Refer to NICE guidance on Thyroid disease: assessment and management
Prior to treatment, it is important to establish that thyroid stimulating hormone (TSH) is elevated, thus confirming primary hypothyroidism. A normal or low TSH may suggest pituitary or hypothalamic disease for which specialist referral is necessary.
TSH should be checked 6 weeks after starting levothyroxine or after any change in dose, then annually once stable.
Alteration in levothyroxine absorption may occur with introduction of other medication such as iron and calcium preparations or drugs altering gastric acid, such as proton pump inhibitors. Thyroid function should be checked 6 weeks after starting such treatment.
Pregnant women with hypothyroidism should be seen by a specialist for titration of levothyroxine regimens. Upon confirmation of pregnancy it is recommended that, due to the early increase in levothyroxine requirements, levothyroxine dosage is doubled on Saturdays and Sundays until review by a specialist.
Although generic prescribing remains appropriate for the majority of patients, a small proportion report re-emergence of symptoms after switching between levothyroxine products and hence may benefit from consistent prescribing of a specific brand. See MHRA for further information.
Levothyroxine liquid is significantly more expensive than levothyroxine tablets. Therefore tablets are the preferred formulation, where appropriate.
Liothyronine should only be used on the recommendation of a Health Service endocrine specialist in secondary care; prescribers in primary care should not initiate liothyronine. For further information please see Shared Care Guideline.
