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Principles of treatment The aim of treatment is to achieve a T4 level in the normal range a TSH level in the normal range AND The doses is primarily titrated to the TSH level The typical dose is 1.6g/Kg, but the dose should be started low and titrated up to this Typically this means doses are in the 100-200g per day range Initially give 25-50g, and review after 6 weeks Start at the lower end for frail and elderly patients Adjust the dose every 6 weeks so that TSH levels are in the normal range (not suppressed) Low TSH suggests over-replacement of T4 (even if T4 is not elevated) titrate the dose down until TSH returns to the normal range High TSH suggests under-replacement increase the dose of levothyroxine The half life of T4 is about 7 days, so any change in the dose will not be clinically noticeable for about 4 weeks