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Ah H, Ld P, Pn T, Depesina D, Chaudhury N, Oe O, M S, Cm D. Liothyronine (LT3) prescribing in England: Are cost constraints inhibiting guideline implementation? Clin Endocrinol (Oxf) 2024; 101:62-68. [PMID: 38752469 DOI: 10.1111/cen.15061] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/08/2023] [Revised: 04/01/2024] [Accepted: 04/08/2024] [Indexed: 06/12/2024]
Abstract
BACKGROUND Primary hypothyroidism affects about 3% of the general population in Europe. In most cases people with hypothyroidism are treated with levothyroxine. In the context of the 2023 British Thyroid Association guidance and the 2020 Competitions and Marketing Authority (CMA) ruling, we examined prescribing data for levothyroxine, Natural desiccated thyroid (NDT) and liothyronine by dose, regarding changes over the years 2016-2022. DESIGN Monthly primary care prescribing data for each British National Formulary code were analysed for levothyroxine, liothyronine and NDT. PATIENTS AND MEASUREMENTS The rolling 12-month total/average of cost or prescribing volume was used to identify the moment of change. Results included number of prescriptions, the actual costs, and the cost/prescription/mcg of drug. RESULTS Liothyronine: In 2016 94% of the total 74,500 prescriptions were of the 20 mcg dose. In 2020 the percentage prescribed in the 5 mcg and 10 mcg doses started to increase so that by 2022 each reached nearly 27% of total liothyronine prescribing. The average cost/prescription in 2016 of 20 mcg was £404/prescription and this fell by 80% to £101 in 2022; while the 10 mcg cost of £348/prescription fell by only 35% to £255 and the 5 mcg cost of £355/prescription fell by 38% to £242/prescription. The total prescriptions of liothyronine in 2016 were 74,605, falling by 30% up to 2019 when they started to grow again - most recently at 60,990-15% lower than the 2016 figure, with the result that total costs fell by 70% to £9 m/year. CONCLUSIONS Liothyronine costs fell after the CMA ruling but remain orders of magnitude higher than for levothyroxine. The remaining 0.2% of patients with liothyronine treated hypothyroidism are still absorbing 16% of medication costs. The lower liothyronine 5cmg and 10 mcg doses as recommended by BTA are 240% the costs of the 20 mcg dose. Thus, following latest BTA guidance which recommends the lower liothyronine doses still incurs substantial additional costs vs the prescribing liothyronine in the no longer recommended treatment regime. High drug price continues to impact clinical decisions, potentially limiting liothyronine therapy availability to a considerable number of patients who could benefit from this treatment.
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Affiliation(s)
- Heald Ah
- The School of Medicine and Manchester Academic Health Sciences Centre, University of Manchester, Manchester, UK
- Dcepartment of Endocrinology and Diabetes, Salford Royal Hospital, Salford, UK
| | - Premawardhana Ld
- Thyroid Research Group, Systems Immunity Research Institute, Cardiff University School of Medicine, Cardiff, UK
| | - Taylor Pn
- Thyroid Research Group, Systems Immunity Research Institute, Cardiff University School of Medicine, Cardiff, UK
| | | | - Nadia Chaudhury
- Department of Endocrinology and Diabetes, University Hospitals Coventry and Warwickshire, Coventry, UK
| | - Okosieme Oe
- Thyroid Research Group, Systems Immunity Research Institute, Cardiff University School of Medicine, Cardiff, UK
| | | | - Dayan Cm
- Thyroid Research Group, Systems Immunity Research Institute, Cardiff University School of Medicine, Cardiff, UK
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Lafontaine N, Brown SJ, Perros P, Papini E, Nagy EV, Attanasio R, Hegedüs L, Walsh JP. Use of thyroid hormones in hypothyroid and euthyroid patients: A survey of members of the Endocrine Society of Australia. Clin Endocrinol (Oxf) 2024; 100:477-485. [PMID: 38462996 DOI: 10.1111/cen.15049] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/26/2023] [Revised: 02/23/2024] [Accepted: 02/27/2024] [Indexed: 03/12/2024]
Abstract
OBJECTIVE Hypothyroidism is a common endocrine condition usually managed with levothyroxine (LT4). However, controversy remains around the use of liothyronine (LT3). We aimed to investigate the practices of Australian endocrinologists when managing patients with hypothyroidism, their use of LT3 + LT4 combination therapy and use of thyroid hormones in euthyroid patients. DESIGN AND PARTICIPANTS Members of the Endocrine Society of Australia (ESA) were invited to participate in an online questionnaire. MEASUREMENTS We analysed questionnaires that had complete demographic data. RESULTS Eighty-seven questionnaires fulfilled the criteria. LT4 was used as first line treatment for hypothyroidism by all respondents. Only 45% reported that their patients were dispensed the brand of LT4 that they recommend. LT3 (alone or in combination) was prescribed by 44% in their clinical practice. Although 49% of respondents would consider LT3 + LT4 in patients with normal TSH who had ongoing symptoms of hypothyroidism, the inability of LT4 to restore normal physiology was ranked the least likely explanation for persistent symptoms and only 32% would consider it for themselves if they were diagnosed with hypothyroidism. The majority (55%), in accordance with evidence, would not prescribe thyroid hormone to euthyroid individuals but 39% would consider use in euthyroid female infertility with high levels of thyroid antibodies and 11% in euthyroid patients with a simple goitre growing over time. LT4 use in pregnancy was variable among members. CONCLUSIONS Australian endocrinologists mostly follow international guidelines when prescribing thyroid hormone therapy and many prescribe combination LT3 and LT4 therapy, particularly for patients who remain symptomatic on LT4 monotherapy. Prescribing practices are largely similar to other countries who have completed similar questionnaires.
