Management of Primary Hypothyroidism: Statement by the British Thyroid Association Executive Committee

Statement by the British Thyroid Association Executive Committee

Onyebuchi Okosieme; Jackie Gilbert; Prakash Abraham; Kristien Boelaert; Colin Dayan; Mark Gurnell; Graham Leese; Christopher McCabe; Petros Perros; Vicki Smith; Graham Williams; Mark Vanderpump


Clin Endocrinol. 2016;84(6):799-808. 

In This Article

Summary of ETA and ATA Guidelines

The key recommendations are summarized in Table 1, Table 2, Table 3, Table 4, Table 5, Table 6, Table 7, Table 8, Table 9 and Table 10, and each Table addresses a relevant question reviewed in either or both guidelines.

  • L-T4 is the treatment of choice in hypothyroidism. The goal of therapy is to restore physical and psychological well-being and normalize serum TSH (Table 1).

  • The adequacy of therapy should be determined both by clinical and biochemical assessment, and undertreatment and overtreatment should be avoided due to their detrimental health effects (Table 2).

  • There is insufficient evidence to recommend monitoring serum T3 as a therapeutic target in hypothyroidism (Table 3).

  • A proportion of patients on L-T4 therapy have persistent symptoms despite normal serum TSH levels. Such symptoms should be acknowledged and alternative aetiologies sought (Table 4).

  • There is insufficient evidence that combination therapy with L-T4 and L-T3 therapy is superior to L-T4 monotherapy (Table 5).

  • L-T4/L-T3 therapy may be considered as an 'experimental approach' in compliant L-T4-treated hypothyroid patients who have persistent complaints despite reference range serum TSH values, provided they have received adequate chronic disease support and associated autoimmune diseases have been ruled out (ETA) (Table 5 and Table 6). There is currently insufficient evidence to support the routine use of such a trial of L-T4 and L-T3 outside a 'formal clinical trial or N of 1 trial' (ATA) (Table 5).

  • Thyroid hormone therapy is not recommended in euthyroid individuals with (i) suggestive symptoms of hypothyroidism, (ii) obesity, (iii) depression or (iv) urticaria (Table 7).

  • The routine use of thyroid extracts, L-T3 monotherapy, compounded thyroid hormones, iodine containing preparations, dietary supplementation, nutraceuticals and over the counter preparations are not recommended in the management of hypothyroidism (Table 8).

  • Genetic characterization for deiodinase gene polymorphisms is not recommended as a guide to the use of combination L-T3 and L-T4 therapy in hypothyroidism (Table 9).

  • Clinicians treating patients with hypothyroidism have an ethical obligation to avoid potential harmful therapies without proven benefits. The balance of clinical evidence regarding the efficacy of monotherapy vs combination therapy calls for further well-designed randomized controlled trials (Table 10).