Strategies for improved management of hypothyroidism
Management is clear-cut—yet many patients don’t reach treatment goals. To optimize quality of life, master the fine points of T4 replacement and address the impact of comorbidities.
PRACTICE RECOMMENDATIONS
› Prescribe levothyroxine (LT4) to maintain thyroid-stimulating hormone (TSH) at 4 to 7 mIU/L in select patients with primary hypothyroidism for whom that range of the serum TSH level can be considered appropriate (ie, those older than 65 years and those who have underlying coronary artery disease or another debilitating chronic disorder). A
› Counsel all women of childbearing age with primary hypothyroidism that they need to have their dosage of LT4 increased as soon as pregnancy is suspected. A
› Keep in mind that treating hypothyroidism is not always necessary in older patients who have subclinical disease and a serum TSH level < 10 mIU/L. A
Strength of recommendation (SOR)
A Good-quality patient-oriented evidence
B Inconsistent or limited-quality patient-oriented evidence
C Consensus, usual practice, opinion, disease-oriented evidence, case series
Routine treatment of patients with a serum TSH level of 4.5 to 10 mIU/L remains controversial. When TSH is 7.0 to 9.9 mIU/L, treatment is recommended for (1) patients < 65 years and (2) for older patients (> 65 years) only when there are convincing hypothyroid symptoms because of concern about unintended overtreatment.
When the TSH level is anywhere above the upper limit of normal to 6.9 mIU/L, treatment is recommended for patients < 65 years old, patients who have a high titer of thyroid peroxidase antibodies, and patients with goiter—but not for patients > 65 years (and, especially, not for octogenarians) because their upper limit of normal could be as high as 6 to 8 mIU/L, especially if they are otherwise healthy.
Treatment should be considered for women with subclinical hypothyroidism who are trying to conceive or experiencing an infertility problem.
For patients with subclinical hypothyroidism who are not being treated, monitor thyroid function every 6 to 12 months by testing TSH and FT4.
CORRESPONDENCE
Thanh D. Hoang, DO, Division of Endocrinology, Walter Reed National Military Medical Center, 8901 Wisconsin Avenue, Bethesda, MD 20889; thanh.d.hoang.mil@mail.mil
