Choosing Wisely:

Don’t order a total or free triiodothyronine (T3) level when assessing levothyroxine (T4) dose in hypothyroid patients.

Rationale and Comments: T4 is converted into T3 at the cellular level in virtually all organs. Intracellular T3 levels regulate pituitary secretion and blood levels of thyroid-stimulating hormone (TSH), as well as the effects of thyroid hormone in multiple organs; a normal TSH indicates an adequate T4 dose. Conversion of T4 to T3 at the cellular level may not be reflected in the T3 level in the blood. Compared to patients with intact thyroid glands, patients taking T4 may have higher blood T4 and lower blood T3 levels. Thus the blood level of total or free T3 may be misleading (low normal or slightly low); in most patients a normal TSH indicates a correct dose of T4.
Sponsoring Organizations:
  • The Endocrine Society/American Association of Clinical Endocrinologists
  • Sources:
  • AACE/ATA guidelines
  • Disciplines:
  • Endocrinologic
  • References: • Garber JR, Cobin RH, Gharib H, Hennessey JV, Klein I, Mechanick JI, Pessah-Pollack R, Singer PA, Woeber KA. Clinical practice guidelines for hypothyroidism in adults: cosponsored by the American Association of Clinical Endocrinologists and the American Thyroid Association. Endocr Pract. 2012; Sep 11:1-207.

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