Management of Inadequately Controlled Hypothyroidism
Increase the levothyroxine dose by 12.5-25 mcg immediately, as a TSH of 23 mIU/L on 88 mcg indicates severe undertreatment requiring urgent dose adjustment. 1
Immediate Action Required
Your current dose of 88 mcg is clearly insufficient. A TSH level of 23 mIU/L represents overt hypothyroidism despite treatment, carrying significant risks for cardiovascular dysfunction, metabolic abnormalities, and impaired quality of life. 1
Recommended Dose Adjustment
- Increase levothyroxine by 25 mcg to 112-113 mcg daily (the standard increment for patients with TSH >10 mIU/L). 1, 2
- If you are over 70 years old or have cardiac disease, use a more conservative 12.5 mcg increment instead. 1, 2
- For younger patients without cardiac disease, the 25 mcg increase is appropriate and necessary given the severity of TSH elevation. 1
Monitoring Timeline
- Recheck TSH and free T4 in exactly 6-8 weeks after the dose increase—not sooner, as steady-state levels require this time frame. 1, 2
- If you have atrial fibrillation or serious cardiac disease, consider rechecking within 2 weeks instead. 1
- Continue adjusting the dose every 6-8 weeks until TSH normalizes to 0.5-4.5 mIU/L. 1, 2
Critical Issues to Address
Rule Out Medication Adherence Problems
- Poor compliance is the most common cause of persistently elevated TSH in treated patients. 3
- Take levothyroxine on an empty stomach, 30-60 minutes before breakfast, with a full glass of water. 4
- Avoid taking it within 4 hours of calcium supplements, iron, or antacids, which significantly impair absorption. 4
Check for Malabsorption
If TSH remains elevated despite confirmed adherence and appropriate dose increases, consider: 5, 3
- Celiac disease, inflammatory bowel disease, or atrophic gastritis
- Proton pump inhibitor use (reduces acid needed for tablet dissolution)
- Recent bariatric surgery
- Switching to liquid levothyroxine formulation may overcome absorption issues. 6
Review Drug Interactions
Common medications that increase levothyroxine requirements include: 5, 3
- Estrogen therapy or oral contraceptives
- Rifampin, carbamazepine, phenytoin
- Proton pump inhibitors
- Bile acid sequestrants
Why This TSH Level Demands Urgent Treatment
- TSH >10 mIU/L carries approximately 5% annual risk of progression to severe overt hypothyroidism. 1
- At TSH 23, you already have severe overt hypothyroidism causing: 1, 7
- Adverse cardiovascular effects (delayed relaxation, abnormal cardiac output)
- Elevated LDL cholesterol
- Persistent hypothyroid symptoms (fatigue, weight gain, cold intolerance, constipation)
- Significantly impaired quality of life
Target Goal
- Aim for TSH between 0.5-4.5 mIU/L with normal free T4 levels. 1, 2
- Once stable, monitor TSH annually (or every 6-12 months). 1, 2
Common Pitfall to Avoid
- Do not make small, timid dose adjustments—a TSH of 23 requires meaningful intervention, not incremental tinkering. 1
- Do not adjust doses more frequently than every 6-8 weeks, as levothyroxine takes this long to reach steady state. 1, 2
- About 25% of patients on levothyroxine are inadvertently under- or over-treated, emphasizing the need for proper monitoring. 1
Special Consideration
If you have thyroid cancer requiring TSH suppression, this TSH level is still far too high—even cancer patients rarely need TSH >10 mIU/L. 2 However, standard hypothyroidism treatment aims for normal-range TSH, not suppression. 2