Thyroxine withdrawal prior to radioiodine therapy in papillary thyroid carcinoma – current scenarios

Purpose of review This review aims to compare the different methods of achieving adequate thyroid-stimulating hormone (TSH) stimulation prior to radioiodine (RAI) therapy in patients with differentiated thyroid carcinoma (DTC). It focuses on thyroid hormone withdrawal strategies and recombinant human TSH, examining their relative efficacy, safety, and impact on patient quality of life. Additionally, the review highlights recent guideline updates, and how these approaches influence postoperative risk stratification, treatment decision-making, and follow-up. Recent findings Emerging evidence is challenging traditional assumptions regarding optimal TSH stimulation thresholds and the necessity of prolonged thyroid hormone withdrawal, reflecting a broader shift toward individualized, risk-adapted management strategies in DTC. THW (Thyroid hormone withdrawal) delivers higher lesion doses; rhTSH (Recombinant human TSH) reduces whole-body radiation, with similar outcomes in low/intermediate-risk patients. Both achieve comparable ablation success, but rhTSH is safer and better tolerated. Both are suitable for dynamic risk stratification while rhTSH allows continued TSH suppression, aiding follow-up. Summary Both THW and rhTSH are effective, but modern practice is shifting toward individualized, patient-centered use of rhTSH. However, THW still remains relevant in high disease burden and resource-limited settings. Future research is focused on optimizing thresholds, clarifying its role in molecular profiling, re-differentiation, and dosimetry-guided therapies.