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Affiliation(s)
- Nicole Lafontaine
- Medical School, University of Western Australia, Perth, Australia
- Department of Endocrinology & Diabetes, Sir Charles Gairdner Hospital, Perth, Australia
| | - Suzanne J Brown
- Department of Endocrinology & Diabetes, Sir Charles Gairdner Hospital, Perth, Australia
| | - Petros Perros
- Institute of Translational and Clinical Research, Newcastle University, Newcastle upon Tyne, UK
| | - Enrico Papini
- Department of Endocrinology and Metabolism, Ospedale Regina Apostolorum, Rome, Italy
| | - Endre V Nagy
- Division of Endocrinology, Department of Medicine, Faculty of Medicine, University of Debrecen, Debrecen, Hungary
| | - Roberto Attanasio
- Italian Association of Clinical Endocrinologists Scientific Committee, Milan, Italy
| | - Laszlo Hegedüs
- Department of Endocrinology and Metabolism, Odense University Hospital, Odense, Denmark
| | - John P Walsh
- Medical School, University of Western Australia, Perth, Australia
- Department of Endocrinology & Diabetes, Sir Charles Gairdner Hospital, Perth, Australia
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Attanasio R, Žarković M, Papini E, Nagy EV, Negro R, Perros P, Akarsu E, Alevizaki M, Ayvaz G, Bednarczuk T, Beleslin BN, Berta E, Bodor M, Borissova AM, Boyanov M, Buffet C, Burlacu MC, Ćirić J, Díez JJ, Dobnig H, Fadeyev V, Field BCT, Fliers E, Führer-Sakel D, Galofré JC, Hakala T, Jiskra J, Kopp PA, Krebs M, Kršek M, Kužma M, Lantz M, Lazúrová I, Leenhardt L, Luchytskiy V, Marques Puga F, McGowan A, Metso S, Moran C, Morgunova T, Niculescu DA, Perić B, Planck T, Poiana C, Robenshtok E, Rosselet PO, Ruchala M, Ryom Riis K, Shepelkevich A, Tronko MD, Unuane D, Vardarli I, Visser WE, Vryonidou A, Younes YR, Hegedüs L. Patients' Persistent Symptoms, Clinician Demographics, and Geo-Economic Factors Are Associated with Choice of Therapy for Hypothyroidism by European Thyroid Specialists: The "THESIS" Collaboration. Thyroid 2024; 34:429-441. [PMID: 38368541 DOI: 10.1089/thy.2023.0580] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/19/2024]
Abstract
Background: Hypothyroidism is common, however, aspects of its treatment remain controversial. Our survey aimed at documenting treatment choices of European thyroid specialists and exploring how patients' persistent symptoms, clinician demographics, and geo-economic factors relate to treatment choices. Methods: Seventeen thousand two hundred forty-seven thyroid specialists from 28 countries were invited to participate in an online questionnaire survey. The survey included respondent demographic data and treatment choices for hypothyroid patients with persistent symptoms. Geo-economic data for each country were included in the analyses. Results: The response rate was 32.9% (6058 respondents out of 17,247 invitees). Levothyroxine (LT4) was the initial treatment preferred by the majority (98.3%). Persistent symptoms despite normal serum thyrotropin (TSH) while receiving LT4 treatment were reported to affect up to 10.0% of patients by 75.4% of respondents, while 28.4% reported an increasing such trend in the past 5 years. The principal explanations offered for patients' persistent symptoms were psychosocial factors (77.1%), comorbidities (69.2%), and unrealistic patient expectations (61.0%). Combination treatment with LT4+liothyronine (LT3) was chosen by 40.0% of respondents for patients who complained of persistent symptoms despite a normal TSH. This option was selected more frequently by female thyroid specialists, with high-volume practice, working in countries with high gross national income per capita. Conclusions: The perception of patients' dissatisfaction reported by physicians seems lower than that described by hypothyroid patients in previous surveys. LT4+LT3 treatment is used frequently by thyroid specialists in Europe for persistent hypothyroid-like symptoms even if they generally attribute such symptoms to nonendocrine causes and despite the evidence of nonsuperiority of the combined over the LT4 therapy. Pressure by dissatisfied patients on their physicians for LT3-containing treatments is a likely explanation. The association of the therapeutic choices with the clinician demographic characteristics and geo-economic factors in Europe is a novel information and requires further investigation.
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Affiliation(s)
- Roberto Attanasio
- Scientific Committee Associazione Medici Endocrinologi, Milan, Italy
| | - Miloš Žarković
- Clinic of Endocrinology, Diabetes and Diseases of Metabolism, Thyroid Department, Faculty of Medicine, University of Belgrade, Belgrade, Serbia
| | - Enrico Papini
- Department of Endocrinology and Metabolism, Regina Apostolorum Hospital, Rome, Italy
| | - Endre Vezekenyi Nagy
- Division of Endocrinology, Department of Medicine, Faculty of Medicine, University of Debrecen, Debrecen, Hungary
| | - Roberto Negro
- Division of Endocrinology, Ospedale Fazzi, Lecce, Italy
| | - Petros Perros
- Institute of Translational and Clinical Research, Newcastle University, Newcastle upon Tyne, United Kingdom
| | - Ersin Akarsu
- Division of Endocrinology, Department of Internal Medicine, Faculty of Medicine, Gaziantep University, Gaziantep, Turkey
