Subacute Thyroiditis Treatment & Management

Patients are often dehydrated from thyrotoxicosis; encourage all patients to drink 6-8 cups per day of noncaffeinated fluids.

Subacute thyroiditis - all forms

The treatment of subacute thyroiditis is generally supportive to reduce the symptoms of thyrotoxicosis and to control neck pain in the setting of subacute granulomatous thyroiditis. Because no new hormone is being made, antithyroid medications are not effective in these conditions. Although the abnormal thyroid levels are temporary, emotional support is often necessary.

• Thyroid hormone levels in subacute thyroiditis - The release of preformed hormone cannot be stopped in the destructive phase. In patients with very high levels of thyroid hormone, ipodate (iopanoic acid), better known as Gastrografin, may be administered to inhibit the conversion of T4 to the more active form of thyroid hormone, T3. A dose of 1000 mg in 2 divided doses daily usually provides a rapid reduction in T3 and in thyrotoxic symptoms.
• Pain in subacute granulomatous thyroiditis - The thyroid pain can be extreme. Nonsteroidal medications are administered. Avoid high-dose aspirin because, in some circumstances, aspirin can competitively displace thyroid hormone from its binding protein and increase the free, or bioactive, fraction of thyroid hormone, which can make patients feel more thyrotoxic. In extreme cases, stronger pain medications, including narcotic analgesics, are indicated for a brief period of 2-3 weeks. In the most extreme cases, high-dose steroids (eg, prednisone 40-60 mg qd) must be administered. The high-dose steroids rapidly and dramatically decrease the pain and thyroid swelling, but the natural course of thyrotoxicosis and pain (ie, 4-6 wk) is not altered, and the glucocorticoid treatment must be continued for this period.
• Peripheral manifestations of thyrotoxicosis - Patients often find great relief from tachycardia, palpitations, anxiety, and tremor with beta-blocker therapy. Propranolol is generally recommended because of its CNS effects. The patient usually titrates the dose depending on the symptoms. Exercise caution with the initial dose; patients may become hypotensive, because they are often dehydrated from the decrease in oral intake of fluids and increased perspiration from thyrotoxicosis.

Surgical care is almost never recommended for subacute thyroiditis. Surgery is recommended rarely in patients who have frequent recurrences of thyrotoxicosis from lymphocytic thyroiditis or recurrent pain from subacute granulomatous thyroiditis.

Generally, all patients with thyrotoxicosis should be referred to an endocrinology specialist. Distinguishing between the causes of thyrotoxicosis is important, because the therapies are very different.

Avoiding high-dose iodine supplements, such as those found in seaweed tablets, during and after an episode of subacute thyroiditis is important. Inflammation appears to prevent the thyroid from escaping the iodine-induced Wolff-Chaikoff suppression of thyroid hormone synthesis. These patients are likely to become hypothyroid when ingesting large amounts of iodine.

No limitation in activity is necessary, but patients may experience tachycardia with exercise. Good hydration and beta-blocker therapy should allow patients with subacute thyroiditis – caused thyrotoxicosis to exercise normally.