eMedicine Specialties > Pediatrics: General Medicine > Endocrinology
Thyroiditis: Treatment & Medication
Updated: May 1, 2009
- Overview
- Differential Diagnoses & Workup
- Treatment & Medication
- Follow-up
- Multimedia
Treatment
Medical Care
- Acute thyroiditis
- Acute thyroiditis requires immediate parenteral antibiotic therapy before abscess formation begins. For initial antibiotic therapy, administer penicillin or ampicillin to cover gram-positive cocci and the anaerobes that are the usual causes of the disease.
- In patients who are allergic to penicillin, cephalosporins are appropriate.
- Subacute thyroiditis
- Subacute thyroiditis is self-limiting; therefore, the goals of treatment are to relieve discomfort and to control the abnormal thyroid function. The discomfort can usually be relieved with low-dose aspirin (divided every 4-6 h). In the rare cases that aspirin does not relieve the discomfort, administer prednisone for 1 week and then taper.
- Propranolol can be used to reduce signs and symptoms of hyperthyroidism.
- Low-dose levothyroxine may be necessary in some patients who develop hypothyroidism.
- Chronic autoimmune thyroiditis
- Treatment for chronic autoimmune thyroiditis depends on the results of the thyroid function tests. Patients with overt hypothyroidism who have high thyroid-stimulating hormone (TSH) and low free T4 levels require treatment with levothyroxine. The dose is age dependent. TSH levels should be monitored and the dose should be adjusted to maintain levels within the reference range.
- The treatment of subclinical hypothyroidism in patients with elevated TSH and normal free T4 levels is controversial. These children may enter a remission phase and may not have permanent hypothyroidism. This appears to be a minority of subjects. One study found that 4 of 14 subjects had normalization of TSH after a follow-up of 3-12 years. Most pediatric endocrinologists recommend treatment of subclinical hypothyroidism during childhood to ensure normal growth and development. If thyroxine administration may not be permanently required, treatment may be stopped once the patient has completed pubertal development, and thyroid function then can be reassessed. Guidelines for the diagnosis and management of subclinical thyroid disease have been established.
- The use of thyroxine treatment in patients with a goiter due to autoimmune thyroiditis who have normal TSH and free T4 levels is even more controversial. Some studies have suggested that treatment may decrease gland size,7,8 but other studies suggest that reduction in gland size is likely only in children with initially elevated TSH levels.4
Surgical Care
- In acute thyroiditis, surgery may be necessary to drain the abscess and to correct the developmental abnormality responsible for the condition.
- The surgical service consulted depends on the institution and the physician who has the most experience with thyroid surgery. Options include the following:
- Pediatric surgery
- Otolaryngology
- A specialized endocrine surgery service
Consultations
- Acute thyroiditis: Consulting with a pediatric infectious disease specialist may be useful for selecting appropriate antibiotic therapy.
- Subacute and chronic thyroiditis: Consulting with a pediatric endocrinologist should be considered in treating children with these disorders. This is particularly true if the child has experienced poor growth possibly due to hypothyroidism, has symptoms of overt hyperthyroidism, or has a discrete thyroid nodule.
Diet
- No dietary limitations are necessary.
Activity
- Children with overt hyperthyroidism or hypothyroidism have poor exercise tolerance. These children usually limit their own activity. As treatment progresses and thyroid function levels return to normal, their exercise tolerance should increase.
Medication
Antibiotics
These agents are used to treat acute suppurative thyroiditis. First-line antibiotic choices to treat acute thyroiditis include parenteral penicillin or ampicillin. These drugs cover most of the gram-positive cocci and anaerobes that cause the disease.
Penicillin G (Pfizerpen)
Antibiotic with activity against gram-positive, some gram-negative, and some anaerobic bacteria. Penicillin binds to PBPs, inhibiting bacterial cell wall growth.
Adult
1-2 million U IV q4-6h
Pediatric
200,000-300,000 U/kg/d IV divided q4-6h
Decreases PO contraceptive efficacy; probenecid increases the serum concentration of penicillin
Documented hypersensitivity
Pregnancy
B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals
Precautions
Cross allergy to cephalosporin antibiotics; caution in renal dysfunction (decrease dose)
Ampicillin (Principen)
Penicillin antibiotic with activity against gram-positive and some gram-negative bacteria. Binds to PBPs, inhibiting bacterial cell wall growth.
Adult
500-3000 mg IV q4-6h
Pediatric
200-400 mg/kg/d IV divided q4-6h; not to exceed 12 g/d
Decreases PO contraceptive efficacy; probenecid increases the serum concentration of ampicillin
Documented hypersensitivity
Pregnancy
B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals
Precautions
Cross allergy to cephalosporin antibiotics; dose adjustments may be necessary in patients with renal failure
Anti-inflammatory drugs
These drugs are used to decrease discomfort in patients with subacute thyroiditis.
Aspirin (Anacin, Bayer)
Most patients respond well to aspirin as a first-line therapy. Treats mild to moderate pain. Inhibits prostaglandin synthesis, which prevents formation of platelet-aggregating thromboxane A2.
