6.2.1 Thyroid Hormones

Levothyroxine
  • Tablets 25 micrograms, 50 micrograms, 100 micrograms (£1.57 = 100 micrograms)
  • Oral solution 25 micrograms/5ml, 50 micrograms/5ml, 100 micrograms/5ml (£230.10 = 100 micrograms/5ml)

Indications

  • Hypothyroidism

Dose

  • Initially 50–100 micrograms once daily, preferably before breakfast, adjusted in steps of 25–50 micrograms every 3–4 weeks according to response (usual maintenance dose 100–200 micrograms once daily);
  • In cardiac disease, severe hypothyroidism, and patients over 50 years, initially 25 micrograms once daily, adjusted in steps of 25 micrograms every 4 weeks according to response; usual maintenance dose 50–200 micrograms once daily
Liothyronine
  • Tablets 20 micrograms (£206.71)
  • Injection 20 micrograms

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, 10 micrograms 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 CCG Medicines Optimisation team before accepting the request (e-mail D-CCG.MedicinesOptimisation@nhs.net or telephone 01752 398800 - central number for all CCG 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 10 micrograms daily as dual therapy with levothyroxine initiated by an endocrinologist. Liothyronine monotherapy is not supported
  4. 10 micrograms liothyronine is approximately equivalent to 50 micrograms levothyroxine. 10 microgram doses may be achieved by dispersing a 20 microgram tablet in 20ml water, swirling over 10 minutes, then withdrawing the dose of 10ml using an oral syringe
  5. Secondary care to carry out the initial assessment, monitoring and dose adjustment, and prescribe an initial supply of two packs of 28 x 20 microgram tablets. 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 3rd 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 CCG 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)

 

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