| | - Maria Alevizaki
- Endocrine Unit and Diabetes Centre, Department of Clinical Therapeutics, Alexandra Hospital, School of Medicine, National and Kapodistrian University of Athens, Athens, Greece
| | - Göksun Ayvaz
- Department of Endocrinology and Metabolism, Koru Ankara Hospital, Çankaya, Turkey
| | - Tomasz Bednarczuk
- Department of Internal Medicine and Endocrinology, Medical University of Warsaw, Warsaw, Poland
| | - Biljana Nedeljković Beleslin
- Clinic of Endocrinology, Diabetes and Diseases of Metabolism, Thyroid Department, Faculty of Medicine, University of Belgrade, Belgrade, Serbia
| | - Eszter Berta
- Division of Endocrinology, Department of Medicine, Faculty of Medicine, University of Debrecen, Debrecen, Hungary
| | - Miklos Bodor
- Division of Endocrinology, Department of Medicine, Faculty of Medicine, University of Debrecen, Debrecen, Hungary
| | - Anna Maria Borissova
- Clinic of Endocrinology and Metabolism, University Hospital "Sofiamed," Medical Faculty, Sofia University "Saint Kliment Ohridski," Sofia, Bulgaria
| | - Mihail Boyanov
- Clinic of Endocrinology and Metabolism, University Hospital "Alexandrovska," Sofia, Bulgaria
- Department of Internal Medicine, Medical University Sofia, Sofia, Bulgaria
| | - Camille Buffet
- GRC n 16, GRC Thyroid Tumors, Thyroid Disease and Endocrine Tumor Department, APHP, Hôpital Pitié-Salpêtriére, Sorbonne Universitè, Paris, France
| | - Maria-Cristina Burlacu
- Department of Endocrinology Diabetology and Nutrition, Cliniques Universitaires St-Luc, Université Catholique de Louvain, Brussels, Belgium
| | - Jasmina Ćirić
- Clinic of Endocrinology, Diabetes and Diseases of Metabolism, Thyroid Department, Faculty of Medicine, University of Belgrade, Belgrade, Serbia
| | - Juan J Díez
- Department of Endocrinology, Hospital Universitario Puerta de Hierro Majadahonda, Madrid, Spain
- Instituto de Investigación Sanitaria Puerta de Hierro Segovia de Arana, Calle Manuel de Falla, Madrid, Spain
- Department of Medicine, Universidad Autónoma de Madrid, Madrid, Spain
| | - Harald Dobnig
- Thyroid and Osteoporosis Praxis, Kumberg, Austria
- Thyroid Practice for Radiofrequency Ablation, Vienna, Austria
| | - Valentin Fadeyev
- Department of Endocrinology No. 1, N.V. Sklifosovsky Institute of Clinical Medicine, I.M. Sechenov First Moscow State Medical University, Moscow, Russian Federation
| | - Benjamin C T Field
- Section of Clinical Medicine, Faculty of Health & Medical Sciences, University of Surrey, Guildford, United Kingdom
| | - Eric Fliers
- Department of Endocrinology & Metabolism, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
| | - Dagmar Führer-Sakel
- Department of Endocrinology, Diabetes and Metabolism, University Hospital Essen, University of Duisburg-Essen, Essen, Germany
| | - Juan Carlos Galofré
- Department of Endocrinology, Clínica Universidad de Navarra, Pamplona, Spain
- Instituto de Investigación Sanitaria de Navarra, Pamplona, Spain
| | - Tommi Hakala
- Department of Surgery, Tampere University Hospital, Tampere, Finland
| | - Jan Jiskra
- 3rd Department of Medicine, 1st Faculty of Medicine, Charles University, General University Hospital, Prague, Czech Republic
| | - Peter A Kopp
- Division of Endocrinology, Diabetes and Metabolism, University of Lausanne, Lausanne, Switzerland
| | - Michael Krebs
- Division of Endocrinology and Metabolism, Internal Medicine III, Medical University of Vienna, Vienna, Austria
| | - Michal Kršek
- 3rd Department of Medicine, 1st Faculty of Medicine, Charles University, General University Hospital, Prague, Czech Republic
| | - Martin Kužma
- 5th Department of Internal Medicine, Medical Faculty of Comenius University and University Hospital, Bratislava, Slovakia
| | - Mikael Lantz
- Department of Endocrinology, Skåne University Hospital, Malmö, Sweden
| | - Ivica Lazúrová
- 1st Department of Internal Medicine of the Medical Faculty, P.J. Šafárik University Košice, Košice, Slovakia
| | - Laurence Leenhardt
- GRC n 16, GRC Thyroid Tumors, Thyroid Disease and Endocrine Tumor Department, APHP, Hôpital Pitié-Salpêtriére, Sorbonne Universitè, Paris, France
| | - Vitaliy Luchytskiy
- Department of Reproductive Endocrinology, Institute of Endocrinology and Metabolism named after V.P. Komissarenko, National Academy of Medical Science of Ukraine, Kyiv, Ukraine
| | - Francisca Marques Puga
- Endocrinology, Diabetes and Metabolism Service, Centro Hospitalar Universitário de Santo António, Porto, Portugal
| | - Anne McGowan
- Robert Graves Institute, Tallaght University Hospital, Dublin, Ireland
| | - Saara Metso
- Department of Endocrinology, Tampere University Hospital, Tampere, Finland
| | - Carla Moran
- Diabetes & Endocrinology Section, Beacon Hospital, Dublin, Ireland
- School of Medicine, University College Dublin, Dublin, Ireland
| | - Tatyana Morgunova
- Department of Endocrinology No. 1, N.V. Sklifosovsky Institute of Clinical Medicine, I.M. Sechenov First Moscow State Medical University, Moscow, Russian Federation
| | - Dan Alexandru Niculescu
- Department of Endocrinology, Carol Davila University of Medicine and Pharmacy, Bucharest, Romania
| | - Božidar Perić
- Department of Endocrinology, Diabetes and Metabolic Diseases "Mladen Sekso," University Hospital Center "Sisters of Mercy," Zagreb, Croatia
