Treatment algorithm

Please note that formulations/routes and doses may differ between drug names and brands, drug formularies, or locations. Treatment recommendations are specific to patient groups: see disclaimer

ONGOING

all patients

1st line – levothyroxine

Back
ONGOING
|
all patients
1st line – 

levothyroxine

Levothyroxine, a synthetically derived levorotatory isomer of thyroxine, is used for thyroxine replacement therapy. The American Association of Clinical Endocrinologists and American Thyroid Association advocate the use of levothyroxine.[60][61]

The dose of levothyroxine depends on the aetiology of the central hypothyroidism. Generally, therapy is initiated in patients younger than 50 years with a full replacement dose. For those older than 50 years, or with coronary artery disease, a lower initial dose is indicated.

Levothyroxine has a narrow therapeutic index. Careful dosage titration is necessary to avoid the consequences of over- and under-treatment.

Absorption of levothyroxine can be impaired by malabsorptive disorders such as coeliac disease, inflammatory bowel disease, and lactose intolerance. Drugs that may impair levothyroxine absorption include iron, aluminium-containing antacids, calcium carbonate, phosphate binders, bile-acid sequestrants, and proton-pump inhibitors. Levothyroxine should be taken at least 4 hours before or after drugs that may interfere with absorption.[53]

Primary options

levothyroxine: 1.6 micrograms/kg/day orally initially, adjust dose every 4-6 weeks according to response and laboratory values, maximum 300 micrograms/day

More

Consider – treatment of underlying pituitary tumour

Back
ONGOING
|
all patients
Consider – 

treatment of underlying pituitary tumour

Additional treatment recommended for SOME patients in selected patient group

Medical treatments of responsive tumours may include dopaminergic medications or somatostatin analogues. Prolactin-secreting pituitary adenomas are managed primarily with dopamine agonist therapy.[55][56]

Non-prolactin-secreting pituitary adenomas may be managed surgically, depending on tumour size, extent of invasion, and secretory function. Surgical resection may be performed via a trans-sphenoidal or trans-frontal approach.[57][58]

Radiotherapy is an effective treatment for residual or recurrent pituitary adenomas, with excellent rates of tumour control and normalisation of excess hormone secretion. Technical developments in the delivery of radiotherapy, including stereotactic radiosurgery, aim to reduce the amount of radiation delivered to normal brain tissue.[59]

Consider – glucocorticoid

Back
ONGOING
|
all patients
|
presence of adrenal insufficiency
Consider – 

glucocorticoid

Additional treatment recommended for SOME patients in selected patient group

It is important to assess and treat concomitant adrenal hormone deficiency before levothyroxine is initiated. If it is not feasible to assess adrenal function prior to initiating levothyroxine, prophylactic treatment with a glucocorticoid should be considered.[1]

Thyroid hormone replacement in the setting of untreated adrenal insufficiency may precipitate acute adrenal crisis.

Drugs of choice for the treatment of adrenal insufficiency include hydrocortisone and prednisolone.

Primary options

hydrocortisone: 25-30 mg/day orally given in 2 divided doses

OR

prednisolone: 5 to 7.5 mg/day orally

back arrow

Choose a patient group to see our recommendations

Please note that formulations/routes and doses may differ between drug names and brands, drug formularies, or locations. Treatment recommendations are specific to patient groups. See disclaimer

Use of this content is subject to our disclaimer