Thyroiditis: Evaluation and Treatment

 

Am Fam Physician. 2021 Dec ;104(6):609-617.

  Patient information: A handout on this topic is available at https://familydoctor.org/condition/thyroiditis.

Author disclosure: No relevant financial affiliations.

Thyroiditis is a general term for inflammation of the thyroid gland. The most common forms of thyroiditis encountered by family physicians include Hashimoto, postpartum, and subacute. Most forms of thyroiditis result in a triphasic disease pattern of thyroid dysfunction. Patients will have an initial phase of hyperthyroidism (thyrotoxicosis) attributed to the release of preformed thyroid hormone from damaged thyroid cells. This is followed by hypothyroidism, when the thyroid stores are depleted, and then eventual restoration of normal thyroid function. Some patients may develop permanent hypothyroidism. Hashimoto thyroiditis is an autoimmune disorder that presents with or without signs or symptoms of hypothyroidism, often with a painless goiter, and is associated with elevated thyroid peroxidase antibodies. Patients with Hashimoto thyroiditis and overt hypothyroidism are generally treated with lifelong thyroid hormone therapy. Postpartum thyroiditis occurs within one year of delivery, miscarriage, or medical abortion. Subacute thyroiditis is a self-limited inflammatory disease characterized by anterior neck pain. Treatment of subacute thyroiditis should focus on symptoms. In the hyperthyroid phase, beta blockers can treat adrenergic symptoms. In the hypothyroid phase, treatment is generally not necessary but may be used in patients with signs and symptoms of hypothyroidism or permanent hypothyroidism. Nonsteroidal anti-inflammatory drugs and corticosteroids are indicated for the treatment of thyroid pain. Certain drugs may induce thyroiditis, such as amiodarone, immune checkpoint inhibitors, interleukin-2, interferon-alfa, lithium, and tyrosine kinase inhibitors. In all cases of thyroiditis, surveillance and clinical follow-up are recommended to monitor for changes in thyroid function.

Thyroiditis is a general term for inflammation of the thyroid gland, and it can be associated with thyroid dysfunction. Thyroiditis is classified according to clinical symptoms (painful or painless), onset of symptoms (acute, subacute, chronic), and underlying etiology (autoimmunity, infection, drugs, radiation). Painful types of thyroiditis include subacute, suppurative, and radiation induced. Painless types include drug induced, fibrous (Riedel thyroiditis), Hashimoto thyroiditis (HT), postpartum, and silent.

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SORT: KEY RECOMMENDATIONS FOR PRACTICE

Clinical recommendationEvidence ratingComments

In patients with Hashimoto thyroiditis (i.e., chronic autoimmune thyroiditis) and subclinical hypothyroidism, the thyroid-stimulating hormone level should be monitored annually.15,19

C

Expert consensus and disease-oriented evidence

Radioactive iodine uptake and scan is contraindicated in patients who are pregnant or breastfeeding.7,12,21

C

Expert consensus guideline

Beta blockers can treat thyrotoxic symptoms in patients with all forms of thyroiditis.21

B

Inconsistent or limited-quality patient-oriented evidence

Patients with a history of postpartum thyroiditis should have thyroid-stimulating hormone testing annually to evaluate for permanent hypothyroidism.22

C

Consistent and good-quality patient-oriented evidence

If the etiology of thyrotoxicosis is not apparent based on initial evaluation, clinicians should test for thyrotropin receptor antibodies to evaluate for Graves disease and order imaging studies such as thyroid ultrasonography to evaluate thyroidal blood flow and radioactive iodine uptake and scan to determine radioactive iodine uptake.12,21

C

Expert consensus guideline

Patients with subacute thyroiditis should be started on high-dose acetylsalicylic acid or nonsteroidal anti-inflammatory drugs as first-line therapy; corticosteroid therapy should be initiated for subacute thyroiditis in patients with severe neck pain or minimal response to acetylsalicylic acid or nonsteroidal anti-inflammatory drugs after four days.12,26

C

Expert consensus


A = consistent, good-quality patient-oriented evidence; B = inconsistent or limited-quality patient-oriented evidence; C = consensus, disease-oriented evidence, usual practice, expert opinion, or case series. For information about the SORT evidence rating system, go to https://www.aafp.org/afpsort.

The Authors

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BEATRIZ MARTINEZ QUINTERO, MD, is a fellow in the Department of Internal Medicine and the Division of Endocrinology, Diabetes and Metabolism at Virginia Commonwealth University School of Medicine, Richmond....

CYNTHIA YAZBECK, MD, is an endocrinologist in the Division of Endocrinology at Central Virginia Veterans Affairs Health Care System, Richmond.

LORI B. SWEENEY, MD, is an associate professor of medicine in the Division of Endocrinology at Central Virginia Veterans Affairs Health Care System.

Address correspondence to Beatriz Martinez Quintero, MD, Virginia Commonwealth University School of Medicine, 1101 E. Marshall St., Richmond, VA 23298 (email: beamarquin@gmail.com). Reprints are not available from the authors.

Author disclosure: No relevant financial affiliations.

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