| | - Tereza Planck
- Department of Endocrinology, Skåne University Hospital, Malmö, Sweden
| | - Catalina Poiana
- Department of Endocrinology, Carol Davila University of Medicine and Pharmacy, Bucharest, Romania
| | - Eyal Robenshtok
- Thyroid Cancer Service, Endocrinology and Metabolism Institute, Beilinson Hospital and Davidoff Cancer Center, Rabin Medical Center, Sackler Faculty of Medicine, Tel Aviv University, Petah Tikva, Israel
| | | | - Marek Ruchala
- Department of Endocrinology, Metabolism and Internal Medicine, Poznan University of Medical Sciences, Poznań, Poland
| | - Kamilla Ryom Riis
- Department of Endocrinology, Odense University Hospital, Odense C, Denmark
| | - Alla Shepelkevich
- Department of Endocrinology, Belarusian State Medical University, Minsk, Republic of Belarus
| | - Mykola D Tronko
- V.P. Komisarenko Institute of Endocrinology and Metabolism of Academy of Medical Sciences of Ukraine, Kyiv, Ukraine
| | - David Unuane
- Department of Internal Medicine, Endocrine Unit, UZ Brussel, Vrije Universiteit Brussel, Brussels, Belgium
| | - Irfan Vardarli
- Department of Medicine I, Klinikum Vest GmbH, Knappschaftskrankenhaus Recklinghausen, Academic Teaching Hospital, Ruhr-University Bochum, Recklinghausen, Germany
- Division of Endocrinology and Diabetes, 5th Medical Department, Medical Faculty Mannheim, Heidelberg University, Mannheim, Germany
| | - W Edward Visser
- Rotterdam Thyroid Center, Department of Internal Medicine, Erasmus Medical Center, Rotterdam, The Netherlands
| | - Andromachi Vryonidou
- Department of Endocrinology and Diabetes Centre, Hellenic Red Cross Hospital, Athens, Greece
| | | | - Laszlo Hegedüs
- Department of Endocrinology, Odense University Hospital, Odense C, Denmark
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Hidalgo J, Vallejo BA, Soto Jacome C, Ayala IN, Cordova S, Duran M, Golembiewski E, Toro-Tobon D, Brito JP. Real Practice Assessment of Persistent Symptoms After Initiation of Levothyroxine. Endocr Pract 2024; 30:95-100. [PMID: 37913925 DOI: 10.1016/j.eprac.2023.10.132] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/24/2023] [Revised: 10/19/2023] [Accepted: 10/27/2023] [Indexed: 11/03/2023]
Abstract
OBJECTIVE Levothyroxine (LT4) is the standard treatment for hypothyroidism. However, certain patients experience persistent symptoms even after achieving euthyroid status with LT4 therapy. We aimed to determine the frequency of persistent or new symptoms in patients with hypothyroidism after initiating LT4. METHODS This retrospective study included patients with hypothyroidism who started on LT4 between January 2017 and December 2019 at Mayo Clinic in Rochester, Minnesota, USA. Five hundred patient charts were randomly selected for review. Patients with at least 1 documented follow-up encounter after LT4 initiation were evaluated for ≤3 follow-up visits regarding their biochemical status and symptoms. RESULTS We included 356 patients, a majority of whom were female (66.6%), white (92.3%), and obese (71.9%), with an average age of 59.5 years. At the baseline visit, approximately one-half of the patients (177/356, 47.7%) reported hypothyroid symptoms, with fatigue being the most common symptom. During the follow-up periods, we observed that 17.8% (28/157), 17.9% (19/106), and 19.3% (11/57) of patients had normal thyroid stimulating hormone (TSH) values but persistent symptoms, while 12.3% (19/156), 19.9% (16/107), and 8.9% (5/56) had normal TSH values but new symptoms. Overall, during each respective follow-up period, 26.7% (42/157), 27.3% (29/106), and 28% (16/57) of patients experienced persistent or new symptoms alongside normal TSH values, with fatigue being the most constant symptom. CONCLUSION Our findings indicate that approximately 1 in every 4 patients with hypothyroidism receiving LT4 therapy and achieving normal TSH levels experience persistent or new hypothyroid symptoms. The cause of these symptoms remains unclear, emphasizing the need for a better understanding of their underlying causes and the development of effective management strategies.
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Affiliation(s)
- Jessica Hidalgo
- Knowledge and Evaluation Research Unit in Endocrinology, Mayo Clinic, Rochester, Minnesota
| | | | - Cristian Soto Jacome
- Knowledge and Evaluation Research Unit in Endocrinology, Mayo Clinic, Rochester, Minnesota
| | - Ivan N Ayala
- Knowledge and Evaluation Research Unit in Endocrinology, Mayo Clinic, Rochester, Minnesota
| | - Sandra Cordova
- Department of Cardiology, Mayo Clinic, Rochester, Minnesota
| | - Mayra Duran
- Knowledge and Evaluation Research Unit in Endocrinology, Mayo Clinic, Rochester, Minnesota
| | - Elizabeth Golembiewski
- Knowledge and Evaluation Research Unit in Endocrinology, Mayo Clinic, Rochester, Minnesota
| | - David Toro-Tobon
- Division of Endocrinology, Diabetes, Metabolism, and Nutrition, Department of Medicine, Mayo Clinic, Rochester, Minnesota
| | - Juan P Brito
- Knowledge and Evaluation Research Unit in Endocrinology, Mayo Clinic, Rochester, Minnesota; Division of Endocrinology, Diabetes, Metabolism, and Nutrition, Department of Medicine, Mayo Clinic, Rochester, Minnesota.
