Colchicine as a Steroid-Sparing Agent in Relapsing and Steroid-Dependent Subacute Thyroiditis: Preliminary Observations

Dear Editor:

Subacute thyroiditis (SAT) is a self-limiting inflammatory thyroid disorder often triggered by viral infections. Nonsteroidal anti-inflammatory drugs (NSAIDs) or corticosteroids (CS) are standard treatments, but managing SAT can be challenging due to its potential for recurrence during dose tapering or week(s) after continuation of therapy. Recurrence rates are around 12%, with higher incidences in patients treated with CSs compared to those treated with NSAIDs. ¹ High-dose CS, rapid tapering, and shorter CS treatment durations increase relapse risk. ^2,3 Steroid dependency presents a therapeutic challenge due to the well-known adverse effects of prolonged steroid use and may finally lead to hypothyroidism or require thyroidectomy. Steroid dependency, characterized by relapse upon tapering or discontinuation of CS, presents a therapeutic challenge due to the adverse effects of long-term use and can potentially result in hypothyroidism or the need for thyroidectomy.

Colchicine, an anti-inflammatory agent commonly used in treating gout and familial Mediterranean fever, has shown efficacy in various inflammatory conditions. However, its potential in SAT is although reported is underexplored. ⁴ Hereby we present a case series of five steroid-dependent SAT patients successfully managed with a colchicine-supported protocol.

We retrospectively reviewed five cases of steroid-dependent SAT who were treated with a combination of CS and colchicine. Recurrence/relapse was determined based on clinical, laboratory, and ultrasonographic (US) features. Patients were initiated on CS treatment at a dose of either 32 or 24 mg/day methylprednisolone (MPS) depending on the severity of the clinical presentation for at least 10 days, followed by tapering off the dose in 6–12 weeks if they are symptom free. Steroid dependency was defined as the need to restart CS due to relapse during tapering off or the week(s) after discontinuation. Our regimen was to introduce colchicine (0.5 mg bid) at the CS dose where relapse occurred and gradually taper and eventually discontinue treatment. Suggested “treatment discontinuation protocol” (TDP) is as follows: CS were reduced to 4 mg/day MPS and continued for four weeks, and to prevent the rebound, colchicine (0.5 mg bid) was continued for an additional four weeks after CS discontinuation and then stopped. Informed consent was obtained from all patients for the off-label use of colchicine and the publication of their medical information.

Case Presentations

Hereby we present five cases of steroid-dependent SAT, initially treated with 24–32 mg/day of MPS, but required 2–5 CS courses due to relapses. Patients were successfully treated by adding colchicine 0.5 mg bid to their CS regimens. The disease course and treatment regimens for these cases are described in Figure 1. None of the described patients experienced any side effects associated with colchicine. All cases typically showed an initial overt thyrotoxicosis and finally euthyroid after a temporary hypothyroid phase.

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FIG. 1.

The disease course and treatment regimens of cases.

Case 1

A 48-year-old woman with a history of COVID-19 and concomitant SAT presented with typical symptoms. Erythrocyte sedimentation rate (ESR) was 60 mm/h, and C-reactive protein (CRP) was 36 (0–5) mg/L, and US revealed patchy hypoechoic areas in both lobes. The patient had to receive a 32 mg/day MPS regimen thrice due to relapses. Colchicine was added at the 26th week, and the treatment was successfully completed with TDP. No recurrence was observed after 38 months (Fig. 1, Case 1).

Case 2

A 31-year-old female patient with neck pain and myalgia was diagnosed with relapsing SAT and received four MPS courses over 34 weeks due to relapses. At presentation, ESR was 40 mm/h, and CRP was 22 mg/L. US showed patchy hypoechoic areas in both lobes. At the last course MPS was increased to 24 mg/day and then tapered to 12 mg/day over four weeks, while colchicine was also added. CS dose was tapered again and successfully discontinued in 12 weeks with TDP. No recurrence was observed after 24 months (Fig. 1, Case 2).

Case 3

A 43-year-old woman presented with neck pain and palpitations. Examination revealed thyroid tenderness and elevated APR (ESR: 35 mm/h, CRP: 20 mg/L); US revealed patchy hypoechogenic areas found in the left lobe. After NSAID (ibuprofen 2400 mg/day) treatment failed, MPS was initiated at 24 mg/day, but patient required dose adjustments due to several recurrences. Finally, colchicine was added, and treatment was successfully completed with TDP. No recurrence was observed after five months of follow-up (Fig. 1, Case 3).

Case 4

A 42-year-old woman with a history of significant anterior neck pain and fatigue, which did not respond to Etodolac 800 mg/day. Past medical history revealed multiple relapses under MPS, over 17 weeks. Upon admission, a swollen and tender left thyroid lobe and patchy SAT areas were observed on ultrasound, along with elevated APR (ESR: 30 mm/h, CRP: 18 mg/L). Lastly, treatment with 16 mg/day MPS and colchicine was successful, tapering CS off in six weeks according to TDP. The patient was symptom-free after five months (Fig. 1, Case 4).

Case 5

A 31-year-old woman with a history of 15 weeks of fatigue and radiating jaw pain initially responded to 32 mg/day MPS, but relapses occurred during dose reduction, and she could not reduce CS below 8 mg/day due to relapses. At admission, she was cushingoid, had neck tenderness, elevated APR (ESR: 28 mm/h, CRP: 12 mg/L), and US showed right lobe and isthmic enlargement and patchy infiltration. We started 0.5 mg bid colchicine and 12 mg/day MPS. CS therapy was successfully stopped with TDP, and she remained relapse-free at the fifth month of follow-up (Fig. 1, Case 5).