What is the treatment for hypothyroidism symptoms?

Treatment for Hypothyroidism Symptoms

The first-line treatment for hypothyroidism is oral levothyroxine sodium (synthetic T4) therapy, which should be initiated to normalize thyroid-stimulating hormone (TSH) levels and alleviate symptoms. 1

Diagnosis and Assessment

• Hypothyroidism is diagnosed through biochemical testing, with elevated TSH and low free T4 levels indicating overt primary hypothyroidism 1
• Common symptoms include fatigue (68%-83%), weight gain (24%-59%), cognitive issues (45%-48%), cold intolerance, hair loss, constipation, menstrual irregularities, and voice changes 2, 1
• Serum TSH testing is the primary screening test, with multiple tests over a 3-6 month interval recommended to confirm abnormal findings 2
• Follow-up testing of T4 levels in persons with persistently abnormal TSH levels helps differentiate between subclinical (normal T4) and overt (abnormal T4) thyroid dysfunction 2

Treatment Algorithm

Initial Treatment Approach

• Levothyroxine sodium is the standard treatment for hypothyroidism, with dosage tailored to patient-specific factors 1, 3
• For most young patients without comorbidities, treatment can be started with the full calculated dose (typically 1.6 μg/kg/day) 3, 4
• Lower starting doses should be used for:
  • Elderly patients 5, 3
  • Patients with coronary artery disease or atrial fibrillation 1, 3
  • Patients with long-standing severe hypothyroidism 3

Dosage Adjustments and Monitoring

• Monitor TSH levels 6-8 weeks after initiating levothyroxine or changing the dose 1
• Target TSH level should be 0.5-2.0 mIU/L for primary hypothyroidism 3
• Once TSH is at goal, annual monitoring is recommended to avoid overtreatment or undertreatment 1
• For central hypothyroidism (rare), treatment is tailored according to free or total T4 levels, which should be maintained in the upper half of the normal range 3

Special Populations

Pregnancy

• TSH levels may increase during pregnancy, requiring more frequent monitoring and dose adjustments 5
• Untreated maternal hypothyroidism increases risks of complications including spontaneous abortion, gestational hypertension, pre-eclampsia, stillbirth, and premature delivery 5
• Inadequate treatment is associated with low birth weight in neonates 2

Elderly Patients

• Start with lower doses in elderly patients due to increased risk of cardiovascular adverse effects 5, 1
• Atrial arrhythmias, particularly atrial fibrillation, are the most common arrhythmias observed with levothyroxine overtreatment in the elderly 5

Patients with Adrenal Insufficiency

• In patients with both adrenal insufficiency and hypothyroidism, steroids should always be started prior to thyroid hormone to avoid adrenal crisis 6

Common Pitfalls and Considerations

• Overtreatment is common in clinical practice and is associated with increased risk of atrial fibrillation and osteoporosis 3
• For persistently elevated TSH despite adequate replacement dose, check for:
  • Poor medication compliance
  • Malabsorption issues
  • Drug interactions 3
• Untreated hypothyroidism may progress to severe hypothyroidism with decompensation (myxedema coma), which has a mortality rate of up to 30% 1
• Hypothyroidism can cause insulin resistance and hyperglycemia in patients with diabetes, increasing the risk for cardiovascular events 1

Treatment Duration

• Levothyroxine therapy is typically continued for life in patients with chronic hypothyroidism 5, 7
• Regular monitoring is essential to ensure optimal dosing and symptom management 1, 3