Division of Endocrinology and Metabolism, The Brody School of Medicine at East Carolina University; Steven B Nagelberg, MD, Clinical Professor, Department of Medicine, Division of Endocrinology and Metabolism, Drexel University College of Medicine
Contributor Information and Disclosures

Updated: Apr 10, 2009

Treatment

Medical Care

  • The treatment of choice for Hashimoto's thyroiditis (or hypothyroidism of any cause) is thyroid hormone replacement. The drug of choice is orally administered levothyroxine sodium, usually for life.
    • Tailor and titrate the dose to meet the individual patient's requirements. The goal of therapy is to restore a clinically and biochemically euthyroid state. The standard dose is 1.6-1.8 mcg/kg lean body weight per day, but the dose is patient dependent. The free T4 and TSH levels are within reference ranges in the biochemically euthyroid state, with the TSH level in the lower half of the reference range.
    • Patients younger than 50 years who have no history or evidence of cardiac disease can usually be started on full replacement doses.
    • Start patients older than 50 years and younger patients with cardiac disease on a low dose of 25 mcg (0.025 mg) per day, with clinical and biochemical reevaluation in 6-8 weeks. Carefully titrate the dose upward to achieve a clinical and biochemical euthyroid state. Rarely, it may not be possible to achieve a euthyroid state in a patient with baseline cardiac dysrhythmic disease without worsening his or her cardiac status. In such cases, the astute clinician is content to achieve the clinically euthyroid state and to accept a slightly elevated TSH level.
    • Elderly patients usually require a smaller replacement dose of levothyroxine, sometimes less than 1 mcg/kg lean body weight per day.
    • One popular treatment, more so among patients than physicians, is the combined use of liothyronine (T3) and levothyroxine in an effort to mimic more closely thyroid hormone physiology. However, a literature review found that out of 9 controlled clinical trials, only 1 indicated that combined therapy seemed to improve the mood, quality of life, and psychometric performance of patients more than did levothyroxine alone.10 Until investigators can demonstrate a definite advantage to the administration of levothyroxine plus liothyronine, the use of levothyroxine alone should remain the treatment of choice for replacement therapy in hypothyroidism.

Surgical Care

  • Indications for surgery
    • A large goiter with obstructive symptoms, such as dysphagia, voice hoarseness, and stridor, caused by extrinsic obstruction of airflow - Evaluate patients with these symptoms with a barium swallow study and pulmonary function tests, including flow volume loops and a neck computed tomography (CT) scan.
    • Presence of a malignant nodule, as found by cytologic examination by fine-needle aspiration.
    • Presence of a lymphoma diagnosed on fine-needle aspiration - Thyroid lymphoma responds very well to radiotherapy and is the treatment modality of choice in this situation.
    • Cosmetic reasons (for large, unsightly goiters)

Consultations

Endocrinologists

Medication

The goals of pharmacotherapy are to reduce morbidity and to prevent complications.

Synthetic thyroid hormones

Used as thyroid hormone replacements.


Levothyroxine sodium (Levoxyl, Synthroid)

Synthetic thyroid hormone (T4). 3,3,5,5-tetraiodothyronine. Available in 12 strengths for easy dose adjustment; 48-79% absorbed when administered orally; absorption higher in fasting state. Normal T4 levels are achieved within 24 h and normal T3 levels within a few days.

Adult

1.6-1.8 mcg/kg lean body weight/d PO qd
When PO intake is impractical: 80% of PO dose can be administered IV.
Myxedema coma: Loading dose is 4 mcg/kg lean body weight (usually about 300-600 mcg) by IV push, followed by maintenance dose of 50-100 mcg/d; change IV maintenance dose to PO as soon as possible
Obviously judicious dosing may need to be followed in patients with compromised cardiac function

Pediatric

Children usually require a higher dose, as follows:
0-6 months: Usual dose is 8-10 mcg/kg body weight/d, equivalent to 25-50 mcg/d
6-12 months: 6-8 mcg/kg/d PO (equivalent to 50-75 mcg/d)
1-5 years: 5-6 mcg/kg/d PO (equivalent to 75-100 mcg/d)
6-12 years: 4-5 mcg/kg/d PO (equivalent to 100-150 mcg/d)

Cholestyramine may decrease levothyroxine absorption; estrogens may decrease response to thyroid hormone therapy in patients with nonfunctioning thyroid glands; effect of anticoagulants increased when administered with levothyroxine; activity of some beta-blockers may decrease when hypothyroid patient is converted to a euthyroid state

Documented hypersensitivity; uncorrected adrenal insufficiency

Pregnancy

A - Fetal risk not revealed in controlled studies in humans

Precautions

Caution in angina pectoris or cardiovascular disease; monitor thyroid status periodically; caution in patients with adrenocortical insufficiency in whom steroid replacement should precede levothyroxine replacement

More on Hashimoto Thyroiditis

Overview: Hashimoto Thyroiditis
Differential Diagnoses & Workup: Hashimoto Thyroiditis
Treatment & Medication: Hashimoto Thyroiditis
Follow-up: Hashimoto Thyroiditis
References
Further Reading
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References

  1. Hadj-Kacem H, Rebuffat S, Mnif-Feki M, et al. Autoimmune thyroid diseases: genetic susceptibility of thyroid-specific genes and thyroid autoantigens contributions. Int J Immunogenet. Apr 2009;36(2):85-96. [Medline].

  2. Duntas LH. Environmental factors and autoimmune thyroiditis. Nat Clin Pract Endocrinol Metab. Aug 2008;4(8):454-60. [Medline].

  3. Tomer Y, Huber A. The etiology of autoimmune thyroid disease: a story of genes and environment. J Autoimmun. Mar 21 2009;[Medline].

  4. Fava A, Oliverio R, Giuliano S, et al. Clinical evolution of autoimmune thyroiditis in children and adolescents. Thyroid. Feb 18 2009;[Medline].

  5. Vanderpump MP, French JM, Appleton D. The prevalence of hyperprolactinaemia and association with markers of autoimmune thyroid disease in survivors of the Whickham Survey cohort. Clin Endocrinol (Oxf). Jan 1998;48(1):39-44. [Medline].

  6. Vanderpump MP, Tunbridge WM, French JM. The incidence of thyroid disorders in the community: a twenty-year follow-up of the Whickham Survey. Clin Endocrinol (Oxf). Jul 1995;43(1):55-68. [Medline].

  7. Tomer Y, Blackard JT, Akeno N. Interferon alpha treatment and thyroid dysfunction. Endocrinol Metab Clin North Am. Dec 2007;36(4):1051-66; x-xi. [Medline]. [Full Text].

  8. Huber A, Menconi F, Corathers S, et al. Joint genetic susceptibility to type 1 diabetes and autoimmune thyroiditis: from epidemiology to mechanisms. Endocr Rev. Oct 2008;29(6):697-725. [Medline].

  9. Baloch ZW, LiVolsi VA. Fine-needle aspiration of the thyroid: today and tomorrow. Best Pract Res Clin Endocrinol Metab. Dec 2008;22(6):929-39. [Medline].

  10. Escobar-Morreale HF, Botella-Carretero JI, Escobar del Rey F, et al. REVIEW: Treatment of hypothyroidism with combinations of levothyroxine plus liothyronine. J Clin Endocrinol Metab. Aug 2005;90(8):4946-54. [Medline]. [Full Text].

  11. [Best Evidence] Vestgaard M, Nielsen LR, Rasmussen AK, et al. Thyroid peroxidase antibodies in pregnant women with type 1 diabetes: impact on thyroid function, metabolic control and pregnancy outcome. Acta Obstet Gynecol Scand. 2008;87(12):1336-42. [Medline].

  12. Arafah BM. Decreased levothyroxine requirement in women with hypothyroidism during androgen therapy for breast cancer. Ann Intern Med. Aug 15 1994;121(4):247-51. [Medline].

  13. Blackshear JL, Schultz AL, Napier JS. Thyroxine replacement requirements in hypothyroid patients receiving phenytoin. Ann Intern Med. Sep 1983;99(3):341-2. [Medline].

  14. Canaris GJ, Manowitz NR, Mayor G. The Colorado thyroid disease prevalence study. Arch Intern Med. Feb 28 2000;160(4):526-34. [Medline].

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  16. Doniach D, Hudson VR, Roitt IM. Human auto-immune thyroiditis: Clinical studies. Br Med J. 1960;365-74.

  17. Fowler PB, Swale J, Andrews H. Hypercholesterolaemia in borderline hypothyroidism. Stage of premyxoedema. Lancet. Sep 5 1970;2(7671):488-91. [Medline].

  18. Holm LE, Blomgren H, Lowhagen T. Cancer risks in patients with chronic lymphocytic thyroiditis. N Engl J Med. Mar 7 1985;312(10):601-4. [Medline].

  19. Mandel SJ, Larsen PR, Seely EW. Increased need for thyroxine during pregnancy in women with primary hypothyroidism [see comments]. N Engl J Med. Jul 12 1990;323(2):91-6. [Medline].

  20. Rosenbaum RL, Barzel US. Levothyroxine replacement dose for primary hypothyroidism decreases with age. Ann Intern Med. Jan 1982;96(1):53-5. [Medline].

