Table of ContentsView AllTable of ContentsLevothyroxine (T4)Liothyronine (T3)Desiccated Thyroid ExtractFor InfantsDuring PregnancyComplementary/Alternative MedicineFrequently Asked QuestionsNext in Hypothyroidism GuideWhat Is Hypothyroidism (Underactive Thyroid)?
Table of ContentsView All
View All
Table of Contents
Levothyroxine (T4)
Liothyronine (T3)
Desiccated Thyroid Extract
For Infants
During Pregnancy
Complementary/Alternative Medicine
Frequently Asked Questions
Next in Hypothyroidism Guide
The goals of treatment include:
Verywell / Jessica Olah
Hypothyroidism is treated with prescription oral thyroid hormone preparation (usually levothyroxine, a T4 preparation).The ideal dosage is sufficient enough to restore normal thyroid hormone levels without producing toxicity from too much thyroid hormone.
Formulations
In the United States, levothyroxine is available as generic levothyroxine, as well as Synthroid, Levothroid, and Levoxyl brand name tablets. Tirosint is a liquid gel cap form of levothyroxine that has been on the market since 2011.
Dosing
For young, healthy people, healthcare providers will generally begin with what is estimated to be a “full replacement dose” of T4 (that is, a dose that is supposed to completely restore thyroid function to normal).The full replacement dose is estimated according to body weight and, for most people, is between 50 and 200 micrograms (mcg) per day.
For older people or people who havecoronary artery disease, thyroid replacement therapy is usually started gradually, beginning with 25 to 50 mcg daily and increasing over time.
T4 for Younger PeopleBegin with a dose between 50 and 200 micrograms (mcg) per dayBegins with a full replacement doseT4 for Older PeopleBegin with a dose between 25 and 50 micrograms (mcg) per dayDose begins low and gradually gets increased
T4 for Younger PeopleBegin with a dose between 50 and 200 micrograms (mcg) per dayBegins with a full replacement dose
Begin with a dose between 50 and 200 micrograms (mcg) per day
Begins with a full replacement dose
T4 for Older PeopleBegin with a dose between 25 and 50 micrograms (mcg) per dayDose begins low and gradually gets increased
Begin with a dose between 25 and 50 micrograms (mcg) per day
Dose begins low and gradually gets increased
Administration
You should take T4 on an empty stomach to prevent the absorption of the medication from being erratic.Healthcare providers usually recommend taking the medication first thing in the morning, then waiting at least an hour to eat breakfast or drink coffee. Taking the medication at bedtime, several hours after the last meal, also appears to work and can be a more convenient approach for some people.
Monitoring
1:33How the Thyroid Gland Works
1:33
How the Thyroid Gland Works
While symptoms of hypothyroidism usually begin to resolve within two weeks of initiating treatment, it takes about six weeks for TSH levels to stabilize. That is why TSH levels are generally measured six weeks after treatment has begun.
Once the optimal dose of T4 is settled upon, TSH levels are measured every year or so thereafter, to make sure the treatment remains optimized.
While the standard approach to treating hypothyroidism (T4 replacement) works for most people, some people continue to experience symptoms.
According to a 2016 study published in theJournal of Clinical Endocrinology and Metabolism,about 15% of people in the United States with hypothyroidism continue to have symptoms despite being treated for the disease.
Some practitioners may consider liothyronine (T3) as an add-on treatment for select individuals, though this is a matter of debate.
Levothyroxine vs. Combination T4/T3 Therapy for Hypothyroidism
The Controversy
T4 is the major circulating thyroid hormone, but it is not the active form of the hormone. T4 is converted to T3 in the tissues as needed. And T3 is the thyroid hormone that does all the work. T4 is merely a prohormone—a repository of potential T3 and a way of making sure that enough T3 can be created on a minute-to-minute basis as needed.
When you take T4 and not T3, the effects rely on your tissues to convert just the right amount of T4 to T3 at just the right place and at just the right time.
There is emerging evidence suggesting that some people with hypothyroidism might not have an efficient conversion of T4 to T3.When this is the case, despite the fact that T4 levels may be https://www.thyroid.org/hypothyroidism/virnormal, T3 levels may be low, especially in the tissues, where T3 actually does its work.
Why T4 to T3 conversion may be abnormal in some people is, at this point, largely speculation—although at least one group of patients has been identified with a genetic variant (in the deiodinase 2 gene) that reduces the conversion of T4 to T3.