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Ettleson MD, Ibarra S, Wan W, Peterson S, Laiteerapong N, Bianco AC. Demographic, Healthcare Access, and Dietary Factors Associated With Thyroid Hormone Treatments for Hypothyroidism. J Clin Endocrinol Metab 2023; 108:e1614-e1623. [PMID: 37327351 PMCID: PMC10655529 DOI: 10.1210/clinem/dgad331] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/28/2023] [Revised: 05/27/2023] [Accepted: 06/01/2023] [Indexed: 06/18/2023]
Abstract
CONTEXT Clinical guidelines have recommended a trial of liothyronine (LT3) with levothyroxine (LT4) in select patients with hypothyroidism. However, little is known about the real-world use of LT3 and desiccated thyroid extract (DTE) and the characteristics of patients treated with LT3 and DTE. OBJECTIVES (1) Determine national trends of new LT4, LT3, and DTE prescriptions in the United States; (2) determine whether sociodemographic, healthcare access, and dietary factors are associated with different thyroid hormone (TH) therapies. METHODS Parallel cross-sectional studies were conducted using 2 datasets: (1) a national patient claims dataset (2010-2020) and (2) the National Health and Nutrition Examination Study (NHANES) dataset (1999-2016). Included participants had a diagnosis of primary or subclinical hypothyroidism. Study outcomes included the impact of demographics and healthcare access on differences in the proportion of TH therapies consisting of LT4, LT3, and DTE (patient claims) and differences in dietary behaviors between DTE-treated participants and LT4-treated matched controls (NHANES). RESULTS On an average annual basis, 47 711 adults received at least 1 new TH prescription, with 88.3% receiving LT4 monotherapy, 2.0% receiving LT3 therapy, and 9.4% receiving DTE therapy. The proportion receiving DTE therapy increased from 5.4% in 2010 to 10.2% in 2020. In the analysis between states, high primary care and endocrinology physician densities were associated with increased use of LT4 monotherapy (odds ratio 2.51, P < .001 and odds ratio 2.71, P < .001). DTE-treated NHANES participants (n = 73) consumed more dietary supplements compared to LT4-treated participants (n = 146) (4.7 vs 2.1, P < .001). CONCLUSIONS The proportion of new TH therapies containing DTE for hypothyroidism doubled since 2010 while LT3 therapies remained stable. DTE treatment was associated with decreased physician density and increased dietary supplement use.
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Affiliation(s)
- Matthew D Ettleson
- Department of Medicine, Section of Endocrinology, Diabetes, and Metabolism, University of Chicago, Chicago, IL 60637, USA
| | - Sabrina Ibarra
- Department of Medicine, Section of Endocrinology, Diabetes, and Metabolism, University of Chicago, Chicago, IL 60637, USA
| | - Wen Wan
- Department of Medicine, Section of General Internal Medicine, University of Chicago, Chicago, IL 60637, USA
| | - Sarah Peterson
- Department of Clinical Nutrition, Rush University Medical Center, Chicago, IL 60612, USA
| | - Neda Laiteerapong
- Department of Medicine, Section of General Internal Medicine, University of Chicago, Chicago, IL 60637, USA
| | - Antonio C Bianco
- Department of Medicine, Section of Endocrinology, Diabetes, and Metabolism, University of Chicago, Chicago, IL 60637, USA
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Premawardhana LD, Taylor PN, Okosieme OE, Adlan MA, Obuobie EK, Dayan CM. Designing a combined liothyronine (LT3), L- thyroxine (LT4) trial in symptomatic hypothyroid subjects on LT4 - the importance of patient selection, choice of LT3 and trial design. Front Endocrinol (Lausanne) 2023; 14:1282608. [PMID: 38034018 PMCID: PMC10687631 DOI: 10.3389/fendo.2023.1282608] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/24/2023] [Accepted: 10/23/2023] [Indexed: 12/02/2023] Open
Abstract
Approximately 10%-15% of subjects with hypothyroidism on L-thyroxine (LT4) alone have persistent symptoms affecting their quality of life (QoL). Although the cause is unclear, there is evidence that "tissue T3 lack" may be responsible. If so, combining liothyronine (LT3) with LT4 would be helpful. However, randomized controlled trials (RCT), have not established greater efficacy for the LT3 + LT4 combination in these subjects than for LT4 alone. While the trial design may have been responsible, the use of unphysiological, short-acting LT3 preparations and non-thyroid-specific patient-reported outcome measures (PROMs) may have contributed. We recommend attention to the following aspects of trial design for future RCTs of LT3 + LT4 compared to LT4 alone: (a) Subject selection-(i) measurable symptoms (disadvantages should be recognized); (ii) using a validated thyroid specific PROM such as ThyPRO39 or the Composite scale derived from it; (iii) those taking over 1.2 μg/day or 100 μg/day (for pragmatic reasons) of LT4 defining a population likely without intrinsic thyroid activity who depend on exogenous LT4; (iv) recruiting a preponderance of subjects with autoimmune thyroiditis increasing generalisability; and (v) those with a high symptom load with a greater response to combination therapy e.g. those with the deiodinase 2 polymorphism. (b) The use of physiological LT3 preparations producing pharmacokinetic similarities to T3 profiles in unaffected subjects: two long-acting LT3 preparations are currently available and must be tested in phase 2b/3 RCTs. (c) The superiority of a crossover design in limiting numbers and costs while maintaining statistical power and ensuring that all subjects experienced the investigative medication.
