An open-label prospective study by Netherlands researchers found that a quarter of older adults on hypothyroidism medication were able to wean off the drug while maintaining adequate thyroid function, reports MedPage Today.
In patients aged 60 and up, a protocol for stepwise reduction in levothyroxine led to 25.7% successfully discontinuing the medication while maintaining a thyrotropin (TSH) level under 10 mIU/L and a free thyroxine level within the reference range, reported Rosalinde Poortvliet, MD, PhD, of Leiden University Medical Centre in The Netherlands, and colleagues.
These patients maintained a median TSH level of 5.03 mIU/L and a mean free thyroxine level of 1.01 ng/dL after 1 year. Nearly half (48.4%) maintained a thyrotropin level under 4.8 mIU/L, the team wrote in JAMA.
A lower levothyroxine dose at baseline predicted successful discontinuation, with nearly two-thirds (63.6%) of patients on a daily dose of 50 µg or less able to stop treatment.
Levothyroxine is often continued indefinitely because current guidelines lack de-prescribing protocols, according to the study authors. This persists even though hypothyroidism can be transient, with subclinical cases often reverting to normal thyroid function in older adults.
“The new findings show that carefully selected patients aged 60 or older may not require lifelong levothyroxine treatment and could benefit from a supervised trial of discontinuation, particularly in those taking a dose of 50 µg/d or lower,” Poortvliet told MedPage Today.
Levothyroxine ranks in the top three most commonly dispensed medications in the US, and older age is a predictor of initiation, noted Maria Papaleontiou, MD, of the University of Michigan in Ann Arbor, and Anne Cappola, MD, of the University of Pennsylvania in Philadelphia.
“Up to 60% of adults are prescribed levothyroxine for subclinical hypothyroidism … or for non-evidence-based indications,” the duo wrote in an accompanying editorial.
Over-treatment with levothyroxine is a growing concern, with past research linking longer-term use to increased risks for fractures, atrial fibrillation, and cognitive disorders, as well as all cause and cardiovascular mortality.
“Clinicians should reassess the necessity of thyroid hormone therapy to minimise over-treatment and its associated risks, embracing a strategy of patient-centred, evidence-based de-prescribing,” advised Papaleontiou and Cappola.
“In parallel, clinicians need clear, straightforward guidance on when to prescribe levothyroxine. Prevention of inappropriate levothyroxine prescribing would significantly reduce the need to consider de-prescribing. When an initial thyrotropin test is elevated in a non-pregnant woman, the first step is to repeat the test,” they added.
The open-label, prospective study followed 370 community-dwelling adults at primary care practices in the Netherlands from January 2020 to December 2023.
Inclusion required a stable levothyroxine dose (≤150 µg per day) for at least one year with TSH levels under 10 mIU/L. Exclusion criteria included a history of thyroidectomy, radioactive iodine treatment, neck irradiation, and congenital or secondary hypothyroidism.
The study cohort had a median age of 70, and 80% were women. At baseline, the median TSH level was 2.20 mIU/L, and free thyroxine averaged 1.21 ng/dL. The average levothyroxine dose was 84 µg per day.
The protocol called for general practitioners to review TSH and free thyroxine levels at each visit and reduce the levothyroxine dose if the TSH level was less than 10 mIU/L and free thyroxine level was greater than or equal to the lower limit of the reference range.
When those criteria were met, the doctor cut the dose by 12.5 μg to 50 μg per day at baseline, 25 μg to 38 μg per day after six and 12 weeks, and 25 μg per day after 18, 24, and 30 weeks. Thyroid function testing was performed at least six weeks after each dose reduction.
Among the participants who remained on the medication, most ceased dose reductions because their TSH levels rose to 10 mIU/L or above.
While a TSH threshold of 10 mIU/L “may be reasonable” after levothyroxine discontinuation, Papaleontiou and Cappola pointed out that some clinicians and patients may not be comfortable with TSH levels exceeding the reference range to that extent.
“It has been suggested that treatment with levothyroxine may be considered in patients aged 65 or older with subclinical hypothyroidism (TSH range 7.0-9.9 mIU/L) based on observational data supporting an increased risk of mortality from coronary heart disease in this TSH range,” they noted.
Thyroid-related quality of life didn’t differ significantly between those who successfully discontinued the drug and those who didn’t.
A total of 17 serious adverse events occurred (15 unplanned hospitalisations and two deaths), but none was considered related to the study intervention.
There was a lack of data regarding the indication for levothyroxine treatment and measurement of thyroid peroxidase antibodies, Poortvliet’s group noted, which limits the translation of the results to specific subgroups.
Study details
Discontinuation of levothyroxine in adults aged 60 years or older
Janneke Ravensberg, Jacobijn Gussekloo, Saskia Le Cessie et al.
Published in JAMA Network on 6 April 2026
Abstract
Importance
Many adults aged 60 or older take the thyroid hormone levothyroxine, which is generally continued for life. However, it is uncertain whether long-term continuation is always necessary.
Objective
To determine the percentage of adults aged 60 years or older who can successfully discontinue levothyroxine treatment.
Design, Setting, and Participants
This single-group, prospective study included community-dwelling adults aged 60 years or older who were taking levothyroxine at a stable dosage (≤150 µg/d) for at least 1 year and had a thyrotropin (TSH) level of less than 10 mIU/L. The study was conducted at 58 general practices in the Netherlands. Participants were enrolled between January 2020 and July 2022 and final follow-up occurred on December 12, 2023.
Interventions
Open-label, protocol-driven, stepwise dose reduction with thyroid function testing performed at least six weeks after each reduction in levothyroxine dose.
Main Outcomes and Measures
The primary outcome was the proportion of participants who discontinued levothyroxine and had both a thyrotropin level of less than 10 mIU/L and a free thyroxine level within the reference range at one year after the start of discontinuation. The secondary outcomes included factors associated with successful discontinuation (demographics, thyroid function, dose) and thyroid-related quality of life.
Results
Of the 370 participants who started the levothyroxine discontinuation phase (median age, 70 [range, 60-89] years; 80% female; median thyrotropin level, 2.2 [range, 0.02-9.69] mIU/L; mean free thyroxine level, 1.21 [SD, 0.18] ng/dL), 366 completed final follow-up at 1 year. Of the 370 participants (median levothyroxine dose at baseline, 50 [range, 12.5-150] µg/d), 95 (25.7% [95% CI, 21.5%-30.4%]) successfully stopped taking levothyroxine and had a median thyrotropin level of 5.03 mIU/L (range, 1.56-9.40 mIU/L) and a mean free thyroxine level of 1.01 ng/dL (range, 0.80-1.43 ng/dL) at one year. Of the 95 participants who successfully discontinued levothyroxine, 46 (48.4% [95% CI, 38.6%-58.3%]) had a thyrotropin level of less than 4.8 mIU/L. Among the 88 participants taking a levothyroxine dose of 50 µg/d or lower, 56 (63.6%) successfully discontinued this treatment. Thyroid-related quality of life showed no clinically relevant changes overall from baseline to one year and stratified by successful levothyroxine discontinuation vs unsuccessful discontinuation.
Conclusions and Relevance
In this open-label, single-group prospective study, 25.7% of adults aged 60 or older discontinued levothyroxine treatment while maintaining adequate thyroid function at one year. Evaluation of the need to continue levothyroxine should be considered in adults aged 60 or older, particularly in those taking a dose of 50 µg/d or lower.
JAMA article – Discontinuation of Levothyroxine in Adults Aged 60 Years or Older (Open access)
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