From the Guidelines
After receiving Hashimoto's blood work results showing elevated TSH and low FT4/FT3 levels, the next step is typically to begin thyroid hormone replacement therapy with levothyroxine (T4), with a starting dose based on weight and age, often around 1.6 mcg/kg/day for adults, though lower doses (25-50 mcg daily) may be used for elderly patients or those with heart conditions, as recommended by the ASCO guideline update 1. The management of Hashimoto's thyroiditis involves correcting the thyroid hormone deficiency, and the choice of therapy depends on the severity of symptoms and the degree of TSH elevation.
- For patients without risk factors (i.e., < 70 years old, not frail, and without cardiac disease or multiple comorbidities), full replacement can be estimated using ideal body weight for a dose of approximately 1.6 mcg/kg/d, as suggested by the ASCO guideline update 1.
- For those older than age 70 years and/or frail patients with multiple comorbidities (including cardiac disease), consider titrating up from a lower starting dose of 25-50 mcg, as recommended by the ASCO guideline update 1. The goal of therapy is to bring TSH into the normal range (typically 0.5-4.5 mIU/L) and alleviate symptoms such as fatigue, weight gain, and cold intolerance.
- Follow-up blood tests are essential 6-8 weeks after starting treatment to check TSH and adjust medication as needed, with the goal of bringing TSH into the normal range, as recommended by the ASCO guideline update 1.
- Some patients may require combination therapy with liothyronine (T3) if symptoms persist despite normalized TSH, and lifestyle modifications like gluten reduction, stress management, and adequate selenium intake may help manage symptoms, although the evidence for these modifications is not as strong as for thyroid hormone replacement therapy 1. Regular monitoring is crucial, as dosage needs may change over time due to weight fluctuations, aging, pregnancy, or other medication changes, and thyroid hormone replacement corrects the deficiency caused by Hashimoto's autoimmune destruction of thyroid tissue, addressing symptoms like fatigue, weight gain, and cold intolerance.
From the FDA Drug Label
In adult patients with primary (thyroidal) hypothyroidism, serum TSH levels (using a sensitive assay) alone may be used to monitor therapy. The frequency of TSH monitoring during levothyroxine dose titration depends on the clinical situation but it is generally recommended at 6-8 week intervals until normalization
The next steps after receiving Hashimoto's blood work results showing elevated Thyroid-Stimulating Hormone (TSH) levels and low Free Thyroxine (FT4) and/or Free Triiodothyronine (FT3) levels are:
- Monitoring: Serum TSH levels should be monitored at 6-8 week intervals until normalization.
- Dose Titration: The frequency of TSH monitoring during levothyroxine dose titration depends on the clinical situation.
- Follow-up: Clinical (physical examination) and biochemical monitoring may be performed every 6-12 months, depending on the clinical situation, and whenever there is a change in the patient's status. 2 2
From the Research
Next Steps After Receiving Hashimoto's Blood Work Results
After receiving Hashimoto's blood work results showing elevated Thyroid-Stimulating Hormone (TSH) levels and low Free Thyroxine (FT4) and/or Free Triiodothyronine (FT3) levels, the next steps may include:
- Consulting with a healthcare provider to discuss the results and determine the best course of action 3, 4, 5, 6, 7
- Starting levothyroxine (L-T4) treatment to manage hypothyroidism symptoms and prevent further thyroid damage 4, 7
- Monitoring thyroid function and adjusting L-T4 dosage as needed to achieve normal TSH and FT4/FT3 levels 4, 5, 6
- Evaluating thyroid volume and assessing for any changes or abnormalities 4, 6
- Considering prophylactic L-T4 treatment for euthyroid patients with Hashimoto's thyroiditis to reduce the progression of the autoimmune process 7
Laboratory Tests and Monitoring
Laboratory tests and monitoring may include:
- Regular TSH, FT4, and FT3 level checks to assess thyroid function 3, 4, 5, 6
- Thyroid antibody tests (e.g., anti-TPO, anti-TG) to monitor autoimmune activity 3, 4, 5, 7
- Thyroid volume assessments using ultrasound to evaluate thyroid size and structure 4, 6
Treatment and Management
Treatment and management of Hashimoto's thyroiditis may involve: