Slow titration of thyroxine may not be necessary

The traditional "start low, go slow" dose titration strategy for thyroxine in patients with hypothyroidism might not be necessary, with evidence from a clinical trial suggesting immediate initiation of a full dose is well tolerated in patients free of pre-existing cardiovascular disease.Fifty patients with newly-diagnosed hypothyroidism were randomised to start treatment at 1.6 micrograms/kg or a more traditional approach of starting at 25 micrograms increasing by 25 micrograms every four weeks until week 24 and then according to thyroid hormone levels.No cardiac complaints or events were documented during treatment or at bicycle ergometry at baseline, 12 weeks or 24 weeks. Euthyroidism was achieved more rapidly in those on initial full-dose treatment, for example by 13 vs 1 patient by four weeks and 19 vs 9 patients at 12 weeks. Signs and symptoms of hypothyroidism and quality of life improved at a similar rate in both groups. This might have reflected the infrequent assessment of these outcomes, or a physiologically slow response to increased thyroid levels following prolonged hypothyroidism.The study excluded patients with cardiac disease or long-standing antihypertensive medication. Although the study population was relatively young, averaging 47 years, they ranged from 22 to 86 years. The results suggested that treatment in older patients would also be safe in the absence of any history of ischaemic heart disease. Full-dose initiation of treatment would reduce the need for frequent biochemical monitoring, enhance compliance through its simplicity, and reduce costs, the researchers said. An editorial cautioned against widespread adoption of the findings until they were confirmed by larger studies and the passage of time. The main benefit was convenience, with little else gained by the strategy; the number of patients in the study was small; and ignoring current standards of practice could expose clinicians to malpractice claims. There was no compelling reason to "go fast", it said, with the exception of treating myxoedema coma. Reference...