Intended for healthcare professionals

Practice Guidelines

Thyroid disease assessment and management: summary of NICE guidance

BMJ 2020; 368 doi: (Published 29 January 2020) Cite this as: BMJ 2020;368:m41
  1. Melina Vasileiou, research fellow1,
  2. James Gilbert, head of evidence reviews2,
  3. Sarah Fishburn, guideline chair,
  4. Kristien Boelaert, reader in endocrinology and clinical lead3
  5. on behalf of the Guideline Committee
  1. 1National Guideline Centre, Royal College of Physicians, London, UK
  2. 2National Guideline Alliance, Royal College of Obstetricians and Gynaecologists, London, UK
  3. 3University of Birmingham, Birmingham, UK
  1. Correspondence to: M Vasileiou Melina.Vasileiou{at}

What you need to know

  • A starting levothyroxine dose of 1.6 μg/kg/day (rounded to the nearest 25 μg) is recommended for adults under 65 years old with primary hypothyroidism and no history of cardiovascular disease

  • A starting levothyroxine dose of 25-50 μg/day with titration is recommended for adults aged 65 and over and adults with a history of cardiovascular disease

  • Natural thyroid extract is not recommended and liothyronine (alone or in combination with levothyroxine) is not routinely recommended for treating people with primary hypothyroidism

  • Aim to maintain thyroid stimulating hormone (TSH) levels within the reference range when treating primary hypothyroidism with levothyroxine; if symptoms persist consider adjusting the dose of levothyroxine further to achieve optimal wellbeing, but avoid using doses that cause TSH suppression or thyrotoxicosis

  • Radioactive iodine is recommended as first line treatment for thyrotoxicosis with hyperthyroidism unless antithyroid drugs are likely to achieve remission or it is unsuitable

Thyroid disease, comprising thyroid dysfunction and enlargement, is common and often identified in primary care. Conditions causing thyroid dysfunction can be broadly divided into those that result in thyroid gland underactivity (overt and subclinical hypothyroidism) or overactivity (thyrotoxicosis). Hypothyroidism is usually managed by general practitioners. This article summarises some of the most recent recommendations from the NICE guideline “Thyroid disease: assessment and management.”1


NICE recommendations are based on systematic reviews of best available clinical evidence and explicit consideration of cost effectiveness. When minimal evidence is available, recommendations are based on the Guideline Committee’s experience and opinion of what constitutes good practice. The levels of evidence supporting the recommendations is given in italics in square brackets.

The type of evidence underpinning the recommendations in the guideline varied. Most recommendations were based on randomised controlled trials (RCTs) and Guideline Committee consensus. Conducting RCTs can be challenging in some aspects of thyroid disease management, with ethical and practical challenges of …

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