  21. Singer PA, Cooper DS, Levy EG. Treatment guidelines for patients with hyperthyroidism and hypothyroidism. Standards of Care Committee, American Thyroid Association [see comments]. JAMA. Mar 8 1995;273(10):808-12. [Medline].

  22. Singh N, Singh PN, Hershman JM. Effect of calcium carbonate on the absorption of levothyroxine. JAMA. Jun 7 2000;283(21):2822-5. [Medline].

  23. Stone E, Leiter LA, Lambert JR. L-thyroxine absorption in patients with short bowel. J Clin Endocrinol Metab. Jul 1984;59(1):139-41. [Medline].

  24. Surks MI, Chopra IJ, Mariash CN. American Thyroid Association guidelines for use of laboratory tests in thyroid disorders. JAMA. Mar 16 1990;263(11):1529-32. [Medline].

  25. Tunbridge WM. The epidemiology of hypothyroidism. Clin Endocrinol Metab. Mar 1979;DA - 19790611(1):21-7. [Medline].

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Keywords

Hashimoto thyroiditis, Hashimoto’s thyroiditis, thyroid, hypothyroidism, TSH, hypothyroid, levothyroxine, thyroid disease, thyroid problems, goiter, goiters, low thyroid, thyroxine, thyroid hormone, thyroiditis, thyroid treatment, hypothyroidism symptoms, T3 thyroid, T4 thyroid, thyroid disorders, thyroid-stimulating hormone, triiodothyronine, myxedema coma, chronic lymphocytic thyroiditis, struma lymphomatosa, autoimmune thyroid diseases, AITD

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Contributor Information and Disclosures

Author

Stephanie L Lee, MD, PhD, Fellow, Association of Clinical Endocrinology; Director of Thyroid Nodule and Cancer Center, Associate Chief, Section of Endocrinology, Diabetes and Nutrition, Boston Medical Center; Associate Professor, Department of Medicine, Boston University School of Medicine
Stephanie L Lee, MD, PhD is a member of the following medical societies: American College of Endocrinology, American Thyroid Association, and Endocrine Society
Disclosure: Nothing to disclose.

Coauthor(s)

Sylvester Odeke, MD, FACE, Clinical Assistant Professor of Medicine, Division of Endocrinology and Metabolism, The Brody School of Medicine at East Carolina University
Sylvester Odeke, MD, FACE is a member of the following medical societies: American Association of Clinical Endocrinologists, American College of Endocrinology, and North Carolina Medical Society
Disclosure: Nothing to disclose.

Steven B Nagelberg, MD, Clinical Professor, Department of Medicine, Division of Endocrinology and Metabolism, Drexel University College of Medicine
Steven B Nagelberg, MD is a member of the following medical societies: Alpha Omega Alpha, American Association of Clinical Endocrinologists, American College of Physicians, American Diabetes Association, American Medical Association, Endocrine Society, and Pennsylvania Medical Society
Disclosure: Nothing to disclose.

Medical Editor

Ghassem Pourmotabbed, MD†, Former Associate Professor, Department of Internal Medicine, Division of Endocrinology and Metabolism, University of Tennessee School of Medicine and Health Science Center
Ghassem Pourmotabbed, MD† is a member of the following medical societies: American Diabetes Association, American Federation for Medical Research, and Endocrine Society
Disclosure: Nothing to disclose.

Pharmacy Editor

Francisco Talavera, PharmD, PhD, Senior Pharmacy Editor, eMedicine
Disclosure: eMedicine Salary Employment

Managing Editor

Don S Schalch, MD, Professor Emeritus, Department of Internal Medicine, Division of Endocrinology, University of Wisconsin Hospitals and Clinics
Don S Schalch, MD is a member of the following medical societies: American Diabetes Association, American Federation for Medical Research, Central Society for Clinical Research, and Endocrine Society
Disclosure: Nothing to disclose.

CME Editor

Mark Cooper, MBBS, PhD, FRACP, Head, Diabetes & Metabolism Division, Baker Heart Research Institute, Professor of Medicine, Monash University
Disclosure: Nothing to disclose.

Chief Editor

George T Griffing, MD, Professor of Medicine, St Louis University School of Medicine
George T Griffing, MD is a member of the following medical societies: American Association for the Advancement of Science, American College of Medical Practice Executives, American College of Physician Executives, American College of Physicians, American Diabetes Association, American Federation for Medical Research, American Heart Association, Central Society for Clinical Research, Endocrine Society, International Society for Clinical Densitometry, and Southern Society for Clinical Investigation
Disclosure: Nothing to disclose.

 
 
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