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Affiliation(s)
- Lakdasa D. Premawardhana
- Thyroid Research Group, Division of Infection and Immunity, Cardiff University School of Medicine, Heath Park, Cardiff, United Kingdom
| | - Peter Nicholas Taylor
- Thyroid Research Group, Division of Infection and Immunity, Cardiff University School of Medicine, Heath Park, Cardiff, United Kingdom
| | - Onyebuchi E. Okosieme
- Thyroid Research Group, Division of Infection and Immunity, Cardiff University School of Medicine, Heath Park, Cardiff, United Kingdom
| | - Mohamed A. Adlan
- Section of Endocrinology, Ysbyty Ystrad Fawr and Royal Gwent Hospitals, Aneurin Bevan University Health Board, Newport, United Kingdom
| | - Emmanuel K. Obuobie
- Section of Endocrinology, Ysbyty Ystrad Fawr and Royal Gwent Hospitals, Aneurin Bevan University Health Board, Newport, United Kingdom
| | - Colin Mark Dayan
- Thyroid Research Group, Division of Infection and Immunity, Cardiff University School of Medicine, Heath Park, Cardiff, United Kingdom
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Žarković M, Attanasio R, Nagy EV, Negro R, Papini E, Perros P, Cohen CA, Akarsu E, Alevizaki M, Ayvaz G, Bednarczuk T, Berta E, Bodor M, Borissova AM, Boyanov M, Buffet C, Burlacu MC, Ćirić J, Díez JJ, Dobnig H, Fadeyev V, Field BCT, Fliers E, Frølich JS, Führer D, Galofré JC, Hakala T, Jiskra J, Kopp P, Krebs M, Kršek M, Kužma M, Lantz M, Lazúrová I, Leenhardt L, Luchytskiy V, McGowan A, Melo M, Metso S, Moran C, Morgunova T, Mykola T, Beleslin BN, Niculescu DA, Perić B, Planck T, Poiana C, Puga FM, Robenshtok E, Rosselet P, Ruchala M, Riis KR, Shepelkevich A, Unuane D, Vardarli I, Visser WE, Vrionidou A, Younes YR, Yurenya E, Hegedüs L. Characteristics of specialists treating hypothyroid patients: the "THESIS" collaborative. Front Endocrinol (Lausanne) 2023; 14:1225202. [PMID: 38027187 PMCID: PMC10660282 DOI: 10.3389/fendo.2023.1225202] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/19/2023] [Accepted: 10/16/2023] [Indexed: 12/01/2023] Open
Abstract
Introduction Thyroid specialists influence how hypothyroid patients are treated, including patients managed in primary care. Given that physician characteristics influence patient care, this study aimed to explore thyroid specialist profiles and associations with geo-economic factors. Methods Thyroid specialists from 28 countries were invited to respond to a questionnaire, Treatment of Hypothyroidism in Europe by Specialists: an International Survey (THESIS). Geographic regions were defined according to the United Nations Statistics Division. The national economic status was estimated using World Bank data on the gross national income per capita (GNI per capita). Results 5,695 valid responses were received (response rate 33·0%). The mean age was 49 years, and 65·0% were female. The proportion of female respondents was lowest in Northern (45·6%) and highest in Eastern Europe (77·2%) (p <0·001). Respondent work volume, university affiliation and private practice differed significantly between countries (p<0·001). Age and GNI per capita were correlated inversely with the proportion of female respondents (p<0·01). GNI per capita was inversely related to the proportion of respondents working exclusively in private practice (p<0·011) and the proportion of respondents who treated >100 patients annually (p<0·01). Discussion THESIS has demonstrated differences in characteristics of thyroid specialists at national and regional levels, strongly associated with GNI per capita. Hypothyroid patients in middle-income countries are more likely to encounter female thyroid specialists working in private practice, with a high workload, compared to high-income countries. Whether these differences influence the quality of care and patient satisfaction is unknown, but merits further study.
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Affiliation(s)
- Miloš Žarković
- University of Belgrade Faculty of Medicine, Internal Medicine, Belgrade, Serbia
- Clinic of Endocrinology, Diabetes and Diseases of Metabolism, Thyroid Department, Belgrade, Serbia
| | - Roberto Attanasio
- Associazione Medici Endocrinologi, Scientific Committee, Milan, Italy
| | - Endre V. Nagy
- Division of Endocrinology, Department of Medicine, Faculty of Medicine, University of Debrecen, Debrecen, Hungary
| | - Roberto Negro
- Ospedale Vito Fazzi, Department of Endocrinology, Lecce, Italy
| | - Enrico Papini
- Department of Endocrinology and Metabolism, Regina Apostolorum Hospital, Albano Laziale, Roma, Italy
| | - Petros Perros
- Institute of Translational and Clinical Research, Newcastle University, Newcastle Upon Tyne, United Kingdom
| | | | - Ersin Akarsu
- Department of Internal Medicine, Division of Endocrinology, Faculty of Medicine, Gaziantep University, Gaziantep, Türkiye
| | - Maria Alevizaki
- Endocrine Unit and Diabetes Centre, Department of Clinical Therapeutics, Alexandra Hospital, National and Kapodistrian University of Athens Faculty of Medicine, Athens, Greece
| | - Göksun Ayvaz
- Department of Endocrinology and Metabolism, Koru Ankara Hospital, Ankara, Türkiye
| | - Tomasz Bednarczuk
- Department of Internal Medicine and Endocrinology, Medical University of Warsaw, Warsaw, Poland
| | - Eszter Berta
- Division of Endocrinology, Department of Medicine, Faculty of Medicine, University of Debrecen, Debrecen, Hungary
| | - Miklos Bodor
- Division of Endocrinology, Department of Medicine, Faculty of Medicine, University of Debrecen, Debrecen, Hungary
| | - Anna Maria Borissova
- Sofia University Saint Kliment Ohridski, Medical Faculty, Clinic of Endocrinology and Metabolism, University Hospital “Sofiamed”, Sofia, Bulgaria
| | - Mihail Boyanov
- University Hospital Alexandrovska, Clinic of Endocrinology and Metabolism, Medical University-Sofia, Internal Medicine, Sofia, Bulgaria
| | - Camille Buffet
- GRC n 16, GRC Thyroid Tumors, Thyroid Disease and Endocrine Tumor Department, AP-HP, Hôpital Pitié Salpêtrière, Sorbonne University, Paris, France
| | - Maria-Cristina Burlacu
- Department of Endocrinology and Nutrition, Cliniques Universitaires St-Luc, Université Catholique De Louvain, Brussels, Belgium