Adult
325-650 mg PO q4-6h prn for pain
Pediatric
60 mg/kg/d PO divided q4-6h
Warfarin and aspirin used together may increase adverse bleeding effects; aspirin may increase free valproic acid levels, causing an increase in valproic acid toxicity; aspirin may increase serum methotrexate levels
Effects may decrease with antacids and urinary alkalinizers; corticosteroids decrease salicylate serum levels; may antagonize uricosuric effects of probenecid; doses >2 g/d may potentiate glucose-lowering effect of sulfonylurea drugs
Documented hypersensitivity; bleeding disorders or GI bleeding; because of association with Reye syndrome, do not use in children <16 y with varicella or influenza infections
Pregnancy
D - Fetal risk shown in humans; use only if benefits outweigh risk to fetus
Precautions
Patients with platelet and bleeding disorders, renal dysfunction, erosive gastritis, and peptic ulcer disease
Prednisone (Sterapred)
Used when aspirin is ineffective in controlling discomfort in patients with subacute thyroiditis. May decrease inflammation by reversing increased capillary permeability and suppressing PMN activity.
Adult
5-60 mg/d PO qd or divided bid/qid
Pediatric
0.5-1 mg/kg PO qd for 1 wk; then taper downward
Barbiturates, phenytoin, and rifampin may decrease prednisone effectiveness; monitor for hypokalemia with coadministration of diuretics
Documented hypersensitivity; serious infections (excluding meningitis and septic shock), fungal infections, and varicella infections; GI bleeding
Pregnancy
C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus
Precautions
Administer with meals to decrease GI upset; early onset adverse effects include glucose intolerance, hypertension, agitation, and indigestion; late-onset adverse effects include immune suppression and increased susceptibility to sepsis, adrenal suppression, hypertension, urinary calcium loss and osteopenia, and gastric irritation and bleeding
Beta-adrenergic blocking agents
Many signs and symptoms of hyperthyroidism are due to increased beta-adrenergic sensitivity. In particular, these include the hemodynamic abnormalities of tachycardia and hypertension. Beta-adrenergic blockade can reduce many of these symptoms. These agents are the DOC in treating cardiac arrhythmias that result from hyperthyroidism. These agents control cardiac and psychomotor manifestations within minutes.
Propranolol (Inderal)
Can be immediately initiated in patients with hyperthyroidism due to either subacute thyroiditis or autoimmune thyroiditis. Because of the self-limiting nature of these situations, they may be the only drugs needed.
Adult
10-40 mg/dose PO q6h
Pediatric
2.5-10 mg/kg/d PO divided q6-8h; not to exceed 60 mg/d
Adolescents: Administer as in adults
Concomitant use with calcium channel–blocking blocking drugs may depress myocardial contractility or atrioventricular conduction and other serious reactions; hypotension and cardiac arrest have been reported with the concomitant use of propranolol and haloperidol
Coadministration with aluminum salts, barbiturates, NSAIDs, penicillins, calcium salts, cholestyramine, and rifampin may decrease propranolol effects; calcium channel blockers, cimetidine, loop diuretics, and MAOIs may increase toxicity of propranolol; toxicity of hydralazine, haloperidol, benzodiazepines, and phenothiazines may increase with propranolol
Documented hypersensitivity; uncompensated congestive heart failure, cardiogenic shock, bradycardia or heart block, pulmonary edema, severe hyperactive airway disease or COPD, and Raynaud disease; severe asthma
Pregnancy
C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus
Precautions
May cause failure to recognize hypoglycemia in patients with type 1 diabetes; most common adverse drug reactions include bradycardia and CNS depression; when discontinuing propranolol, gradually taper dose over 1-2 wk (abrupt withdrawal may exacerbate symptoms of hyperthyroidism, including thyroid storm)
Hormones
These agents are used to treat hypothyroidism due to autoimmune thyroiditis. Use thyroid-stimulating hormone (TSH) levels to monitor dose and keep them within the reference range.
Levothyroxine (Levothroid, Levoxyl, Synthroid)
Rapidly inhibits release of thyroid hormones via a direct effect on the thyroid gland and inhibits the synthesis of thyroid hormones. Iodide also appears to attenuate the cAMP-mediated effects of thyrotropin. In active form, influences growth and maturation of tissues. Involved in normal growth, metabolism, and development.
Adult
100-200 mcg/d PO
Pediatric
6-12 months: 6-8 mcg/kg/d PO
1-5 years: 4-6 mcg/kg/d PO
5-10 years: 3-4 mcg/kg/d PO
>10 years: 2-3 mcg/kg/d PO
Concomitant iron therapy may interfere with absorption; cholestyramine may decrease absorption
Documented hypersensitivity; acute MI
Pregnancy
A - Fetal risk not revealed in controlled studies in humans
Precautions
Best if taken when stomach is empty; caution in angina pectoris or cardiovascular disease; periodically monitor thyroid status
More on Thyroiditis |
| Overview: Thyroiditis |
| Differential Diagnoses & Workup: Thyroiditis |
 Treatment & Medication: Thyroiditis |
| Follow-up: Thyroiditis |
| Multimedia: Thyroiditis |
| References |
| « Previous Page | Next Page » |
References
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Further Reading
Keywords
thyroiditis, acute thyroiditis, autoimmune thyroiditis, chronic lymphocytic thyroiditis, Hashimoto thyroiditis, subacute thyroiditis, thyroadenitis, acute suppurative thyroiditis, chronic thyroiditis, Riedel struma, Riedel thyroiditis, atrophic thyroiditis, goitrous thyroiditis, vitiligo, hypothyroidism, persistent thyroglossal duct, brachial cleft cysts, Down syndrome, Down’s syndrome, Turner syndrome, Turner’s syndrome, type 1 diabetes, Staphylococcus aureus, Streptococcus hemolyticus, pneumococcus, mumps, measles, influenza, infectious mononucleosis, Coxsackievirus infections, myocarditis, common cold, catscratch fever, sarcoidosis, Q fever, malaria, treatment, diagnosis
