International variation in GP treatment strategies for subclinical hypothyroidism in older adults: a case-based survey

Elzen, Wendy P. J. den; Fliert, A.A. Lefèbre–van de; Virgini, Vanessa; Mooijaart, Simon P.; Frey, Peter; Kearney, Patricia M.; Kerse, Ngaire; Mallen, Christian; McCarthy, Vera J. C.; Muth, Christiane; Rosemann, Thomas; Russell, Audrey; Schers, Henk; Stott, David J.; Waal, Margot W. M. de; Warner, Alex; Westendorp, Rudi G.J.; Rodondi, Nicolas; Gussekloo, Jacobijn

doi:10.3399/bjgp15x683569

Cited by 17 publications

(17 citation statements)

References 20 publications

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“…vitality status, and serum TSH) all affected the decision to prescribe LT4 (33). In further analyses, the study authors found that country, TSH value of case, physician characteristic (sex and years of experience), time since the physician last diagnosed hypothyroidism in their own practice, and age of the physician's patient population all influenced LT4 prescribing.…”

Section: Combination Therapy and Physician Characteristicsmentioning

confidence: 87%

“…The survey focused on patients with overt hypothyroidism, and respondents were members of a specialty society. In contrast, a survey of general practitioners from Europe and New Zealand conducted in approximately 2014 examined LT4 prescribing patterns for treatment of subclinical hypothyroidism (32,33). The country the prescribing physician was from and several characteristics of the patient case (age, Controlling for all physician characteristics (number of years in practice, country of practice, and specialty).…”

Section: Discussionmentioning

confidence: 99%

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Prescribing Therapy for Hypothyroidism: Influence of Physician Characteristics

Jonklaas

Tefera

Shara

2019

Thyroid

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Background: Physician characteristics and perceptions and their effect on choice of therapies for patients with thyroid cancer have been well studied. Some data also exist about physician characteristics and prescribing treatment for subclinical hypothyroidism. The effect of physician characteristics on prescribing thyroid preparations for treating overt hypothyroidism is less studied. Methods: Members of the American Thyroid Association were surveyed in 2017. Physicians were presented with 13 different theoretical patients with hypothyroidism and asked to choose among six therapeutic options, including levothyroxine, synthetic combination therapy, thyroid extract, and liothyronine monotherapy. The 13 patient scenarios incorporated parameters that potentially provide reasons for considering combination therapy (presence of symptoms, low serum triiodothyronine concentration, and documentation of deiodinase polymorphisms). Repeated-measures logistic regression analysis was performed to examine the prescribing of the various therapies. Data regarding the responding physicians were also collected. These data included number of years in practice, country of practice, and specialty. Multivariate repeated-measures logistic regression analysis of prescribing patterns was also conducted controlling for all patient and physician characteristics. Results: Of the 389 survey respondents, 93% prescribed therapy for hypothyroidism. Fifty-three percent of respondents had been in practice for >20 years, and 23% had been in practice for 11-20 years. Sixty-four percent practiced in North America, and 18% practiced in Europe. Eight-six percent were endocrinologists, and 5% were surgeons. In multivariate analysis, physicians from North America were both more likely to prescribe any triiodothyronine-containing therapies (odds ratio [OR] = 1.8 [confidence interval (CI) 1.3-2.4]) and more likely to add liothyronine to levothyroxine therapy (OR = 1.9 [CI 1.2-2.9]). In addition, they were more likely to prescribe desiccated thyroid extract or liothyronine monotherapy (OR = 1.7 [CI 1.0-2.9]). Conclusions: A previous analysis of this survey showed that patient characteristics profoundly affect physician prescribing patterns. The current multivariate analysis shows that physician characteristics affect prescribing patterns. Whether this is due to impact upon physicians of patient-related experiences, media exposure, influence from pharmaceutical companies, educational activities, or other concerns cannot be determined. However, these results have potential importance for understanding physician-patient interactions at a time when the benefits and risks of triiodothyronine-containing therapies have not been fully documented.

