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Hypothyroidism

Checked: 23-08-2020 by Vicky Ryan Next Review: 23-08-2022

Overview

These guidelines have been provided by the Endocrinology Team at NBT so pathways might be slightly different at UHBW

Important points

The treatment of overt hypothyroidism is best achieved with levothyroxine alone, aiming for a TSH in the reference range. Manage as per the 2019 NICE guidance:

Consider starting Levothyroxine (LT4) at a dosage of 1.6 micrograms/kg/day (rounded to the nearest 25 micrograms) for adults under 65 years of age with primary hypothyroidism and no history of cardiovascular disease
Review the person and recheck TSH levels every 3 months after initiation of LT4 therapy and adjust the dose according to symptoms and TFT results
Consider starting LT4 at a dosage of 25–50 micrograms per day with titration for adults aged 65 years and over, and adults with a history of cardiovascular disease. Adjust dose in steps of 25 micrograms every 4 weeks, according to response

5-10% of patients treated for hypothyroidism with levothyroxine still report persistent symptoms. Suggested explanations include awareness of a chronic disease, the presence of associated autoimmune conditions and thyroid autoimmunity. Acknowledgement and alternative investigation of the patient’s symptoms is recommended.

Who to refer

Refer routinely if TFTs are persistently discordant despite compliance and no evidence of malabsorption

Before referral

Further investigation

If TFTs are discordant (usually highlighted by the lab), check compliance and for interfering medications e.g. iron, amiodarone, caffeine. Counsel the patient again on how to take thyroxine e.g. first thing in the morning, on an empty stomach and only with water

Repeat TFTs 8 weeks later with screen for malabsorption e.g. coeliac screen +/- further investigations if suggestive symptoms

Services

Endocrinology NBT

Endocrinology UHBW

Resources

References

Efforts are made to ensure the accuracy and agreement of these guidelines, including any content uploaded, referred to or linked to from the system. However, BNSSG ICB cannot guarantee this. This guidance does not override the individual responsibility of healthcare professionals to make decisions appropriate to the circumstances of the individual patient, in consultation with the patient and/or guardian or carer, in accordance with the mental capacity act, and informed by the summary of product characteristics of any drugs they are considering. Practitioners are required to perform their duties in accordance with the law and their regulators and nothing in this guidance should be interpreted in a way that would be inconsistent with compliance with those duties.

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