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Review
. 2018 Jan 17:11:1.
doi: 10.1186/s13044-018-0045-x. eCollection 2018.

Management of hypothyroidism with combination thyroxine (T4) and triiodothyronine (T3) hormone replacement in clinical practice: a review of suggested guidance

Colin Dayan  1 , Vijay Panicker  2
Affiliations
Review

Management of hypothyroidism with combination thyroxine (T4) and triiodothyronine (T3) hormone replacement in clinical practice: a review of suggested guidance

Colin Dayan et al. Thyroid Res. .

Abstract

Background: Whilst trials of combination levothyroxine/liothyronine therapy versus levothyroxine monotherapy for thyroid hormone replacement have not shown any superiority, there remains a small subset of patients who do not feel well on monotherapy. Whilst current guidelines do not suggest routine use of combination therapy they do acknowledge a trial in such patients may be appropriate. It appears that use of combination therapy and dessicated thyroid extract is not uncommon but often being used by non-specialists and not adequately monitored. This review aims to provide practical advice on selecting patients, determining dose and monitoring of such a trial.

Main body: It is important to select the correct patient for a trial so as to not delay diagnosis or potentially worsen an undiagnosed condition. An appropriate starting dose may be calculated but accuracy is limited by available formulations and cost. Monitoring of thyroid function, benefits and adverse effects are vital in the trial setting given lack of evidence of safe long term use. Also important is that patients understand set up of the trial, potential risks involved and give consent.

Conclusion: Whilst evidence is lacking on whether a small group of patients may benefit from combination therapy a trial may be indicated in those who remain symptomatic despite adequate levothyroxine monotherapy. This should be undertaken by clinicians experienced in the field with appropriate monitoring for adverse outcomes in both short and long term.

Keywords: Levothyroxine; Liothyronine; T3; T4; Thyroid hormone replacement.

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Conflict of interest statement

Not applicable – review no original study.Not applicable.The authors declare that they have no competing interests.Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.

Figures

Fig. 1
Fig. 1
Mean values for a free T3, b free T4 and c TSH over a 24 h period in 10 patients with hypothyroidism on either LT4/LT3 combination or LT4 alone. From Saravanan et al. [63], used with permission
Fig. 2
Fig. 2
Proposed timeline for a trial of combination T4/T3 therapy
Fig. 3
Fig. 3
Change in costs for Liothyronine compared to Levothyroxine in the United Kingdom since 2009. Data from BNF and drug tariff, graph by British Thyroid Association
See this image and copyright information in PMC

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