| | - Jasmina Ćirić
- University of Belgrade Faculty of Medicine, Internal Medicine, Belgrade, Serbia
- Clinic of Endocrinology, Diabetes and Diseases of Metabolism, Thyroid Department, Belgrade, Serbia
| | - Juan J. Díez
- Department of Endocrinology, Hospital Universitario Puerta De Hierro Majadahonda, Madrid, Spain
- Instituto De Investigación Sanitaria Puerta De Hierro Segovia De Arana, Majadahonda, Madrid, Spain
- Department of Medicine, Universidad Autónoma De Madrid, Madrid, Spain
| | - Harald Dobnig
- Thyroid Endocrinology, Osteoporosis Institute Dobnig, Graz, Austria
| | - Valentin Fadeyev
- Department of Endocrinology No. 1, N.V. Sklifosovsky Institute of Clinical Medicine, I.M. Sechenov First Moscow State Medical University, Moscow, Russia
| | - Benjamin C. T. Field
- University of Surrey Faculty of Health and Medical Sciences, Section of Clinical Medicine, Prague, United Kingdom
| | - Eric Fliers
- Department of Endocrinology & Metabolism, Amsterdam UMC, University of Amsterdam, Amsterdam, Netherlands
| | | | - Dagmar Führer
- University Hospital Essen, Department of Endocrinology, Diabetes and Metabolism, University-Duisburg-Essen, Essen, Germany
| | - Juan Carlos Galofré
- Departmento De Endocrinologia e Nutrición, Clínica Universidad De Navarra, Pamplona, Spain
| | - Tommi Hakala
- Department of Surgery, Tampere University Hospital, Tampere, Finland
| | - Jan Jiskra
- 3rd Department of Medicine, 1st Faculty of Medicine, Charles University, General University Hospital, Prague, Czechia
| | - Peter Kopp
- Division of Endocrinology, Diabetology and Metabolism, University of Lausanne, Lausanne, Switzerland
| | - Michael Krebs
- Department of Medicine III, Division of Endocrinology, Medical University of Vienna, Vienna, Austria
| | - Michal Kršek
- 3rd Department of Medicine, 1st Faculty of Medicine, Charles University, General University Hospital, Prague, Czechia
| | - Martin Kužma
- 5th Department of Internal Medicine, Medical Faculty of Commenius University and University Hospital, Bratislava, Slovakia
| | - Mikael Lantz
- Department of Endocrinology, Skåne University Hospital, Malmö, Sweden
| | - Ivica Lazúrová
- P. J. Šafárik University Košice, 1st Department of Internal Medicine of the Medical Faculty, Košice, Slovakia
| | - Laurence Leenhardt
- Hopital Pitie-Salpetriere, Thyroid and Endocrine Tumors Unit, Institut of Endocrinology, Sorbonne University, Paris, France
| | - Vitaliy Luchytskiy
- Department of Reproductive Endocrinogy, Institute of Endocrinology and Metabolism named after V.P. Komissarenko, National Academy of Medical Science of Ukraine, Kyiv, Ukraine
| | - Anne McGowan
- Robert Graves Institute, Tallaght University Hospital, Dublin, Ireland
| | - Miguel Melo
- Department of Endocrinology, Diabetes and Metabolism, Medical Faculty, University of Coimbra, Coimbra, Portugal
| | - Saara Metso
- Department of Internal Medicine, Tampere University Hospital, Tampere, Finland
| | - Carla Moran
- Diabetes & Endocrinology Section, Beacon Hospital, Dublin, Ireland
- School of Medicine, University College Dublin, Dublin, Ireland
| | - Tatyana Morgunova
- Department of Endocrinology No. 1, N.V. Sklifosovsky Institute of Clinical Medicine, I.M. Sechenov First Moscow State Medical University, Moscow, Russia
| | - Tronko Mykola
- Institute of Endocrinology and Metabolism named after V.P. Komissarenko, National Academy of Medical Science of Ukraine, Kyiv, Ukraine
| | - Biljana Nedeljković Beleslin
- University of Belgrade Faculty of Medicine, Internal Medicine, Belgrade, Serbia
- Clinic of Endocrinology, Diabetes and Diseases of Metabolism, Thyroid Department, Belgrade, Serbia
| | - Dan Alexandru Niculescu
- Department of Endocrinology, Carol Davila University of Medicine and Pharmacy, Bucharest, Romania
| | - Božidar Perić
- Department of Endocrinology, Diabetes and Metabolic Diseases “Mladen Sekso”, University Hospital Center “Sisters of Mercy”, Zagreb, Croatia
| | - Tereza Planck
- Department of Endocrinology, Skåne University Hospital, Malmö, Sweden
| | - Catalina Poiana
- Department of Endocrinology, Carol Davila University of Medicine and Pharmacy, Bucharest, Romania
| | - Francisca Marques Puga
- Endocrinology, Diabetes and Metabolism Service, Porto Hospital and University Centre, Porto, Portugal
| | - Eyal Robenshtok
- Endocrinology Institute, Rabin Medical Center, Tel Aviv University Sackler Faculty of Medicine, Tel Aviv, Israel
| | | | - Marek Ruchala
- Department of Endocrinology, Metabolism and Internal Medicine, Poznan University of Medical Sciences, Poznan, Poland
| | - Kamilla Ryom Riis
- Department of Endocrinology, Odense University Hospital, Odense, Denmark
| | - Alla Shepelkevich
- Department of Endocrinology, Belarusian State Medical University, Minsk, Belarus
| | - David Unuane
- Department of Internal Medicine, Endocrine Unit, UZ Brussel, Vrije Universiteit Brussel, Brussel, Belgium
| | - Irfan Vardarli
- Department of Medicine I, Klinikum Vest GmbH, Knappschaftskrankenhaus Recklinghausen, Recklinghausen, Germany
- 5th Medical Department, Division of Endocrinology and Diabetes, Medical Faculty Mannheim, Heidelberg University, Mannheim, Germany
| | - W. Edward Visser
- Rotterdam Thyroid Center, Department of Internal Medicine, Erasmus MC, Rotterdam, Netherlands
| | - Andromachi Vrionidou
- Department of Endocrinology and Diabetes Centre, Hellenic Red Cross Hospital, Athens, Greece
| | - Younes R. Younes
- East Surrey Hospital, Surrey & Sussex Healthcare NHS Trust, Redhill, Surrey, United Kingdom
| | | | - Laszlo Hegedüs
- Department of Endocrinology, Odense University Hospital, Odense, Denmark
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Cassemiro JF, Ilera V, Batalles S, Reyes A, Nagy EV, Papini E, Perros P, Hegedüs L, Ramos HE. Use of thyroid hormones in hypothyroid and euthyroid patients: a 2022 THESIS questionnaire survey of members of the Latin American Thyroid Society (LATS). Thyroid Res 2023; 16:40. [PMID: 37773072 PMCID: PMC10542243 DOI: 10.1186/s13044-023-00182-4] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/07/2023] [Accepted: 09/15/2023] [Indexed: 09/30/2023] Open
Abstract
