Before starting

Required

• Baseline
  • ECG
  • Free T4
  • Thyroid function tests
  • Thyroid stimulating hormone

Referring patients with hypothyroidism

Consider referring patients with hypothyroidism who:

• are less than 16 years of age
• are pregnant or post-partum
• have evidence of pituitary disease
• have particular management problems (e.g. ischaemic heart disease or treatment with amiodarone or lithium)

After started or dose changed

Required

• From 6 weeks; repeated every 3 months
  • Thyroid stimulating hormone

Consider

• From 6 weeks; repeated every 3 months
  • Free T4 · Where symptoms are ongoing

Adjusting doses

Adjust dose based on clinical and biochemical response. Aim to restore physical and psychological well-being; maintain normal lab range TSH levels; and avoid over-treatment.

Patients without risk factors

For patients without risk factors, adjust doses every 4 weeks in increments of 25–50 micrograms according to response.

Patients with risk factors

Patients with risk factors include those with:

• age over 65 years
• cardiac disease
• severe hypothyroidism
• thyroid cancer
• adrenal insufficiency
• who are pregnant

For these patients adjust doses cautiously, for example, every 4 weeks in increments of 25 micrograms according to response.

Passing to ongoing once stable monitoring

Patients who record 2 similar measurements within the reference range 3 months apart should be considered for ongoing once stable monitoring.

Ongoing once stable

Required

• Annually
  • Thyroid stimulating hormone · used to monitor both adherence and to ensure dose remains correct

Bibliography

• NICE Clinical Knowledge Summaries (CKS). Hypothyroidism. Updated Jan 2020 [cited 30/07/2020]
• The Association of Clinical Biochemistry, British Thyroid Association and British Thyroid Foundation. UK Guidelines for the Use of Thyroid Function Tests July 2006 [cited 30/07/2020]
• Wockhardt UK Ltd. Summary of Product Characteristics – Levothyroxine 25 micrograms Tablets. Last revised 02/2020 [cited 30/07/2020]
• Joint Formulary Committee. British National Formulary (online) London: BMJ Group and Pharmaceutical Press [cited 30/07/2020]
• British Medical Journal (BMJ). Consensus statement for good practice and audit measures in the management of hypothyroidism and hyperthyroidism. BMJ 1996;313:539 [cited 30/07/2020]
• Medicines and Healthcare products Regulatory Agency (MHRA). Levothyroxine: a review of clinical and quality considerations. Guidance published January 2013 [cited 30/07/2020]
• National Institute for Health and Care Excellence (NICE). The contractor establishes and maintains a register of patients with hypothyroidism who are currently treated with levothyroxine [NM99]. Aug 2015 [cited 31/07/2020]
• National Institute for Health and Care Excellence (NICE). Thyroid disease: assessment and management [NG145]. Nov 2019 [cited 31/07/2020]

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