Eur Thyroid J. 2018;7:225-37. doi: 10.1159/000491388. Epub 2018 Jul 19
Diagnosis and treatment of central hypothyroidism are much more complex than for primary hypothyroidism. For the first time, guidelines summarize all the available evidence to provide a thorough state of the art summary of current knowledge for this condition. Based on this review of the literature, the authors make 34 recommendations for optimal care of affected patients. These range from diagnostic criteria, indication for genetic testing, starting dose and dose adaptations of levothyroxine in the context of different conditions, and treatment monitoring during follow-up. For example, recommendation 3 suggests to consider the diagnosis of central congenital hypothyroidism in the context of low FT4 and slightly increased TSH (<10 mU/l, or inappropriately lower than expected from the FT4 level), stressing the clinical experience of even slightly increased TSH levels in this context. Recommendation 11 states that this biochemical constellation should be confirmed at least on two separate occasions for a definitive diagnosis.
The strength of these guidelines is that it comprises recommendations for adults and pediatric patients, and precisely defines specific needs of patients with congenital central hypothyroidism. However, the authors stress that all of their recommendations were developed in the complete absence of randomized controlled trial evidence on the diagnosis and treatment of central hypothyroidism, an important aspect for future studies.