American Thyroid Association Guidelines on Treatment of Hypothyroidism

Part II in a series covering the American Thyroid Association guidelines on the treatment of hypothyroidism. This section covers recommendations regarding managing comorbid diseases, patient subpopulations, treatment nonadherence, secondary hypothyroidism, management of symptoms when thyroid function is normal, and ethical considerations.

Managing Comorbid Diseases
Underlying medical conditions (eg, atherosclerotic heart disease) should be considered when establishing treatment goals in patients with hypothyroidism. Patients with psychosocial, behavioral, and mental health conditions do not require different treatment goals, but should be referred to specialty care when necessary for treatment of these comorbidities.

Treatment in Patient Subpopulations
The following are treatment recommendations for different subpopulations with hypothyroidism:

  • Elderly patients: Treatment should be initiated at low doses with slow titration based on serum thyroid-stimulating hormone (TSH) assessment. Normal serum TSH ranges are higher in the elderly patient; thus, higher serum TSH goals may be needed as a patient ages. The American Thyroid Association (ATA) suggests raising the target serum TSH to 4-6 mIU/L in people age 70 to 80 years.
  • Pregnant patients: Levothyroxine should be dose titrated to achieve a TSH concentration within the following trimester-specific reference range: 0.1-2.5 mIU/L for the first trimester, 0.2 to 3.0 mIU/L  for the second trimester, and 0.3 to 3.0 mIU/L for the third trimester. Serum TSH should be reassessed every four weeks in the first and second trimester and once during the third trimester. Women already taking levothyroxine who become pregnant may require 2 additional doses per week of their current levothyroxine dose (given as one extra dose twice weekly with several days separation) as soon as pregnancy is confirmed.
  • Infants and children: For overt hypothyroidism, newborns typically require levothyroxine replacement therapy at 10 mcg/kg/day, 1-year-old-children at 4 to 6 mcg/kg/day, and adolescents at 2 to 4 mcg/kg/day. Once endocrine maturation is complete, transition to the average adult dose of 1.6 mcg/kg/day can be made. Treatment for subclinical hypothyroidism also is recommended in children due to the benefit of avoiding any potential negative impact on growth and development as well as the relatively low risk of treatment. Treatment is not recommended for children with a TSH of 5 to 10 mIU/L.

Managing Treatment Nonadherence
For patients with suboptimal adherence to daily levothyroxine treatment, use of observed therapy and reducing the frequency of treatment to twice weekly or weekly may be considered. With reduced frequency of treatment, the starting dose should be equal to the weight-adjusted dose that would be prescribed for daily use (ie, 7 times the daily dose if given weekly).

Treatment Recommendations in Secondary Hypothyroidism
In patients with secondary hypothyroidism, the primary biochemical treatment goal should be to maintain serum-free  thyroxine values in the upper half of the reference range. However, patients who are older or have comorbidities may require a lower serum free thyroxine target level. For patients whose only available biochemical thyroid parameters are thyroid hormone levels, tissue markers of thyroid hormone action may be used as adjunctive measures for assessing the adequacy of levothyroxine replacement therapy.

Management of Patients with Symptoms of Hypothyroidism but Normal Thyroid Function
The ATA recommends against the use of levothyroine treatment in patients with normal thyroid function who have symptoms that overlap with hypothyroidism. Levothyroxine should not be used in the treatment of depression, obesity, urticaria, or factitious thyrotoxicosis.

Ethics of Treating Hypothyroidism
According to the ATA, the clinical ethics surrounding use of levothyroxine treatment for hypothyroidism focus on the following ethical principles in medicine: the principles of beneficence and non-maleficence. The principles should “guide the risk/benefit analysis in clinical practice, and protect clinicians from deviating from practice to satisfy inappropriate patient demands. Additional ethical obligations revolve around the professional virtues of competence and intellectual honesty,” according to the ATA.

March 12, 2015

American Thyroid Association Hypothyroidism Guideline Summary Continues at:

Part III: American Thyroid Association Guideline: Treatment of Hypothyroidism Other Than Levothyroxine Monotherapy

Part IV: American Thyroid Association Guideline: Treatment of Hospitalized Patients with Hypothyroidism and Use of Thyroid Hormone Analogs

Part I: American Thyroid Association Continues to Recommend Levothyroxine as First-Line Therapy for Hypothyroidism

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