Trends in thyroid hormone prescribing and consumption in the UK

Mitchell, Anna L.; Hickey, B; Hickey, Janis; Pearce, Simon H. S.

doi:10.1186/1471-2458-9-132

Cited by 59 publications

(75 citation statements)

References 9 publications

(9 reference statements)

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“…T hyroid hormone is one of the most frequently prescribed therapies in the United States and Europe, and several studies of primary care practices indicate increasing levothyroxine prescriptions over the past few decades (1,2). Further, thyroid hormone therapy is being initiated for milder thyrotropin (TSH) elevation (3) and in some cases without clear clinical rationale in both primary care (4) and endocrinology specialist settings (5).…”

Section: Introductionmentioning

confidence: 99%

Thyroid Hormone Therapy and Risk of Thyrotoxicosis in Community-Resident Older Adults: Findings from the Baltimore Longitudinal Study of Aging

Mammen

McGready

Oxman

et al. 2015

Thyroid

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Background: Both endogenous and exogenous thyrotoxicosis has been associated with atrial fibrillation and low bone mineral density. Therefore, this study investigated the risk factors associated with prevalent and incident thyrotoxicosis and the initiation of thyroid hormone therapy in a healthy, aging cohort. Methods: A total of 1450 ambulatory community volunteer participants in the Baltimore Longitudinal Study of Aging examined at the NIA Clinical Research Unit in Baltimore, MD, have undergone longitudinal monitoring of serum thyrotropin (TSH) and thyroid hormone (free thyroxine and free triiodothryonine) levels as well as medication use every one to four years, depending on age, between 2003 and 2014. Results: The prevalence of low TSH was 9.6% for participants on thyroid hormone and 0.8% for nontreated individuals ( p < 0.001). New cases occurred at a rate of 17.7/1000 person-years of exposure to thyroid hormone therapy [CI 9-32/1000] and 1.5/1000 person-years in the unexposed population [CI 0.7-2.9/1000]. Women were more likely to be treated and more often overtreated than men were. The adjusted hazard ratio (HR) for thyrotoxicosis between treated and untreated women was 27.5 ([CI 7.2-105.4]; p < 0.001) and 3.8 for men ([CI 1.2-6.3]; p < 0.01). White race/ethnicity and older age were risk factors for thyroid hormone therapy but not overtreatment. Body mass index was not associated with starting therapy (HR = 1.0). Thyroid hormone initiation was highest among women older than 80 years of age (3/100 person-years). For one-third of treated participants with follow-up data, overtreatment persisted at least two years. Conclusions: Iatrogenic thyrotoxicosis accounts for approximately half of both prevalent and incident low TSH events in this community-based cohort, with the highest rates among older women, who are vulnerable to atrial fibrillation and osteoporosis. Physicians should be particularly cautious in treating subclinical hypothyroidism in elderly women in light of recent studies demonstrating no increased risk of cardiovascular morbidity or death for individuals with elevated TSH levels <10 mIU/L.

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Section: Introductionmentioning

confidence: 99%

Thyroid Hormone Therapy and Risk of Thyrotoxicosis in Community-Resident Older Adults: Findings from the Baltimore Longitudinal Study of Aging

Mammen

McGready

Oxman

et al. 2015

Thyroid

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“…More data are available on changes in thyroid hormone prescription. Thus, the annual number of thyroid hormone prescription items dispensed in England more than doubled from 1998 to 2007 (12), and in the Tayside region in Scotland, the prevalence of treated hypothyroidism increased by 63% from 1994 to 2001 (13). In Denmark, the incidence rate of treated hypothyroidism increased by w80% from 1997 to 2008, which may be explained both by more extensive detection and treatment of hypothyroidism and by an increased incidence of hypothyroidism due to the introduction of iodized salt (14).…”

Section: Huntmentioning

confidence: 99%

Changes in the prevalence of hypothyroidism: the HUNT Study in Norway

Åsvold

Vatten

Bjøro

2013

European Journal of Endocrinology

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Objective: Untreated hypothyroidism is common in iodine-replete areas. Frequent thyroid function testing and use of levothyroxine treatment for subclinical hypothyroidism suggest that the prevalence may have decreased. Therefore, in this study, we examined changes in the prevalence of hypothyroidism in a Norwegian county from 1995-1997 to 2006-2008 The corresponding decrease among men was 43% from 0.21 to 0.12% (PR 0.57; 95% CI 0.28-1.16). The prevalence of untreated subclinical hypothyroidism decreased by 64% from 3.0 to 1.1% in women (PR 0.36; 95% CI 0.31-0.42) and decreased by 54% from 2.1 to 1.0% in men (PR 0.46; 95% CI 0.38-0.56). Conversely, the prevalence of treated hypothyroidism among women increased by 60% from 5.0 to 8.0% (PR 1.60, 95% CI 1.50-1.71), and the corresponding prevalence in men doubled from 1.0 to 2.0% (PR 1.96; 95% CI 1.59-2.41). The prevalence of any form of hypothyroidism remained essentially similar at 9% in women and 3% in men. Conclusions: The prevalence of untreated hypothyroidism in this Norwegian county decreased strongly from 1995-1997 to 2006-2008. The findings suggest that the prevalence of untreated hypothyroidism in populations with easy access to thyroid function testing and levothyroxine treatment may now be low.

