What is the treatment for myxedema symptoms?

From the Guidelines

The primary treatment for myxedema symptoms is thyroid hormone replacement therapy, typically with levothyroxine (T4), and may require hospital admission and endocrine consultation for severe cases. According to the American Society of Clinical Oncology (ASCO) guideline update 1, the management of myxedema symptoms involves thyroid hormone supplementation, with the goal of normalizing TSH levels. For severe symptoms, such as myxedema coma, hospital admission and intravenous levothyroxine may be necessary, along with supportive care and steroids if indicated 1.

Treatment Approach

• For asymptomatic patients with TSH levels between 4.5 and 10 mIU/L, monitoring of TSH every 4-6 weeks is recommended 1.
• For patients with moderate symptoms and TSH levels persistently above 10 mIU/L, thyroid hormone supplementation should be considered, with monitoring of TSH every 6-8 weeks while titrating hormone replacement to goal 1.
• For severe symptoms, such as myxedema coma, hospital admission and intravenous levothyroxine may be necessary, along with supportive care and steroids if indicated 1.

Dosage and Administration

• The dosage of levothyroxine may vary depending on the severity of symptoms and the patient's individual needs, but typically ranges from 1.6-1.8 mcg/kg/day for most adults 1.
• For elderly patients or those with heart disease, starting doses should be lower, with more gradual increases 1.
• Levothyroxine should be taken on an empty stomach, 30-60 minutes before breakfast, to ensure optimal absorption.

Monitoring and Follow-up

• Regular monitoring of TSH levels is essential, typically every 6-8 weeks during dose adjustments and then annually once stable 1.
• FT4 levels can be used to help interpret ongoing abnormal TSH levels on therapy, as TSH may take longer to normalize 1.

From the FDA Drug Label

The therapy of myxedema coma requires simultaneous administration of glucocorticoids. Patients with pituitary myxedema should receive adrenocortical hormone replacement therapy at or before the start of liothyronine sodium injection (T 3) therapy Similarly, patients with primary myxedema may also require adrenocortical hormone replacement therapy since a rapid return to normal body metabolism from a severely hypothyroid state may result in acute adrenocortical insufficiency and shock

The treatment for myxedema symptoms involves:

• Thyroid hormone replacement therapy, such as liothyronine sodium injection (T3)
• Glucocorticoids for myxedema coma
• Adrenocortical hormone replacement therapy for patients with pituitary or primary myxedema
• Careful fluid management to prevent cardiac decompensation and water intoxication
• Treatment of underlying infections and other comorbid conditions 2

From the Research

Myxedema Symptoms and Treatment

• Myxedema symptoms can range from minimal to life-threatening, including cold intolerance, fatigue, weight gain, dry skin, constipation, and voice changes 3.
• Myxedema coma is a rare endocrine emergency resulting from the decompensation of severe hypothyroidism, characterized by deterioration of mental status, hypothermia, hypotension, hyponatremia, and hypoventilation 4, 5.

Treatment of Myxedema Symptoms

• Symptom relief and normalized thyroid-stimulating hormone levels are achieved with levothyroxine replacement therapy, started at 1.5 to 1.8 mcg per kg per day 3.
• Patients older than 60 years or with known or suspected ischemic heart disease should start at a lower dosage of levothyroxine (12.5 to 50 mcg per day) 3.
• In cases of myxedema coma, treatment with thyroid hormone replacement should be initiated upon suspicion of the disease, even prior to obtaining laboratory confirmation, and stress doses of hydrocortisone should also be given until coexisting adrenal insufficiency is excluded 5.
• A combination therapy of levothyroxine and liothyronine may be effective in treating myxedema coma, as demonstrated in a case study where an 84-year-old Japanese man was treated with 200 μg levothyroxine and 50 μg liothyronine until the fifth hospital day, followed by monotherapy with levothyroxine 4.

Special Considerations

• Patients with malabsorption, such as those who have undergone bariatric surgery, may require a higher daily dose of oral levothyroxine and may benefit from using liquid L-T4 instead of tablets 6.
• More frequent monitoring of serum Thyroid Stimulating Hormone is necessary in patients with malabsorption to prevent severe forms of hypothyroidism 6.