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Open access

Andrea del Toro-Diez, Ernesto Solá-Sánchez, and Michelle Mangual-García


Primary hypothyroidism is one of the most common endocrine disorders with widely available treatment. A minority of patients remain with uncontrolled hypothyroidism despite therapy. The objective of this case series was to demonstrate that medication non-adherence, rather than malabsorption, should be sought as the most common cause of unsuppressed TSH levels in patients receiving treatment for this condition. Non-adherence is often considered as a diagnosis of exclusion. Nonetheless, a diagnosis of malabsorption requires a more extensive workup, including imaging and invasive procedures, which increase healthcare costs and burden to the patient. The findings of this study allow for a cost-effective approach to uncontrolled hypothyroidism.

Learning points

  • Medication non-adherence is a common cause of insuppressible TSH levels.

  • Once weekly levothyroxine is an alternative approach to non-compliant patients.

  • Assessing compliance is more cost-effective and less burdensome than testing for malabsorption.