It appears that healthcare providers should be treating at least some people (albeit, a small group, most likely) who have hypothyroidism with both T4 and T3.
Liothyronine is a synthetic form of T3, and it is available in a manufactured form as the brand Cytomel, and also as generic liothyronine.T3 can also be compounded.
Calculation of appropriate doses of T3 is trickier than appropriately dosing T4. T4 is inactive, so if you take too much there is no immediate direct tissue effect. T3 is a different story, though, as it is the active thyroid hormone. So if you take too much T3, you can experiencehyperthyroid effectsdirectly—a risk, for instance, to people with cardiac disease.
When adding T3 to T4 during thyroid replacement therapy, most experts recommend administering a ratio of T4:T3 —between 13:1 to 16:1, which is the natural ratio of people without thyroid disease.
If you’re taking combined T4/T3 therapy, your practitioner will usually check a TSH level six weeks after you begin treatment.T3 levels are not generally checked because currently available T3 formulations lead to wide fluctuations in T3 blood levels throughout the day.
Medications Used to Treat Thyroid Disease
Desiccated thyroid extract contains both thyroxine (T4) and triiododothyronine (T3), and is derived from the thyroid glands of pigs.
Important Note
Moreover, the ratio of T4 and T3 in desiccated thyroid extract (about 4 to 1) is not the same as the human ratio (about fourteen to 1). So, even though desiccated thyroid extract is often considered to be “natural,” its ratio of T4-to-T3 hormone does not mimic that of human physiology.
In an infant diagnosed withcongenital hypothyroidism, the goals of treatment are to restore thyroid levels to normal as quickly and safely as possible.The quicker the thyroid levels are normalized, the better the cognitive and motor skills development of the infant.
Levothyroxine is the treatment of choice for congenital hypothyroidism.
Often, a liquid form of levothyroxine is given to infants. It’s important to not mix the levothyroxine withsoy infant formulaor any calcium or iron-fortified preparations. Soy, calcium, and iron can all reduce the infant’s ability to absorb the medication properly.
Children being treated for congenital hypothyroidism are evaluated on a regular schedule, often every several months for at least the first three years of life.
According to the European Society for Paediatric Endocrinology,in congenital hypothyroidism, serum T4 or free T4 and TSH blood tests should be performed at the following times:Every one to three months during the first 12 months of lifeEvery one to four months between 1 and 3 years of ageEvery six to 12 months thereafter until growth is completeEvery two weeks after the initiation of T4 treatment, and every two weeks until TSH level is normalizedFour to six weeks after any change in doseAt more frequent intervals when there’s any concern about medication dosing or if there are any abnormal results
According to the European Society for Paediatric Endocrinology,in congenital hypothyroidism, serum T4 or free T4 and TSH blood tests should be performed at the following times:
If permanent hypothyroidism has not been established, levothyroxine treatment may be discontinued for a month at age 3, and the child retested. If levels remain normal, transient hypothyroidism is the presumed diagnosis. If levels become abnormal, permanent hypothyroidism is diagnosed.
Children with transient congenital hypothyroidism who are taken off medication should have periodicthyroid evaluation and retesting, as these children face an increased risk of developing a thyroid problem throughout their lives.
Before Pregnancy
According to guidelines from American Thyroid Association, the dosage of thyroid hormone (levothyroxine) replacement medication for a woman with pre-existing hypothyroidism should be adjusted to aim for a TSH level below 2.5 mIU/L prior to conception.
The TSH level should be maintained at the following trimester-specific levels:First trimester: Between 0.1 and 2.5 mIU/LSecond trimester: Between 0.2 to 3.0 mIU/LThird trimester: Between 0.3 to 3.0 mIU/L
The TSH level should be maintained at the following trimester-specific levels:
Managing Thyroid Problems During Pregnancy
Complementary Alternative Medicine (CAM)
In addition to the traditional treatment of your hypothyroidism with thyroid hormone replacement,implementing lifestyle habits, mind-body practices, and dietary changes in your health care can offer many benefits.
For example, some experts suggest that certain yoga poses (specifically, shoulder stands and inverted poses where the feet are elevated) may be beneficial to blood flow to the thyroid gland, or to the reduction of general stress that contributes to worsening symptoms of hypothyroidism.
