Levothyroxine Dose Titration Calculator
Calculate levothyroxine starting dose or TSH-based titration adjustment. Per ATA 2014, ICMR thyroid guidelines, and FOGSI pregnancy recommendations.
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Also Known As
Starting dose of levothyroxine
Healthy adult <65 years: 1.6 mcg/kg/day (full replacement). A 60 kg patient needs ~100 mcg/day.
Elderly (>65) or cardiac disease: Start low — 25-50 mcg/day. Uptitrate by 12.5-25 mcg every 4-6 weeks to avoid precipitating angina or arrhythmia.
Pregnancy: 2.0-2.4 mcg/kg/day. If already on thyroxine and confirms pregnancy — increase IMMEDIATELY by 2 extra tablets per week, even before TSH result.
Subclinical hypothyroidism (TSH 4-10, normal T4): Treat if TSH >10, pregnancy/planning, symptoms, goitre, anti-TPO positive, or age <65 with cardiac risk.
TSH targets
- Non-pregnant adult: TSH 0.4-4.0 mIU/L
- Elderly >70-80: TSH 4-6 acceptable (avoid over-replacement)
- Pregnancy T1: TSH <2.5 mIU/L (ATA 2017)
- Pregnancy T2/T3: TSH <3.0 mIU/L
- Post-thyroidectomy for DTC, high-risk: TSH <0.1 mIU/L (suppression)
Titration rules of thumb
- Recheck TSH no earlier than 6-8 weeks after any dose change.
- Small changes: 12.5 mcg/day. Bigger gaps: 25 mcg/day.
- Take thyroxine on empty stomach, 30-60 minutes before food. NOT with calcium, iron, PPIs, soy milk, or coffee.
- If TSH suppressed — risk of AF and osteoporosis. De-escalate.
- Non-adherence is the #1 cause of persistent elevated TSH in India — ask before raising dose.
Costs in India
- Branded (Eltroxin, Thyronorm, Thyrox): ₹2-3 per tablet. Monthly cost ~₹60-120 depending on strength.
- Jan Aushadhi generic: ₹15-30/month — same molecule, bioequivalent. Government supply.
- Once switched, recheck TSH at 6-8 weeks — bioequivalence is regulatory but minor TSH shifts can occur.
Frequently Asked Questions
▸Why empty stomach with thyroxine?
Food (especially calcium, iron, fibre, soy, coffee) reduces absorption by 30-50%. Take 30-60 min before breakfast, or at bedtime ≥3 hours after dinner (equally effective per RCTs).
▸Can I switch between brands?
Yes, but recheck TSH 6-8 weeks after switching. Although bioequivalence is regulated, narrow therapeutic index means minor changes can shift TSH.
▸My patient has TSH 8 but no symptoms — treat?
Subclinical hypothyroidism. Treat if: age <65, anti-TPO positive, pregnancy/planning, TSH >10, goitre, or symptoms. Otherwise observe with 6-monthly TSH.
▸How much extra in pregnancy?
Increase by ~30% (typically 2 extra tablets per week). Do this IMMEDIATELY on confirming pregnancy — do not wait for TSH. Recheck TSH every 4 weeks until 20 weeks, then once in T3.
▸TSH normal but patient still tired — increase dose?
No. Persistent fatigue with normal TSH is rarely thyroid-related. Screen for anaemia, vitamin D, B12 deficiency, depression, sleep apnoea — all very common in Indians.
▸Liothyronine (T3) combination?
Not routinely recommended (ATA 2014). Reserve for persistent symptoms despite normal TSH on monotherapy, after ruling out other causes.
References
- Jonklaas J et al. Guidelines for the Treatment of Hypothyroidism. American Thyroid Association. Thyroid 2014;24(12):1670-751
- Alexander EK et al. 2017 Guidelines of the ATA for the Diagnosis and Management of Thyroid Disease During Pregnancy. Thyroid 2017;27(3):315-89
- ICMR — Standard Treatment Workflow: Hypothyroidism in Adults
- Indian Thyroid Society / FOGSI Recommendations for Thyroid Disease in Pregnancy 2021
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