Treatment algorithm

Please note that formulations/routes and doses may differ between drug names and brands, drug formularies, or locations. Treatment recommendations are specific to patient groups: see disclaimer

ACUTE

hyperthyroid (thyrotoxic) phase

1st line – supportive care

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ACUTE
|
hyperthyroid (thyrotoxic) phase
1st line – 

supportive care

Not all patients require treatment, as symptoms may be mild and/or subsiding by the time the diagnosis is made. During this phase, treatment is supportive. Symptoms are due to the release of preformed thyroid hormone, and antithyroid drugs that inhibit new hormone synthesis are ineffective.

Some patients do not require analgesics if the discomfort does not interfere with daily activities.

Plus – non-steroidal anti-inflammatory drug (NSAID) or corticosteroid

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ACUTE
|
hyperthyroid (thyrotoxic) phase
|
with thyroid pain and tenderness
Plus – 

non-steroidal anti-inflammatory drug (NSAID) or corticosteroid

Treatment recommended for ALL patients in selected patient group

If needed, NSAIDs (e.g., ibuprofen, naproxen, indometacin) are used in the management of thyroid pain.[4]​ Analgesics may be needed for several weeks.

Thyroid pain that is severe, unresponsive to NSAIDs, or prevents patients from swallowing or sleeping, may be treated with corticosteroids (e.g., prednisolone).[4][22]​​[28][50]​​ If pain does not respond to corticosteroids in 1-2 days, the diagnosis should be reconsidered. A relatively high dose of prednisolone is usually required for 1-2 weeks, followed by taper over 2-4 weeks (or longer, depending on clinical course).[4]​ Some data suggest that lower doses of corticosteroid may be effective for pain control.[51][52][53]​ Corticosteroid treatment may be associated with reduced incidence of permanent hypothyroidism compared with treatment with an NSAID.[54][55]​ Note, however, that if corticosteroids are stopped too early, the pain may return.[56]

Primary options

ibuprofen: 300-400 mg orally every 6-8 hours when required, maximum 2400 mg/day

OR

naproxen: 250-500 mg orally twice daily when required, maximum 1250 mg/day

OR

indometacin: 25-50 mg orally three times daily when required

Secondary options

prednisolone: 40-60 mg orally once daily for several weeks then taper gradually according to response

Plus – beta-blocker or calcium-channel blocker

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ACUTE
|
hyperthyroid (thyrotoxic) phase
|
with tachycardia or anxiety or tremor
Plus – 

beta-blocker or calcium-channel blocker

Treatment recommended for ALL patients in selected patient group

Many patients have only mild symptoms of hyperthyroidism that do not require treatment. However, if thyrotoxic symptoms (e.g., tachycardia, anxiety, and/or tremor) are troublesome, patients can benefit from treatment with a beta-blocker or calcium-channel blocker.[4][28]

Beta-blockers (e.g., propranolol, atenolol) are recommended for the management of sinus tachycardia in thyrotoxic patients.[4]

Calcium-channel blockers (e.g., verapamil, diltiazem) can be used in the thyrotoxic phase when beta-blockers are contraindicated (e.g., in patients with bronchospasm and asthma) or not tolerated, but are associated with increased risk for hypotension.[4]

Patients should be adequately hydrated before using a beta-blocker to prevent heart rate reduction resulting in hypotension. Patients are often volume depleted from heat intolerance and reduced oral intake due to thyroid pain.

Primary options

propranolol: 20-40 mg orally (immediate-release) every 4-6 hours

OR

atenolol: 50-100 mg orally once daily

Secondary options

verapamil: 80 mg orally (immediate-release) three times daily

OR

diltiazem: 30-60 mg orally (immediate-release) three to four times daily

Plus – potassium iodide plus prednisolone

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ACUTE
|
hyperthyroid (thyrotoxic) phase
|
with severe thyrotoxicosis
Plus – 

potassium iodide plus prednisolone

Treatment recommended for ALL patients in selected patient group

Inhibiting the conversion of thyroxine (T4) to triiodothyronine (T3) may benefit patients with severe symptoms of thyrotoxicosis (because T3 is 20-50 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, along with high doses of corticosteroid, such as prednisolone.[57]

Primary options

potassium iodide: 250 mg orally three times daily

and

prednisolone: 40 mg orally once daily for 2-3 weeks then taper over 4-6 weeks

hypothyroid phase

1st line – observation and regular reassessment

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ACUTE
|
hypothyroid phase
|
mild (thyroid-stimulating hormone [TSH] <10-15 mIU/L)
1st line – 

observation and regular reassessment

The treatment is supportive in mild cases (i.e., TSH <10-15 mIU/L). Generally, patients with this degree of hypothyroidism do not require thyroid hormone therapy with levothyroxine, unless the patient is actively trying to conceive or is already pregnant.[58]

If the patient's energy levels do not interfere with the activities of daily living and there are no other symptoms, no therapy is offered. Thyroid function (TSH and free thyroxine level) is checked every 4-6 weeks, when symptoms can also be assessed.

Consider – levothyroxine

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ACUTE
|
hypothyroid phase
|
mild (thyroid-stimulating hormone [TSH] <10-15 mIU/L)
Consider – 

levothyroxine

Additional treatment recommended for SOME patients in selected patient group

Levothyroxine should be considered if, with subsequent testing, the TSH level increases.

A low to moderate dose of levothyroxine can be given for up to several months for a patient adversely affected by hypothyroidism, or with hypothyroidism that is moderate to severe biochemically (TSH >15 IU/L), and/or accompanied by fatigue that interferes with daily activities.

TSH should be checked every 4-6 weeks during treatment with levothyroxine, and the dose adjusted to maintain a normal TSH level. Treatment should be withdrawn after 3-6 months to determine if endogenous function has returned to normal.[4]​ Most patients (85% to 90%) return to normal thyroid function and will not need long-term levothyroxine.[2]​ If raised, levothyroxine may be restarted in a patient with permanent hypothyroidism subsequent to subacute thyroiditis.[1][2][22]

Primary options

levothyroxine: 50 micrograms orally once daily initially, adjust dose according to thyroid function tests

1st line – levothyroxine

Back
ACUTE
|
hypothyroid phase
|
moderate (thyroid-stimulating hormone [TSH] >15 mIU/L)
1st line – 

levothyroxine

Patients who have moderate deficiency (i.e., TSH >15 mIU/L) should be treated with levothyroxine to normalise the TSH.

This dose of levothyroxine can be maintained for several months and then stopped without a taper. Thyroid function (TSH and free thyroxine level) should be checked every 4-6 weeks during treatment. Generally, the hypothyroid phase of subacute thyroiditis is resolved by this time. Thyroid function tests should be checked 4-6 weeks after stopping the levothyroxine, to confirm normal thyroid function.

Primary options

levothyroxine: 75-125 micrograms orally once daily initially, adjust dose according to thyroid function tests

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Please note that formulations/routes and doses may differ between drug names and brands, drug formularies, or locations. Treatment recommendations are specific to patient groups. See disclaimer

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