Moreover, some people find that guided meditation is helpful for the thyroid, as are other stress-reducing strategies like prayer, gentle yoga, tai chi, and needlework.
Self-Treatment
It’s important to be open and honest with your healthcare provider from the start about your use of complementary therapies, so you can ensure that nothing you’re doing (or want to try) will interfere with your thyroid care.
While some holistic or CAM practitioners may be able to recommend approaches to support your thyroid, immune and hormonal systems, it’s important to be cautious of any product that’s marketed as a “cure” for your disease, or marketed as being without side effects.
Natural Treatment for Hypothyroidism
Levothyroxine, the most commonly prescribed medication for treating an underactive thyroid, can cause side effects such as:Weight changesHeadacheDiarrheaChanges in appetiteChanges in menstrual cycleHeat sensitivityJoint painIf you experience symptoms of an allergic reaction, get emergency help.
Levothyroxine, the most commonly prescribed medication for treating an underactive thyroid, can cause side effects such as:
If you experience symptoms of an allergic reaction, get emergency help.
Diet and Hypothyroidism
25 Sources
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Mincer DL, Jialal I.Hashimoto Thyroiditis. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing. Available from: https://www.ncbi.nlm.nih.gov/books/NBK459262/McAninch EA, Bianco AC.The History and Future of Treatment of Hypothyroidism[published correction appears in Ann Intern Med. 2016 Mar 1;164(5):376].Ann Intern Med. 2016;164(1):50‐56. doi:10.7326/M15-1799Eghtedari B, Correa R.Levothyroxine. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing Available from: https://www.ncbi.nlm.nih.gov/books/NBK539808/Benvenga S, Carlé A.Levothyroxine Formulations: Pharmacological and Clinical Implications of Generic Substitution.Adv Ther. 2019;36(Suppl 2):59‐71. doi:10.1007/s12325-019-01079-1Chakera AJ, Pearce SH, Vaidya B.Treatment for primary hypothyroidism: current approaches and future possibilities.Drug Des Devel Ther. 2012;6:1‐11. doi:10.2147/DDDT.S12894Kim MI.Hypothyroidism in the Elderly. In: Feingold KR, Anawalt B, Boyce A, et al., editors. Endotext [Internet]. South Dartmouth (MA): MDText.com, Inc. Available from: https://www.ncbi.nlm.nih.gov/books/NBK279005/Ala S, Akha O, Kashi Z, Asgari H, Bahar A, Sasanpour N.Dose administration time from before breakfast to before dinner affect thyroid hormone levels?.Caspian J Intern Med.Pirahanchi Y, Jialal I. Physiology,Thyroid Stimulating Hormone (TSH). In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing. Available from: https://www.ncbi.nlm.nih.gov/books/NBK499850/Peterson SJ, Mcaninch EA, Bianco AC.Is a Normal TSH Synonymous With “Euthyroidism” in Levothyroxine Monotherapy?. J Clin Endocrinol Metab.Dayan C, Panicker V.Management of hypothyroidism with combination thyroxine (T4) and triiodothyronine (T3) hormone replacement in clinical practice: a review of suggested guidance.Thyroid Res. 2018;11:1. Published 2018 Jan 17. doi:10.1186/s13044-018-0045-xToft AD, Beckett GJ.Thyroid function tests and hypothyroidism.BMJ. 2003;326(7384):295‐296. doi:10.1136/bmj.326.7384.295Dayan C, Panicker V.Management of hypothyroidism with combination thyroxine (T4) and triiodothyronine (T3) hormone replacement in clinical practice: a review of suggested guidance.Thyroid Res. 2018;11:1. Published 2018 Jan 17. doi:10.1186/s13044-018-0045-xMcAninch EA, Bianco AC.The Swinging Pendulum in Treatment for Hypothyroidism: From (and Toward?) Combination Therapy.Front Endocrinol (Lausanne). 