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“…19,20 Indeed, evidence shows that there may be some disadvantages to shorter prescriptions. Shorter prescriptions may (1) increase the costs to the health system through increased GP administrative workload and dispensing fees to pharmacists, 21 (2) increase costs incurred by the patient, 22 (3) have a negative impact on patient satisfaction 23 and (4) have a negative impact on adherence. 24 Whether or not the most commonly used prescription length should be changed was identified as a key area for research in the DH's 2011 roundtable, Making Best Use of Medicines.…”

Section: Guidance and Policy On Repeat Prescription Lengthmentioning

confidence: 99%

“…In a study on patients' perceptions of, and satisfaction with, a 28-day prescribing policy for thyroid hormone, Mitchell et al 23 found widespread dissatisfaction. The most common reasons cited for being dissatisfied were the inconvenience of having to pick up the prescription/ tablets more frequently, as it interferes with the working day.…”

Section: Limitations Of the Evidencementioning

confidence: 99%

“…The most common reasons cited for being dissatisfied were the inconvenience of having to pick up the prescription/ tablets more frequently, as it interferes with the working day. 23 A qualitative study 61 that investigated patients with chronic conditions' experiences of repeat prescriptions in the NHS found that patients often described shorter prescriptions as a hassle. 61 Respondents reported that managing a repeat prescription was a time-consuming task.…”

Section: Limitations Of the Evidencementioning

confidence: 99%

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Clinical effectiveness and cost-effectiveness of issuing longer versus shorter duration (3-month vs. 28-day) prescriptions in patients with chronic conditions: systematic review and economic modelling

Miani

Martin

Exley

et al. 2017

Health Technol Assess

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BackgroundTo reduce expenditure on, and wastage of, drugs, some commissioners have encouraged general practitioners to issue shorter prescriptions, typically 28 days in length; however, the evidence base for this recommendation is uncertain.ObjectiveTo evaluate the evidence of the clinical effectiveness and cost-effectiveness of shorter versus longer prescriptions for people with stable chronic conditions treated in primary care.Design/data sourcesThe design of the study comprised three elements. First, a systematic review comparing 28-day prescriptions with longer prescriptions in patients with chronic conditions treated in primary care, evaluating any relevant clinical outcomes, adherence to treatment, costs and cost-effectiveness. Databases searched included MEDLINE (PubMed), EMBASE, Cumulative Index to Nursing and Allied Health Literature, Web of Science and Cochrane Central Register of Controlled Trials. Searches were from database inception to October 2015 (updated search to June 2016 in PubMed). Second, a cost analysis of medication wastage associated with < 60-day and ≥ 60-day prescriptions for five patient cohorts over an 11-year period from the Clinical Practice Research Datalink. Third, a decision model adapting three existing models to predict costs and effects of differing adherence levels associated with 28-day versus 3-month prescriptions in three clinical scenarios.Review methodsIn the systematic review, from 15,257 unique citations, 54 full-text papers were reviewed and 16 studies were included, five of which were abstracts and one of which was an extended conference abstract. None was a randomised controlled trial: 11 were retrospective cohort studies, three were cross-sectional surveys and two were cost studies. No information on health outcomes was available.ResultsAn exploratory meta-analysis based on six retrospective cohort studies suggested that lower adherence was associated with 28-day prescriptions (standardised mean difference –0.45, 95% confidence interval –0.65 to –0.26). The cost analysis showed that a statistically significant increase in medication waste was associated with longer prescription lengths. However, when accounting for dispensing fees and prescriber time, longer prescriptions were found to be cost saving compared with shorter prescriptions. Prescriber time was the largest component of the calculated cost savings to the NHS. The decision modelling suggested that, in all three clinical scenarios, longer prescription lengths were associated with lower costs and higher quality-adjusted life-years.LimitationsThe available evidence was found to be at a moderate to serious risk of bias. All of the studies were conducted in the USA, which was a cause for concern in terms of generalisability to the UK. No evidence of the direct impact of prescription length on health outcomes was found. The cost study could investigate prescriptions issued only; it could not assess patient adherence to those prescriptions. Additionally, the cost study was based on products issued only and did not account for underlying patient diagnoses. A lack of good-quality evidence affected our decision modelling strategy.ConclusionsAlthough the quality of the evidence was poor, this study found that longer prescriptions may be less costly overall, and may be associated with better adherence than 28-day prescriptions in patients with chronic conditions being treated in primary care.Future workThere is a need to more reliably evaluate the impact of differing prescription lengths on adherence, on patient health outcomes and on total costs to the NHS. The priority should be to identify patients with particular conditions or characteristics who should receive shorter or longer prescriptions. To determine the need for any further research, an expected value of perfect information analysis should be performed.Study registrationThis study is registered as PROSPERO CRD42015027042.FundingThe National Institute for Health Research Health Technology Assessment programme.

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Trends in thyroid hormone prescribing and consumption in the UK

Cited by 59 publications

References 9 publications

Thyroid Hormone Therapy and Risk of Thyrotoxicosis in Community-Resident Older Adults: Findings from the Baltimore Longitudinal Study of Aging

Thyroid Hormone Therapy and Risk of Thyrotoxicosis in Community-Resident Older Adults: Findings from the Baltimore Longitudinal Study of Aging

Changes in the prevalence of hypothyroidism: the HUNT Study in Norway

Clinical effectiveness and cost-effectiveness of issuing longer versus shorter duration (3-month vs. 28-day) prescriptions in patients with chronic conditions: systematic review and economic modelling

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