Clinical Practice Guidelines for Hypothyroidism In Adults

Cosponsored by the American Association of Clinical Endocrinologists and the American Thyroid Association

Jeffrey R. Garber, MD, FACP, FACE; Rhoda H. Cobin, MD, FACP, MACE; Hossein Gharib, MD, MACP, MACE; James V. Hennessey, MD, FACP; Irwin Klein, MD, FACP; Jeffrey I. Mechanick, MD, FACP, FACE, FACN; Rachel Pessah-Pollack, MD; Peter A. Singer, MD, FACE; Kenneth A. Woeber, MD, FRCPE


Endocr Pract. 2012;18(6):988-1028. 

In This Article

Abstract and Introduction


Objective: Hypothyroidism has multiple etiologies and manifestations. Appropriate treatment requires an accurate diagnosis and is influenced by coexisting medical conditions. This paper describes evidence-based clinical guidelines for the clinical management of hypothyroidism in ambulatory patients.

Methods: The development of these guidelines was commissioned by the American Association of Clinical Endocrinologists (AACE) in association with American Thyroid Association (ATA). AACE and the ATA assembled a task force of expert clinicians who authored this article. The authors examined relevant literature and took an evidence-based medicine approach that incorporated their knowledge and experience to develop a series of specific recommendations and the rationale for these recommendations. The strength of the recommendations and the quality of evidence supporting each was rated according to the approach outlined in the American Association of Clinical Endocrinologists Protocol for Standardized Production of Clinical Guidelines—2010 update.

Results: Topics addressed include the etiology, epidemiology, clinical and laboratory evaluation, management, and consequences of hypothyroidism. Screening, treatment of subclinical hypothyroidism, pregnancy, and areas for future research are also covered.

Conclusions: Fifty-two evidence-based recommendations and subrecommendations were developed to aid in the care of patients with hypothyroidism and to share what the authors believe is current, rational, and optimal medical practice for the diagnosis and care of hypothyroidism. A serum thyrotropin is the single best screening test for primary thyroid dysfunction for the vast majority of outpatient clinical situations. The standard treatment is replacement with L-thyroxine. The decision to treat subclinical hypothyroidism when the serum thyrotropin is less than 10 mIU/L should be tailored to the individual patient.


These updated clinical practice guidelines (CPGs)[1–3] summarize the recommendations of the authors, acting as a joint American Association of Clinical Endocrinologists (AACE) and American Thyroid Association (ATA) task force for the diagnostic evaluation and treatment strategies for adults with hypothyroidism, as mandated by the Board of Directors of AACE and the ATA.

The ATA develops CPGs to provide guidance and recommendations for particular practice areas concerning thyroid disease, including thyroid cancer. The guidelines are not inclusive of all proper approaches or methods, or exclusive of others. the guidelines do not establish a standard of care, and specific outcomes are not guaranteed. Treatment decisions must be made based on the independent judgment of health care providers and each patient's individual circumstances. A guideline is not intended to take the place of physician judgment in diagnosing and treatment of particular patients (for detailed information regarding ATA guidelines, see the Supplementary Data, available online at

The AACE Medical Guidelines for Clinical Practice are systematically developed statements to assist health care professionals in medical decision making for specific clinical conditions. Most of their content is based on literature reviews. In areas of uncertainty, professional judgment is applied (for detailed information regarding AACE guidelines, see the Supplementary Data).

These guidelines are a document that reflects the current state of the field and are intended to provide a working document for guideline updates since rapid changes in this field are expected in the future. We encourage medical professionals to use this information in conjunction with their best clinical judgment. The presented recommendations may not be appropriate in all situations. Any decision by practitioners to apply these guidelines must be made in light of local resources and individual patient circumstances.

The guidelines presented here principally address the management of ambulatory patients with biochemically confirmed primary hypothyroidism whose thyroid status has been stable for at least several weeks. They do not deal with myxedema coma. The interested reader is directed to the other sources for this information.[4] The organization of the guidelines is presented in Table 1.

Table 1.


Organization of Clinical Practice Guidelines for Hypothyroidism in Adults

Serum thyrotropin (TSH) is the single best screening test for primary thyroid dysfunction for the vast majority of outpatient clinical situations, but it is not sufficient for assessing hospitalized patients or when central hypothyroidism is either present or suspected. The standard treatment is replacement with L-thyroxine which must be tailored to the individual patient. The therapy and diagnosis of subclinical hypothyroidism, which often remains undetected, is discussed. L-triiodothyronine in combination with L-thyroxine for treating hypothyroidism, thyroid hormone for conditions other than hypothyroidism, and nutraceuticals are considered.