2019;10:446. Published 2019 Jul 9. doi:10.3389/fendo.2019.00446Hoang TD, Olsen CH, Mai VQ, Clyde PW, Shakir MK.Desiccated thyroid extract compared with levothyroxine in the treatment of hypothyroidism: a randomized, double-blind, crossover study.J Clin Endocrinol Metab. 2013;98(5):1982‐1990. doi:10.1210/jc.2012-4107Segni M.Congenital Hypothyroidism. In: Feingold KR, Anawalt B, Boyce A, et al., editors. Endotext [Internet]. South Dartmouth (MA): MDText.com, Inc. Available from: https://www.ncbi.nlm.nih.gov/books/NBK279004/Colucci P, Yue CS, Ducharme M, Benvenga S.A Review of the Pharmacokinetics of Levothyroxine for the Treatment of Hypothyroidism.Eur Endocrinol. 2013;9(1):40‐47. doi:10.17925/EE.2013.09.01.40Léger J, Olivieri A, Donaldson M, et al. European Society for Paediatric Endocrinology consensus guidelines on screening, diagnosis, and management of congenital hypothyroidism. J Clin Endocrinol Metab.Segni M.Disorders of the Thyroid Gland in Infancy, Childhood and Adolescence. In: Feingold KR, Anawalt B, Boyce A, et al., editors. Endotext [Internet]. South Dartmouth (MA): MDText.com, Inc. Available from: https://www.ncbi.nlm.nih.gov/books/NBK279032/Alexander EK, Pearce EN, Brent GA, et al.Guidelines of the American Thyroid Association for the Diagnosis and Management of Thyroid Disease During Pregnancy and the Postpartum [published correction appears in Thyroid. 2017 Sep;27(9):1212].Thyroid. 2017;27(3):315‐389. doi:10.1089/thy.2016.0457Okosieme OE, Lazarus JH.Hypothyroidism in Pregnancy. In: Feingold KR, Anawalt B, Boyce A, et al., editors. Endotext [Internet]. South Dartmouth (MA): MDText.com, Inc. Available from: https://www.ncbi.nlm.nih.gov/books/NBK279154/Singh P, Singh B, Dave R, Udainiya R.The impact of yoga upon female patients suffering from hypothyroidism.Complement Ther Clin Pract. 2011;17(3):132‐134. doi:10.1016/j.ctcp.2010.11.004Brake MK, Bartlett C, Hart RD, Trites JR, Taylor SM.Complementary and alternative medicine use in the thyroid patients of a head and neck practice.Otolaryngol Head Neck Surg. 2011;145(2):208‐212. doi:10.1177/0194599811407564Rizzo LFL, Mana DL, Serra HA.Drug-induced hypothyroidism.Medicina (B Aires).American Thyroid Association.Hypothyroidism.MedlinePlus.Levothyroxine.
Mincer DL, Jialal I.Hashimoto Thyroiditis. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing. Available from: https://www.ncbi.nlm.nih.gov/books/NBK459262/
McAninch EA, Bianco AC.The History and Future of Treatment of Hypothyroidism[published correction appears in Ann Intern Med. 2016 Mar 1;164(5):376].Ann Intern Med. 2016;164(1):50‐56. doi:10.7326/M15-1799
Eghtedari B, Correa R.Levothyroxine. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing Available from: https://www.ncbi.nlm.nih.gov/books/NBK539808/
Benvenga S, Carlé A.Levothyroxine Formulations: Pharmacological and Clinical Implications of Generic Substitution.Adv Ther. 2019;36(Suppl 2):59‐71. doi:10.1007/s12325-019-01079-1
Chakera AJ, Pearce SH, Vaidya B.Treatment for primary hypothyroidism: current approaches and future possibilities.Drug Des Devel Ther. 2012;6:1‐11. doi:10.2147/DDDT.S12894
Kim MI.Hypothyroidism in the Elderly. In: Feingold KR, Anawalt B, Boyce A, et al., editors. Endotext [Internet]. South Dartmouth (MA): MDText.com, Inc. Available from: https://www.ncbi.nlm.nih.gov/books/NBK279005/
Ala S, Akha O, Kashi Z, Asgari H, Bahar A, Sasanpour N.Dose administration time from before breakfast to before dinner affect thyroid hormone levels?.Caspian J Intern Med.
Pirahanchi Y, Jialal I. Physiology,Thyroid Stimulating Hormone (TSH). In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing. Available from: https://www.ncbi.nlm.nih.gov/books/NBK499850/
Peterson SJ, Mcaninch EA, Bianco AC.Is a Normal TSH Synonymous With “Euthyroidism” in Levothyroxine Monotherapy?. J Clin Endocrinol Metab.
