American Thyroid Association Guidelines for Treatment of Hypothyroidism

 Elderly patients: Treatment should be initiated at low doses with slow titration
based on serum thyroid-stimulating hormone (TSH) assessment. Normal serum TSH
ranges are higher in the elderly patient; thus, higher serum TSH goals may be
needed as a patient ages. The American Thyroid Association (ATA) suggests raising
the target serum TSH to 4-6 mIU/L in people age 70 to 80 years.

 Pregnant patients: Levothyroxine should be dose titrated to achieve a TSH

concentration within the following trimester-specific reference range: 0.1-2.5 mIU/L
for the first trimester, 0.2 to 3.0 mIU/L for the second trimester, and 0.3 to 3.0 mIU/L
for the third trimester. Serum TSH should be reassessed every four weeks in the first
and second trimester and once during the third trimester. Women already taking
levothyroxine who become pregnant may require 2 additional doses per week of
their current levothyroxine dose (given as one extra dose twice weekly with several
days separation) as soon as pregnancy is confirmed.

 Infants and children: For overt hypothyroidism, newborns typically require

levothyroxine replacement therapy at 10 mcg/kg/day, 1-year-old-children at 4 to 6
mcg/kg/day, and adolescents at 2 to 4 mcg/kg/day. Once endocrine maturation is
complete, transition to the average adult dose of 1.6 mcg/kg/day can be made.
Treatment for subclinical hypothyroidism also is recommended in children due to the
benefit of avoiding any potential negative impact on growth and development as well
as the relatively low risk of treatment. Treatment is not recommended for children
with a TSH of 5 to 10 mIU/L.
THYROID HORMONE REPLACEMENT THERAPY
The prevalence of coronary artery disease increases with age. Significant cardiac disease, therefore, is more
likely in an older hypothyroid patient than in a younger one. This means that you must use great caution in
treating elderly hypothyroid patients. Too vigorous a schedule for replacing thyroid hormone can precipitate
angina pectoris, rhythm disturbances, or even a myocardial infarction.

For the older patient with nonemergent hypothyroidism, the most conservative approach is to begin by giving
levothyroxine, 25 µg/dfor 1 to 2 weeks, followed by 50 µg/dfor another 1 to 2 weeks, and then by 100 µg/d.If the
last dosage is tolerated, it becomes the long-term therapeutic dosage. Check thyroid function after 6 weeks on
the 100 µg/ddosing schedule. The 6-week interval is necessary because thyroxine has a long half-life (6.6 days).
If the free T4 value is still not in the normal range, the daily dose of levothyroxine may be increased to 125 µg.
The usual replacement dosage for younger adults is 100 to 150 µg/d, but elderly patients generally need less
hormone. In one group of elderly hypothyroid patients, the average replacement dose was 118 µg/d (compared
with 158 µg/dgiven to younger patients).12
Measurement of thyroid hormone levels 6 weeks after reaching the projected long-term replacement dosage is
critical, because elderly patients seldom can tolerate iatrogenic hyperthyroidism for very long. At that time, make
sure that the TSH level is in the normal range and not suppressed. This distinction is readily made with an
immunoradiometric assay for TSH. Even if the free T4 level is within the normal range, a suppressed TSH implies
chemical hyperthyroidism, a condition that should be avoided because of its probable effect on accelerating
osteoporosis, particularly in elderly women.
Occasionally, when an elderly patient with severe coronary artery disease is given incremental doses of thyroid
hormone, such severe angina results that only partial replacement is possible. Thus, the patient continues to
have hypothyroidism, even though of modest degree. This is particularly unfortunate, because the increased
cholesterol levels associated with hypothyroidism can lead to acceleration of coronary artery disease.

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