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Managing symptoms in hypothyroid patients on adequate levothyroxine: a narrative review

Lookup NU author(s): Dr Salman Razvi


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The current standard of care for hypothyroidism is levothyroxine (LT4) monotherapy to reduce levels of thyrotropin (thyroid stimulating hormone, TSH) to within its reference range and amelioration of any symptoms. A substantial minority continue to report hypothyroid-like symptoms despite optimised TSH, however. These symptoms are not specific to thyroid dysfunction and are frequent among the euthyroid population, creating a therapeutic dilemma for the treating clinician as well as the patient. We present a concise, narrative review of the clinical research and evidence-based guidance on the management of this challenging population. The clinician may endeavour to ensure that the serum TSH is within the target range. However, the symptomatic patient may turn to alternative non-evidence-based therapies in the hope of obtaining relief. Accordingly, it is important for the clinician to check for conditions unrelated to the thyroid that could account for the ongoing symptoms such as other autoimmune conditions, anaemia or mental health disorders. Systematic and thorough investigation of the potential causes of persistent symptoms while receiving LT4 therapy will resolve the problem for most patients. There may be some patients that may benefit from additional treatment with liothyronine (LT3), although it is unclear as yet as to which patient group may benefit the most from combined LT4 + LT3 therapy. In the future, personalised treatment with LT4 + LT3 may be of benefit for some patients with persistent symptoms of hypothyroidism such as those with polymorphisms in the deiodinase enzyme 2 (DIO2). For now, this remains a subject for research.

Publication metadata

Author(s): Razvi S, Mrabeti S, Luster M

Publication type: Review

Publication status: Published

Journal: Endocrine Connections

Year: 2020

Volume: 9

Issue: 11

Pages: R241-R250

Online publication date: 01/11/2020

Acceptance date: 11/10/2020

ISSN (electronic): 2049-3614


DOI: 10.1530/EC-20-0205

PubMed id: 33112818