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Section: Combination Therapy and Physician Characteristicsmentioning

confidence: 87%

Section: Discussionmentioning

confidence: 99%

Prescribing Therapy for Hypothyroidism: Influence of Physician Characteristics

Jonklaas

Tefera

Shara

2019

Thyroid

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“…8 The lack of evidence for older patients may have contributed to significant treatment variation by primary care clinicians. 9 This study combined data from the Institute for Evidence-Based Medicine in Old Age (IEMO) 80-plus thyroid trial 10 and the subgroup of participants in the Thyroid Hormone Replacement for Untreated Older Adults With Subclinical Hypothyroidism Trial (TRUST) aged 80 years and older. 5 The 2 trials examined the effects of managing subclinical hypothyroidism with levothyroxine on quality of life in adults aged 80 years and older.…”

mentioning

confidence: 99%

Association Between Levothyroxine Treatment and Thyroid-Related Symptoms Among Adults Aged 80 Years and Older With Subclinical Hypothyroidism

Mooijaart

Puy

Stott

et al. 2019

JAMA

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109

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IMPORTANCE It is unclear whether levothyroxine treatment provides clinically important benefits in adults aged 80 years and older with subclinical hypothyroidism. OBJECTIVE To determine the association of levothyroxine treatment for subclinical hypothyroidism with thyroid-related quality of life in adults aged 80 years and older. DESIGN, SETTING, AND PARTICIPANTS Prospectively planned combined analysis of data involving community-dwelling adults aged 80 years and older with subclinical hypothyroidism. Data from a randomized clinical trial were combined with a subgroup of participants aged 80 years and older from a second clinical trial. The trials were conducted between April 2013 and May 2018. Final follow-up was May 4, 2018. EXPOSURES Participants were randomly assigned to receive levothyroxine (n = 112; 52 participants from the first trial and 60 from the second trial) or placebo (n = 139; 53 participants from the first trial and 86 from the second trial). MAIN OUTCOMES AND MEASURES Co-primary outcomes were Thyroid-Related Quality of Life Patient-Reported Outcome (ThyPRO) questionnaire scores for the domains of hypothyroid symptoms and tiredness at 1 year (range, 0-100; higher scores indicate worse quality of life; minimal clinically important difference, 9). RESULTS Of 251 participants (mean age, 85 years; 118 [47%] women), 105 were included from the first clinical trial and 146 were included from the second clinical trial. A total of 212 participants (84%) completed the study. The hypothyroid symptoms score decreased from 21.7 at baseline to 19.3 at 12 months in the levothyroxine group vs from 19.8 at baseline to 17.4 at 12 months in the placebo group (adjusted between-group difference, 1.3 [95% CI, −2.7 to 5.2]; P = .53). The tiredness score increased from 25.5 at baseline to 28.2 at 12 months in the levothyroxine group vs from 25.1 at baseline to 28.7 at 12 months in the placebo group (adjusted between-group difference, −0.1 [95% CI, −4.5 to 4.3]; P = .96). At least 1 adverse event occurred in 33 participants (29.5%) in the levothyroxine group (the most common adverse event was cerebrovascular accident, which occurred in 3 participants [2.2%]) and 40 participants (28.8%) in the placebo group (the most common adverse event was pneumonia, which occurred in 4 [3.6%] participants). CONCLUSIONS AND RELEVANCE In this prospectively planned analysis of data from 2 clinical trials involving adults aged 80 years and older with subclinical hypothyroidism, treatment with levothyroxine, compared with placebo, was not significantly associated with improvement in hypothyroid symptoms or fatigue. These findings do not support routine use of levothyroxine for treatment of subclinical hypothyroidism in adults aged 80 years and older.

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“…[14] In most adult patients, an average dose of 1.6 mcg/kg/day is required. The initial dose may be 1 mcg/kg/day in healthy patients or a fixed dose of 12.5–25 mcg in patients at risk of heart failure.…”

Section: Dose Of Levothyroxinementioning

confidence: 99%

Patient-centered management of hypothyroidism

Kalra

Agarwal²,

Aggarwal

et al. 2017

Indian J Endocr Metab

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This communication from the National Indian Patient-centered Thyroid management group (InPACT) deals with a novel, yet essential, aspect of hypothyroidism management. The authors describe the role and scope of patient-centered care in this condition. They focus on the relevance of a patient-centered clinical approach, which will help decide appropriate targets, as well as techniques to achieve those targets. Means of helping persons with hypothyroidism live a healthy life, such as education about precaution in concomitant food and medications intake, as well as sick day management, are discussed.

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International variation in GP treatment strategies for subclinical hypothyroidism in older adults: a case-based survey

Abstract: BackgroundThere is limited evidence about the impact of treatment for subclinical hypothyroidism, especially among older people.

Cited by 17 publications

References 20 publications

Prescribing Therapy for Hypothyroidism: Influence of Physician Characteristics

Prescribing Therapy for Hypothyroidism: Influence of Physician Characteristics

Association Between Levothyroxine Treatment and Thyroid-Related Symptoms Among Adults Aged 80 Years and Older With Subclinical Hypothyroidism

Patient-centered management of hypothyroidism

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