Levothyroxine

• Tablets 25micrograms, 50micrograms, 100micrograms (£0.81 = 100micrograms)
• Oral solution sugar free 25micrograms/5ml, 50micrograms/5ml, 100micrograms/5ml (£159.20 = 100micrograms/5ml)

Indications

• Hypothyroidism

Dose

• Initially 50–100micrograms once daily, preferably before breakfast, adjusted in steps of 25–50micrograms every 3–4 weeks according to response (usual maintenance dose 100–200micrograms once daily);
• In cardiac disease, severe hypothyroidism, and patients over 50 years, initially 25micrograms once daily, adjusted in steps of 25micrograms every 4 weeks according to response; usual maintenance dose 50–200micrograms once daily

Liothyronine

• Hard capsules 5micrograms (£55.00 = 5micrograms daily), 10micrograms (£65.00 = 10micrograms daily)
• Tablets 20micrograms (£60.43)
• Injection 20micrograms

Indications

• Hypothyroidism that has not responded adequately to levothyroxine therapy or patients who have persistent symptoms felt to be secondary to thyroid hormone deficiency despite seemingly adequate replacement therapy with levothyroxine
• Preparation for radioiodine remnant ablation (RRA) in patients with thyroid cancer (secondary care only)

Dose

• Hypothyroidism: Oral, 10micrograms daily as a single dose, or in 2 divided doses, in combination with a reduced dose of levothyroxine
• Elderly- smaller initial doses

Notes

1. Liothyronine is not appropriate for initiation by GPs
2. GPs who receive a request from a consultant to prescribe liothyronine for a patient who has not previously received liothyronine should contact the ICB Medicines Optimisation team before accepting the request (e-mail d-icb.medicinesoptimisation@nhs.net or telephone 01752 398800 - central number for all ICB Medicines Optimisation teams in Devon)
3. Liothyronine may be suitable for a small number of patients whose symptoms have not resolved despite optimal treatment with levothyroxine. Liothyronine is restricted to a maximum dose of 10micrograms daily as dual therapy with levothyroxine initiated by an endocrinologist. Liothyronine monotherapy is not supported
4. For patients with difficulty in swallowing, the SmPC recommendation for liothyronine hard capsules is for the contents of a capsule to be emptied into a minimum of 20ml of water. The entire liquid should be consumed after swirling the mixture to ensure ingestion of the full dose. 
5. Secondary care to carry out the initial assessment, monitoring and dose adjustment, and prescribe an initial supply of 56 days of treatment. GPs will be asked to prescribe following this and will be informed if the treatment is to continue or not following the formal 3-month assessment.
6. Consider a trial off liothyronine every 3^rd year to ensure continued clinical benefit.
7. There is no convincing evidence to support routine use of thyroid extracts, liothyronine monotherapy, compounded thyroid hormones, iodine containing preparations, dietary supplementation and over the counter preparations in the management of hypothyroidism
8. Liothyronine for RRA should be prescribed from the centre undertaking the treatment, and should not be prescribed in primary care
9. NHS Devon and local endocrinologists have agreed protocols to support specialist initiation, and GP review of liothyronine. Click here for initiation protocol (new patients) and here for the review protocol (existing patients) (under review)