Dayan C, Panicker V.Management of hypothyroidism with combination thyroxine (T4) and triiodothyronine (T3) hormone replacement in clinical practice: a review of suggested guidance.Thyroid Res. 2018;11:1. Published 2018 Jan 17. doi:10.1186/s13044-018-0045-x
Toft AD, Beckett GJ.Thyroid function tests and hypothyroidism.BMJ. 2003;326(7384):295‐296. doi:10.1136/bmj.326.7384.295
McAninch EA, Bianco AC.The Swinging Pendulum in Treatment for Hypothyroidism: From (and Toward?) Combination Therapy.Front Endocrinol (Lausanne). 2019;10:446. Published 2019 Jul 9. doi:10.3389/fendo.2019.00446
Hoang TD, Olsen CH, Mai VQ, Clyde PW, Shakir MK.Desiccated thyroid extract compared with levothyroxine in the treatment of hypothyroidism: a randomized, double-blind, crossover study.J Clin Endocrinol Metab. 2013;98(5):1982‐1990. doi:10.1210/jc.2012-4107
Segni M.Congenital Hypothyroidism. In: Feingold KR, Anawalt B, Boyce A, et al., editors. Endotext [Internet]. South Dartmouth (MA): MDText.com, Inc. Available from: https://www.ncbi.nlm.nih.gov/books/NBK279004/
Colucci P, Yue CS, Ducharme M, Benvenga S.A Review of the Pharmacokinetics of Levothyroxine for the Treatment of Hypothyroidism.Eur Endocrinol. 2013;9(1):40‐47. doi:10.17925/EE.2013.09.01.40
Léger J, Olivieri A, Donaldson M, et al. European Society for Paediatric Endocrinology consensus guidelines on screening, diagnosis, and management of congenital hypothyroidism. J Clin Endocrinol Metab.
Segni M.Disorders of the Thyroid Gland in Infancy, Childhood and Adolescence. In: Feingold KR, Anawalt B, Boyce A, et al., editors. Endotext [Internet]. South Dartmouth (MA): MDText.com, Inc. Available from: https://www.ncbi.nlm.nih.gov/books/NBK279032/
Alexander EK, Pearce EN, Brent GA, et al.Guidelines of the American Thyroid Association for the Diagnosis and Management of Thyroid Disease During Pregnancy and the Postpartum [published correction appears in Thyroid. 2017 Sep;27(9):1212].Thyroid. 2017;27(3):315‐389. doi:10.1089/thy.2016.0457
Okosieme OE, Lazarus JH.Hypothyroidism in Pregnancy. In: Feingold KR, Anawalt B, Boyce A, et al., editors. Endotext [Internet]. South Dartmouth (MA): MDText.com, Inc. Available from: https://www.ncbi.nlm.nih.gov/books/NBK279154/
Singh P, Singh B, Dave R, Udainiya R.The impact of yoga upon female patients suffering from hypothyroidism.Complement Ther Clin Pract. 2011;17(3):132‐134. doi:10.1016/j.ctcp.2010.11.004
Brake MK, Bartlett C, Hart RD, Trites JR, Taylor SM.Complementary and alternative medicine use in the thyroid patients of a head and neck practice.Otolaryngol Head Neck Surg. 2011;145(2):208‐212. doi:10.1177/0194599811407564
Rizzo LFL, Mana DL, Serra HA.Drug-induced hypothyroidism.Medicina (B Aires).
American Thyroid Association.Hypothyroidism.
MedlinePlus.Levothyroxine.
Alexander EK et al.Guidelines of the American Thyroid Association for the Diagnosis and Management of Thyroid Disease During Pregnancy and the Postpartum.Thyroid.
Léger J et al.European Society for Paediatric Endocrinology Consensus Guidelines on Screening, Diagnosis, and Management of Congenital Hypothyroidism.J Clin Endocrinol Metab.
McAninch EA, Bianco AC.The history and future of treatment of hypothyroidism.Ann Intern Med.
Panicker V et al.Common Variation in the DIO2 Gene Predicts Baseline Psychological Well-being and Response to Combination Thyroxine Plus Triiodothyronine Therapy in Hypothyroid patients.J Clin Endocrinol Metab.
Peterson SJ, McAninch EA, Bianco AC.Is a Normal TSH Synonymous With “Euthyroidism” in Levothyroxine Monotherapy?J Clin Endocrinol Metab.
Ross DS.Treatment of primary hypothyroidism in adults. Cooper DS, Mulder JE, eds. UpToDate. Waltham, MA: UpToDate Inc.
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