Hypothyroidism Treatment & Management

  • Author: Shikha Bharaktiya, MD; Chief Editor: George T Griffing, MD   more...
 
Updated: Jul 22, 2011
 

Medical Care

The treatment goals for hypothyroidism are the reversal of clinical progression and the corrections of metabolic derangements as evidenced by normal blood levels of TSH and free T4. Thyroid hormone is administered to supplement or replace endogenous production. In general, hypothyroidism can be adequately treated with a constant daily dose of levothyroxine (LT4).

Clinical benefits begin in 3-5 days and level off after 4-6 weeks. Anticipated full replacement doses may be initiated in individuals who are otherwise young and healthy. In elderly patients or those with known ischemic heart disease, treatment should begin with one fourth to one half the expected dose, and the dose should be adjusted in small increments no sooner than 4-6 weeks.

Achieving a TSH level within the reference range may be slowed because of delay of hypothalamic-pituitary axis readaptation and may take several months. After dose stabilization, patients can be monitored with annual clinical evaluations and TSH monitoring. Patients should be monitored for symptoms and signs of overtreatment, which include tachycardia, palpitations, nervousness, tiredness, headache, increased excitability, sleeplessness, tremors, and possible angina.

A meta-analysis of randomized controlled trials of thyroxine-triiodothyronine combination therapy (T4 + T3) versus thyroxine monotherapy (T4) for treatment of clinical hypothyroidism found no difference in the effectiveness of the combination vs monotherapy in bodily pain, depression, fatigue, body weight, anxiety, quality of life, total cholesterol, LDL-C, HDL-C and triglyceride levels. Hence, T4 monotherapy remains the treatment of choice.[12]

Pregnancy

Hypothyroidism in pregnancy is associated with preeclampsia, anemia, postpartum hemorrhage, cardiac ventricular dysfunction, spontaneous abortion, low birth weight, impaired cognitive development, and fetal mortality. Even mild disease may be associated with adverse affects for offspring.

Increased dosage requirements should be anticipated during pregnancy, especially in the first and second trimesters. Studies have suggested that patients with hypothyroidism should augment the LT4 dose by 30% at the confirmation of pregnancy, followed by adjustments according to TSH levels. For previously diagnosed women, serum TSH should be measured every 3-4 weeks during the first half of pregnancy and every 6 weeks thereafter. LT4 dose should be adjusted to maintain a serum TSH less than 2.5 mIU/L. TSH and free T4 levels should be measured every 3-4 weeks after every dosage adjustment.[13]

Autoimmune thyroid disease without overt hypothyroidism has been associated with a higher miscarriage rate. Negro et al showed that euthyroid Caucasian women with positive anti-TPO antibodies treated with levothyroxine during the first trimester had lower miscarriage rates when compared with those who were not treated. They also had lower incidence of premature delivery, comparable to women without thyroid antibodies.[14] This will need to be confirmed by other studies, and, if confirmed, there will be an indication to treat euthyroid pregnant women who have thyroid antibodies.

LT4 should not be taken with prenatal vitamin preparations containing iron and calcium. After delivery, the LT4 dose can be reduced to the prepregnancy level and TSH should be checked in 6 weeks.

Subclinical hypothyroidism

Significant controversy persists regarding the treatment of patients with mild hypothyroidism. Some have argued that treatment of these patients improves symptoms, prevents progression to overt hypothyroidism, and may have cardioprotective benefits. Reviews by the US Preventive Services Task Force[15] and an independent expert panel[16] found inconclusive evidence to recommend aggressive treatment of patients with TSH levels of 4.5-10 mIU/L. The Endocrine Society recommends thyroxine replacement in pregnant women with subclinical hypothyroidism[17] ; the American College of Obstetricians and Gynecologists does not recommend it as a routine measure.[18]

Ultrasonography may have prognostic value in subclinical hypothyroidism. In an Italian study, progression to overt hypothyroidism occurred more often in patients whose ultrasonographic thyroid scan showed diffuse hypoechogenicity (an indication of chronic thyroiditis).[19]

Following subclinical hypothyroidism and treating on a case-by-case basis is reasonable. Treatment of subclinical hypothyroidism has been shown to reduce total cholesterol, non-HDL cholesterol, and apolipoprotein B,[20] and to decrease arterial stiffness and systolic blood pressure.[21] In patients with concomitant subclinical hypothyroidism and iron deficiency anemia, iron supplementation may be ineffective if LT4 is not given.[22]

The American Association of Clinical Endocrinologists (AACE) guidelines state that treatment is indicated in patients with TSH levels above 10 mIU/mL or in patients with TSH levels between 5 and 10 mIU/mL in conjunction with goiter and/or positive antithyroid peroxidase antibodies, as these patients have the highest rates of progression to overt hypothyroidism. An initial dose of 25-50 mcg/d of LT4 can be used and can be titrated every 6-8 weeks, to achieve a target TSH of between 0.3 and 3 mIU/mL.[23]

Myxedema coma

An effective approach is to use intravenous LT4 at a dose of 4 mcg/kg of lean body weight, or approximately 200-250 mcg as a bolus in a single or divided dose, depending on the patient's risk of cardiac disease followed by 100 mcg 24 hours later and then 50 mcg daily IV or PO along with stress doses of intravenous glucocorticoids. Adjustment of the dose can then be made based on clinical and laboratory along with stress doses of intravenous glucocorticoids. Use of intravenous triiodothyronine is controversial and based on expert opinion. It has a higher frequency of adverse cardiac events and is generally reserved for patients who are not improving clinically on LT4. LT3 can be given initially as a 10 mcg IV bolus and repeated every 8-12 hours until the patient can take maintenance oral doses of T4. Advanced age, high dose T4 therapy, and cardiac complications had the highest associations with mortality.[24]

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Surgical Care

Surgery is indicated for large goiters that compromise tracheoesophageal function; surgery is rarely needed in patients with hypothyroidism and is more common in the treatment of hyperthyroidism.

