American Thyroid Association Guidelines on Treatment of Hypothyroidism

Part II in a series covering the American Thyroid Association guidelines on the treatment of hypothyroidism. This section covers recommendations regarding managing comorbid diseases, patient subpopulations, treatment nonadherence, secondary hypothyroidism, management of symptoms when thyroid function is normal, and ethical considerations.

Written by Priyathama Vellanki MD

Managing Comorbid Diseases
Underlying medical conditions (eg, atherosclerotic heart disease) should be considered when establishing treatment goals in patients with hypothyroidism. Patients with psychosocial, behavioral, and mental health conditions do not require different treatment goals, but should be referred to specialty care when necessary for treatment of these comorbidities.

Treatment in Patient Subpopulations
The following are treatment recommendations for different subpopulations with hypothyroidism:

Managing Treatment Nonadherence
For patients with suboptimal adherence to daily levothyroxine treatment, use of observed therapy and reducing the frequency of treatment to twice weekly or weekly may be considered. With reduced frequency of treatment, the starting dose should be equal to the weight-adjusted dose that would be prescribed for daily use (ie, 7 times the daily dose if given weekly).

Treatment Recommendations in Secondary Hypothyroidism
In patients with secondary hypothyroidism, the primary biochemical treatment goal should be to maintain serum-free  thyroxine values in the upper half of the reference range. However, patients who are older or have comorbidities may require a lower serum free thyroxine target level. For patients whose only available biochemical thyroid parameters are thyroid hormone levels, tissue markers of thyroid hormone action may be used as adjunctive measures for assessing the adequacy of levothyroxine replacement therapy.

Management of Patients with Symptoms of Hypothyroidism but Normal Thyroid Function
The ATA recommends against the use of levothyroine treatment in patients with normal thyroid function who have symptoms that overlap with hypothyroidism. Levothyroxine should not be used in the treatment of depression, obesity, urticaria, or factitious thyrotoxicosis.

Ethics of Treating Hypothyroidism
According to the ATA, the clinical ethics surrounding use of levothyroxine treatment for hypothyroidism focus on the following ethical principles in medicine: the principles of beneficence and non-maleficence. The principles should “guide the risk/benefit analysis in clinical practice, and protect clinicians from deviating from practice to satisfy inappropriate patient demands. Additional ethical obligations revolve around the professional virtues of competence and intellectual honesty,” according to the ATA.

March 12, 2015

American Thyroid Association Hypothyroidism Guideline Summary Continues at:

Part III: American Thyroid Association Guideline: Treatment of Hypothyroidism Other Than Levothyroxine Monotherapy

Part IV: American Thyroid Association Guideline: Treatment of Hospitalized Patients with Hypothyroidism and Use of Thyroid Hormone Analogs

Part I: American Thyroid Association Continues to Recommend Levothyroxine as First-Line Therapy for Hypothyroidism


Jonklaas J, Bianco AC, Bauer AJ, et al. Guidelines for the Treatment of Hypothyroidism. Thyroid. 2014 Sep 29. [Epub ahead of print] Accessed March 12, 2015.