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● Levotyroxine is the drug of choice for most patients irrespective of the underlying etiology (iodine defficiency, Hashimoto and other forms of threoiditis, thyroidectomy and radioiodine treatments, thyreostatic drugs such as thionamides and lithium). 
● Treatment is indicated in cases with symptoms and/or with TSH>10 mIU/L. TSH levels between 4.5 and 10 mIU/L require levothyroxine treatment only in conjunction with pregnancy, presence of anti-TPO antibodies, coronary artery disease, or heart failure. The benefit of levothyroxine treatment of other patients in this TSH range is unclear.
● Start with one-quarter of the average daily maintenance dose of 2 µg/kg and with one-eighth in patients with cardiac disease. Double the dose every 4-6 weeks until TSH has returned to the reference range of 0.5-4.5 mIU/L. Thereafter control TSH level every 6-12 months together with symptoms of hyperthyreosis such as tachycardia and -arrhythmia, tremor, and sleeplessness. Avoid switching levothyroxine preparations due to differences in bioequivalence.
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