An Evaluation of the Results of the Steroid and Non-steroidal Anti-inflammatory Drug Treatments in Subacute Thyroiditis in relation to Persistent Hypothyroidism and Recurrence

Abstract

Subacute thyroiditis (SAT) is an inflammatory thyroid disease. The main purpose of the treatment is to relieve pain and control the inflammatory process. The aim of the present study was to evaluate the therapeutic effects of steroid and non-steroidal anti-inflammatory drugs (NSAIDs) in SAT. Initial laboratory data, treatment response, and long-term results of 295 SAT patients treated with ibuprofen or methylprednisolone were evaluated. After the exclusion of 78 patients, evaluation was made of 126 patients treated with 1800 mg ibuprofen and 91 patients treated with 48 mg methylprednisolone. In 59.5% of 126 patients treated with ibuprofen, there was no adequate clinical response at the first control visit. In 54% of patients, the treatment was changed to steroids in mean 9.5 days. Symptomatic remission was achieved within two weeks in all patients treated with methylprednisolone. The total recurrence rate was 19.8%, and recurrences were observed more frequently in patients receiving only steroid therapy than in patients treated with NSAID only (23% vs. 10.5% p:0.04). Persistent hypothyroidism developed in 22.8% of patients treated only with ibuprofen and in 6.6% of patients treated with methylprednisolone only. Treatment with only ibuprofen (p:0.039) and positive thyroid peroxidase antibody (anti-TPO) (p:0.029) were determined as the main risk factors for permanent hypothyroidism. NSAID treatment is not as effective as steroid treatment in early clinical remission. Steroid treatment was detected as a protective factor against permanent hypothyroidism. Therefore, steroid therapy may be considered especially in anti-TPO positive SAT patients and patients with highlevel acute phase reactants. Subacute thyroiditis (SAT) is an inflammatory thyroid disease with a background of possible viral etiology, and it manifests with clinical symptoms, including severe neck pain, fever, and fatigue 1-3. The diagnosis of this disorder is based on physical examination, clinical symptoms, laboratory, and ultrasonographic findings. SAT mostly presents with thyrotoxicosis and is followed by hypothyroidism before complete remission 3,4. Although SAT is a self-limiting disease within weeks, it requires treatment for the painful condition and thyrotoxicosis symptoms. The primary goal of the treatment is relief of symptoms that can be provided by beta-blocker agents, NSAIDs, and steroids. Although there is no consensus on initial therapy, the recommended approach is to start treatment with NSAIDs in mild cases and steroids in severe disease, but there are not enough data in the literature about the short

C-reactive protein and thyroid-stimulating hormone levels as risk factors for hypothyroidism in patients with subacute thyroiditis

“…A study in the 1990s has reported that TSH receptor antibodies became positive in many patients with SAT, probably resulting in thyroid dysfunction ( 28 ). While other studies have reported female and thyroid antibody positivity as risk factors for hypothyroidism ( 12 , 17 , 29 ), no statistical results could confirm the aforementioned factors in this study. Instead, CRP and TSH were found to be risk factors for hypothyroidism, especially CRP levels of more than 97.80 mg/L and TSH levels of less than 0.10 mIU/L.…”

“…The risk of recurrence in patients with SAT was HLA-dependent, and the co-presence of HLA-B*18:01 and –B*35 was a determining factor ( 16 ). Some studies have shown that patients who received corticosteroid therapy tended to receive T4 therapy, whereas some studies have shown the opposite ( 13 , 17 ).…”

Two Important Issues in Subacute Thyroiditis Management: Delayed Diagnosis and Inappropriate Use of Antibiotics

“…Fever and palpitations were present in approximately half of the patients in parallel with findings in the literature, while weight loss was present in a small number of patients [3]. ESR and CRP levels were above the upper limit of normal, similar to data reported in the literature [1, 3, 4, 13]. In addition, some authors have suggested that there may be a 1- to 6-week delay between the onset of symptoms and the appearance of laboratory findings [3, 14].…”

Frequency of Thyroid Antibodies at the Diagnosis of Subacute Thyroiditis

“…Latrofa showed that the Anti-Tg epitope pattern in SAT is different from that in Hashimoto's disease and that the anti-Tg release in SAT disease is transient, with no autoimmune significance (10). It has been hypothesized that patients with autoimmune thyroid disease who have anti-TPO positivity may also develop subacute thyroiditis (8,11) Recently published studies have established that the clinical importance of overlapping of SAT and autoimmune thyroid disease is that autoimmunity has been demonstrated to increase the rate of permanent hypothyroidism after SAT (12)(13)(14)(15)(16). Until recently, an increase in the level of TRAb, just like anti-TPO and anti-Tg, was not expected in patients with SAT.…”