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8 Treatment HOSPITALIZED PATIENTS Î In hospitalized, non-critically ill patients with a pre-established diagnosis of hypothyroidism who are found to have an elevated TSH measurement, consideration should be given to institution or adjustment of levothyroxine replacement. (S-L). Note: Factors such as the degree of clinical and biochemical hypothyroidism, active comorbidities, and details of administration of levothyroxine (e.g., dosage, timing, and other factors impacting absorption) are relevant considerations in this situation. Î The therapeutic goal of levothyroxine replacement in noncritically ill patients is long-term normalization of serum TSH when steady-state thyroid hormone levels are achieved. (S-L) Note: The ATA does not recommend titrating the levothyroxine dose to serum free thyroxine levels unless serum TSH cannot be relied upon (e.g., following pituitary surgery). Î For hospitalized but not critically ill patients, oral levothyroxine treatment is recommended. If this is not feasible, other enteral routes can be used. However, if there are concerns about significant malabsorption or there are other clinical reasons why a patient cannot be given enteral levothyroxine, intravenous levothyroxine may be administered until enteral absorption improves. (W-L) Note: If using intravenous levothyroxine, the equivalent intravenous dose is approximately 75%, assuming the enteral levothyroxine dose had achieved euthyroidism. Î For hospitalized but not critically ill patients who are about to be treated with levothyroxine, the possibility of adrenal insufficiency should be considered. If there is sufficient clinical or biochemical evidence to consider this diagnosis, adrenal insufficiency should be ruled out, or empiric treatment should be provided. (S-L). Î The ATA recommends against the routine use of liothyronine as a form of therapy for hospitalized patients with heart failure and low serum triiodothyronine concentrations given the mixed data from short-term trials, the hypothetical risks, and pending further randomized trials confirming benefit and safety. (W-M). Myxedema Coma Î Initial thyroid hormone replacement for myxedema coma should be levothyroxine given intravenously. (S-L). Note: A loading dose of 200-400 μg of levothyroxine may be given, with lower doses given for smaller or older patients and those with a history of coronary disease or arrhythmia. A daily replacement dose of 1.6 μg/kg body weight, reduced to 75% as long as it is being intravenously administered, can be given thereafter. Oral therapy, or other enteral therapy if the oral route cannot be employed, may be instituted after the patient improves clinically.

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