PURPOSE Inconsistencies in the medical management of hypothyroidism have been reported between endocrinologists in different countries. This study aimed to identify the attitudes of Latin America thyroid specialists towards the use of thyroid hormones. METHODS Online survey of members of the Latin America Thyroid Society. RESULTS 81/446 (18.2%) completed the questionnaire. Levothyroxine (LT4) was the initial treatment of choice for all respondents. 56.8% would consider LT4 use in biochemically euthyroid patients: infertile women with elevated anti-thyroid antibodies (46.9%), resistant depression (17.3%) and growing goiter (12%). Most respondents preferred tablets (39.5%) over liquid formulations (21.0%) or soft gel capsules (22.2%) and would not consider switching formulations in patients with persistent symptoms. 39.5% would never use LT4 + liothyronine (LT3) combination therapy in symptomatic euthyroid patients, due to low quality evidence for benefit. 60.5% reported that persistence of symptoms despite normal TSH is rare (below 5% of patients) and its prevalence has been stable over the last five years. Psychosocial factors (84.0%), comorbidities (86.4%) and the patient unrealistic expectation (72.8%) were considered the top three explanations for this phenomenon. CONCLUSION LT4 tablets is the treatment of choice for hypothyroidism. A significant proportion of respondents would use LT4 in some groups of euthyroid individuals, contrasting the recommendations of the major clinical practice guideline indications. LT4 + LT3 combination treatment in euthyroid symptomatic patients was considered by nearly 50%. Practices based on weak or absent evidence included use of thyroid hormones for euthyroid subjects by 56.8% of respondents and use of LT4 + LT3 treatment by 60.5% of respondents for patients with persistent symptoms. In contrast to many European countries, LATS respondents report a low and unchanged proportion of dissatisfied patients over the last five years.
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Affiliation(s)
- Jessica F Cassemiro
- Department of Bioregulation, Health & Science Institute, Federal University of Bahia, Avenida Reitor Miguel Calmon, S/N. Vale do Canela. Room 325, Salvador, Bahia, Brazil
| | - Veronica Ilera
- Department of Endocrinology, Hospital Ramos Mejía, Caba, Argentina
| | | | - Adriana Reyes
- Department of Endocrinology, Hospital Ramos Mejía, Caba, Argentina
| | - Endre V Nagy
- Division of Endocrinology, Department of Medicine, Faculty of Medicine, University of Debrecen, Debrecen, Hungary
| | - Enrico Papini
- Department of Endocrinology and Metabolism, Regina Apostolorum Hospital, Rome, Italy
| | - Petros Perros
- Department of Endocrinology, Royal Victoria Infirmary, Newcastle upon Tyne, UK
| | - Laszlo Hegedüs
- Department of Endocrinology, Odense University Hospital, Odense, Denmark
| | - Helton Estrela Ramos
- Department of Bioregulation, Health & Science Institute, Federal University of Bahia, Avenida Reitor Miguel Calmon, S/N. Vale do Canela. Room 325, Salvador, Bahia, Brazil.
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Hennessey JV. Levothyroxine Monotherapy: What Works Better for the Individual With Hypothyroidism? Endocr Pract 2023; 29:572-580. [PMID: 37419564 DOI: 10.1016/j.eprac.2022.12.013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/05/2022] [Accepted: 12/16/2022] [Indexed: 07/09/2023]
Abstract
OBJECTIVE I explore objective data not supporting the addition of liothyronine (medication) (LT3) to levothyroxine (medication) (LT4) in patients with hypothyroidism. Accurate identification of patients with symptomatic (almost exclusively overt) hypothyroidism is important in evaluating clinical outcomes of therapies. Recent studies have documented that nearly a third of individuals who are offered thyroid hormone are euthyroid at the time of initiation. Additionally, others are clinically diagnosed without biochemical confirmation, so a sizable proportion of those started on LT4 are not hypothyroid. The assumption that nonhypothyroid symptoms will resolve with LT4 is problematic. The true underlying cause of these symptoms remains unidentified and untreated. METHODS In a narrative fashion I will review the positive predictive value of and correlation of symptoms consistent with hypothyroidism and confirmed hypothyroidism likely to favorably respond to thyroid hormone replacement. RESULTS Following a review of the reliability of thyroid-stimulating hormone (TSH) in predicting a euthyroid state, the correlation of circulating triiodothyronine (serum measurement) (T3) levels with symptoms and predictive value of T3 to forecast the outcome of adding LT3 to LT4 will be reviewed. The utility of striving for high, middle, or low TSH set points within the expected range to predict changes in clinical quality of life and the ability of blinded patients to sense subtle differences along this spectrum will be documented. In addition, the clinical impact of single nucleotide polymorphisms in the type 2 deiodinase gene will be reviewed. Finally, the overall satisfaction of selected patients with their thyroid hormone treatments will be outlined and preferences for T3-containing treatments from blinded studies will be summarized. CONCLUSION Basing thyroid hormone treatment decisions on patient symptoms likely results in missed diagnoses We should encourage primary care physicians to assess a differential diagnosis, exclude other diagnoses, and not assume a thyroid etiology when TSH is normal. Modifying treatment to a particular TSH target or adjusting based on a low T3 level does not seem to enhance patient outcomes. Finally, pending further trials of "symptomatic" participants, using sustained release LT3 to mimic normal physiology, and including monocarboxylate 10 transporter and Type 2 deiodinase polymorphisms and objective outcomes, I will continue to depend on therapy with LT4 monotherapy and seek alternative explanations for my patients' nonspecific symptoms.
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Affiliation(s)
- James V Hennessey
- Department of Medicine, Harvard Medical School, Boston, Massachusetts.
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