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Consultations

Patients with a nodular thyroid, suspicious thyroid nodules, or compressive symptoms such as dysphagia; pregnant women; patients with underlying cardiac disorders or other endocrine disorders; persons younger than 18 years; and those unresponsive to treatment should be referred to an endocrinologist.

Some patients with thyroiditis can develop hyperthyroidism (or symptoms consistent with hyperthyroidism) before developing hypothyroidism and may benefit from consultation with an endocrinologist.

Suspected myxedema coma is a medical emergency with a high risk of mortality that requires initiation of parenteral (intravenous) LT4 and glucocorticoids prior to laboratory confirmation. An urgent endocrinology consultation should be obtained.

Rarely an increase in size of a goiter in a patient with autoimmune thyroid disease could be a lymphoma and should be evaluated by an endocrinologist.

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Diet

No specific diets are required for hypothyroidism.

Subclinical hypothyroidism has been seen in increased frequency in patients with greater iodine intake. The World Health Organization recommends a daily dietary iodine intake of 150 mcg for adults, 200 mcg for pregnant and lactating women, and 50-120 mcg for children.

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Activity

Patients who have hypothyroidism have generalized hypotonia and may be at risk for ligamental injury, particularly from excessive force across joints. Thus, patients should exercise caution with certain activities, such as contact sports or heavy physical labor.

Patients with uncontrolled hypothyroidism may have difficulty maintaining concentration in low-stimulus activities and may have slowed reaction times. Patients should use caution if an activity has a risk of injury (eg, operating presses or heavy equipment, driving).

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Contributor Information and Disclosures
Author

Shikha Bharaktiya, MD  Clinical Fellow, Department of Internal Medicine, Division of Endocrinology and Metabolism, University of Texas Medical School at Houston

Disclosure: Nothing to disclose.

Coauthor(s)

Philip R Orlander, MD  Assistant Dean for Educational Affairs, Vice-Chair of Medicine for Education, Director and Professor, Division of Endocrinology, University of Texas Health Science Center at Houston

Philip R Orlander, MD is a member of the following medical societies: American Association of Clinical Endocrinologists, American Diabetes Association, Endocrine Society, and Texas Medical Association

Disclosure: Nothing to disclose.

Walter R Woodhouse, MD, MSA  Associate Clinical Professor, Department of Family Practice, Medical College of Ohio

Walter R Woodhouse, MD, MSA is a member of the following medical societies: American Academy of Family Physicians, American Academy of Pain Medicine, and Society of Teachers of Family Medicine

Disclosure: Nothing to disclose.

Anu Bhalla Davis, MD  Assistant Professor, Department of Internal Medicine, Division of Diabetes, Endocrinology, and Metabolism, University of Texas Medical School at Houston

Disclosure: Nothing to disclose.

Specialty Editor Board

Frederick H Ziel, MD  Associate Professor of Medicine, University of California, Los Angeles, David Geffen School of Medicine; Physician-In-Charge, Endocrinology/Diabetes Center, Director of Medical Education, Kaiser Permanente Woodland Hills; Chair of Endocrinology, Co-Chair of Diabetes Complete Care Program, Southern California Permanente Medical Group

Frederick H Ziel, MD is a member of the following medical societies: American Association of Clinical Endocrinologists, American College of Endocrinology, American College of Physicians, American College of Physicians-American Society of Internal Medicine, American Diabetes Association, American Federation for Medical Research, American Medical Association, American Society for Bone and Mineral Research, California Medical Association, Endocrine Society, and International Society for Clinical Densitometry

Disclosure: Nothing to disclose.

Francisco Talavera, PharmD, PhD  Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Medscape Salary Employment

Arthur B Chausmer, MD, PhD, FACP, FACE, FACN, CNS  Professor of Medicine (Endocrinology, Adj), Johns Hopkins School of Medicine; Affiliate Research Professor, Bioinformatics and Computational Biology Program, School of Computational Sciences, George Mason University; Principal, C/A Informatics, LLC

Arthur B Chausmer, MD, PhD, FACP, FACE, FACN, CNS is a member of the following medical societies: American Association of Clinical Endocrinologists, American College of Endocrinology, American College of Nutrition, American College of Physicians, American College of Physicians-American Society of Internal Medicine, American Medical Informatics Association, American Society for Bone and Mineral Research, Endocrine Society, and International Society for Clinical Densitometry

Disclosure: Nothing to disclose.

Mark Cooper, MBBS, PhD, FRACP  Head, Diabetes & Metabolism Division, Baker Heart Research Institute, Professor of Medicine, Monash University

Disclosure: Nothing to disclose.

Chief Editor

George T Griffing, MD  Professor of Medicine, St Louis University School of Medicine

George T Griffing, MD is a member of the following medical societies: American Association for the Advancement of Science, American College of Medical Practice Executives, American College of Physician Executives, American College of Physicians, American Diabetes Association, American Federation for Medical Research, American Heart Association, Central Society for Clinical Research, Endocrine Society, International Society for Clinical Densitometry, and Southern Society for Clinical Investigation

Disclosure: Nothing to disclose.

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