Diagnosis and Management of

Treatment-Refractory Hypothyroidism:
an Expert Consensus Report

M. Centanni, S. Benvenga, I. Sachmechi

 INTRODUCTION
Serum level of TSH
above the upper
target level (4.5 mU/L)
Refractory to
Oral Thyroxine

Unresolved Hypothyroid
symptoms
(Levothyroxine > 1.9 μg/kg
daily)
 High Doses of
Thyroxine

Confirm
Compliance

 Search for Causes

Cardiovascular
of Decreased
and Other Side Absorption or
Effects Increased Demand
for Thyroxine
Levothyroxine is the First-line
Treatment for Hypothyroidism
and the Most Widely Used

Examination of The Causes of Its

Frequent Sub-Optimal
Performance is Warranted
 Laboratory Findings
American Thyroid Association (ATA) TSH is the most reliable
marker of adequacy of replacement treatment, and a value within
the reference range (0.4–4.0 mIU/L) should be considered the
therapeutic target

Hypothyroidism is Typically Characterized by

an Elevated TSH (above 10 mIU/L)
In Combination With a Subnormal FT4

Subclinical Hypothyroidism is Generally Characterized by a Serum

TSH Level Above the Upper Reference Limit, Combined with a
Normal FT4
 Primary Factors Contributing to
Refractory Hypothyroidism
Non-compliance

Switching to a Generic Levothyroxine

Non-Pathologic Causes with Different Bioavailability
of Refractory
Hypothyroidism
Drugs That Treat GI Conditions/ Dietary
Considerations

Pregnancy
 Primary Factors Contributing to
Refractory Hypothyroidism
Concomitant GI Diseases

Pathologic Causes Changes in Body Weight/

of Refractory Body Mass

Hypothyroidism

Poor Conversion of T4 to T3
 Discussion
Due to The Narrow Therapeutic Index of Levothyroxine,
Individualized Dose Titration Can Sometimes Require
Considerable Trial and Error,
There are several drawbacks to this approach

Cardiovascular and Other

Effects on Bone Integrity Effect

Increased Use of Patient Satisfaction with

Healthcare Resources Therapy
 Diagnosing and Managing Refractory Hypothyroidism

Confirm the Diagnosis and

Ask About Compliance
Laboratory Results

Check the Patient’s

Review the Thyroxine
Medication Bottles and
Ingestion History
Tablets
Diagnosing and Managing Refractory Hypothyroidism

Investigate for
Consider Increased
Levothyroxine
Turnover or Excretion
Malabsorption

Perform a Thyroxine Treat the Patient

Absorption Test Holistically
 Alternative Levothyroxine
Formulations
Significant Reduction
in Dose Adjustments

Two Novel Formulations of

Levothyroxine Sodium:
Softgel and Liquid

Significant
Improvement in
Hypothyroid
Symptom
 Conclusions
There is a frequently encountered subset of hypothyroid patients who are
refractory to standard thyroid hormone replacement treatment and require
unexpectedly high doses of levothyroxine or who have erratic control of
hypothyroidism, alternating between over-replacement and under-
replacement

The common approach to managing patients with unusual thyroxine needs is

to escalate the dose of levothyroxine until targeted TSH levels are achieved.
This approach can increase the risk for prolonged exposure to supratherapeutic
doses of Levothyroxine which increase the chances of adverse outcomes
 Conclusions
In our view, clinicians should take a systematic approach to managing patients
whom they suspect of having treatment- refractory hypothyroidism
This may include searching for occult medical conditions, or other factors that
may affect the absorption of levothyroxine, before up-titrating the dose of the
traditional levothyroxine therapy

In all cases, we advocate that the eight-step algorithm presented be used to

carefully assess patient needs before treatment choices are made
The early discovery of these factors via a thoughtful patient work-up may
avoid unnecessary thyroid medication adjustments and their consequences for
patients, clinicians, and the healthcare system
THANK YOU