Use of Thyroid Hormones in Hypothyroid and Euthyroid Patients: A 2020 THESIS Questionnaire Survey of Members of the Swedish Endocrine Society

Abstract

BackgroundThe standard treatment of hypothyroidism is levothyroxine (LT-4). However, there are several controversies regarding treatment of hypothyroid patients.AimTo investigate the Swedish endocrinologists’ use of thyroid hormones in hypothyroid and euthyroid individuals.MethodsPhysician members of the Swedish Endocrine Society (SEF) were invited by e-mail to participate in an online survey investigating this topic.ResultsOut of the eligible 411 members, 116 (28.2%) responded. The majority (98.9%) stated that L-T4 is the treatment of choice. However, around 50% also prescribed liothyronine (L-T3) or a combination of L-T4+L-T3 in their practice. Combination therapy was mostly (78.5%) used in patients with persistent hypothyroid symptoms despite biochemical euthyroidism on L-T4 treatment. Most respondents prescribed L-T4 tablets and did not expect any major changes with alternative formulations such as soft-gel capsules or liquid formulations in situations influencing the bioavailability of L-T4. In euthyroid patients, 49.5% replied that treatment with thyroid hormones was never indicated, while 47.3% would consider L-T4 for euthyroid infertile women with high thyroid peroxidase (TPO) antibody levels.ConclusionThe treatment of choice for hypothyroidism in Sweden is L-T4 tablets. Combination therapy with L-T4+L-T3 tablets was considered for patients with persistent symptoms despite biochemical euthyroidism. Soft-gel capsules and liquid solutions of L-T4 were infrequently prescribed. Swedish endocrinologists’ deviation from endocrine society guidelines merits further study.

Use of thyroid hormones in hypothyroid and euthyroid patients: a THESIS* survey of Belgian specialists *THESIS: treatment of hypothyroidism in Europe by specialists: an international survey

“…This is the first survey on the use of TH by Belgian specialists. As elsewhere in Europe [ 12 – 20 ] and in agreement with international guidelines, the survey confirmed that LT4 is the treatment of choice for Belgian hypothyroid patients. However, a significant proportion of respondents also use TH for more controversial indications, such as infertile euthyroid TPOAb positive women and a growing benign goiter.…”

“…However, a significant proportion of respondents also use TH for more controversial indications, such as infertile euthyroid TPOAb positive women and a growing benign goiter. A similar or even greater preference for the treatment of infertile euthyroid women in the presence of thyroid autoimmunity was reported by French (31.7%), Greek (31.9%), Romanian (36.4%), Italian (37.3%), Danish (42.1%), Swedish (47.3%), Spanish (48.5%) and Polish (63.4%) endocrinologists who responded to this question, respectively [ 12 – 20 ], although the limited available evidence does not support this approach. In the case of assisted reproductive technology, all large randomized controlled trials in this population concluded that there is no benefit from LT4 treatment [ 21 , 22 ], which was confirmed in the recent TABLET trial including euthyroid TPOAb positive women with a medical history of (recurrent) miscarriage or receiving treatment for infertility [ 23 ].…”

“…In contrast to current evidence, a surprisingly high proportion of Belgian specialists (50%) consider TH treatment in patients with a euthyroid benign goiter growing over time, a rate similar to Bulgarian (55%), Polish (40.9%) and French (40.2%) colleagues [ 14 , 15 , 19 ], but higher than 24.2% of Greek [ 18 ], 21.2% of Spanish [ 17 ],18% of Italians [ 12 ],14% of Swedish [ 20 ] and 12.5% of Danish endocrinologists who responded to this question [ 13 ]. This response may be related to adherence of older endocrinologists to outdated clinical practices, no longer recommended by recent guidelines [ 25 ].…”

“…However, a higher number of respondents (20% of Belgians) are willing to switch to combination treatment in patients with normal TSH and persisting symptoms of hypothyroidism on LT4, a tendency noted in other THESIS surveys (25% of Greeks [ 18 ], 32.2% of Polish [ 15 ], 40% of Italians [ 12 ]. This proportion was even higher in Danish (71%) and Swedish (78.5%) specialists [ 13 , 20 ], despite the lack of evidence of superiority of combined treatment over LT4 and lack of long-term safety data. The preference towards combined treatment was more frequent in Belgian endocrinologists than other Belgian physicians, but was not influenced by the physician working environment or years of practice.…”

“…This survey is part of THESIS (Treatment of Hypothyroidism in Europe by Specialists: An International Survey), an international initiative investigating whether differences in practice between 28 European countries impact management of hypothyroidism [ 12 – 20 ]. The aim of our survey was to identify current attitudes on the treatment of hypothyroid and euthyroid patients with thyroid hormones in Belgium.…”