What evidence supports this proposal? - Healthy Evidence

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What evidence supports this proposal?

helvella profile image

Much of today's news (other than something to do with Europe, Scotland, coal, ...) is filled with proposals for changing what medicines are available on prescription.

The top of the list is liothyronine. From the BBC report:

'Low value' medicines on the list and their annual cost to the NHS:

£30.93m on Liothyronine to treat underactive thyroid

What evidence is there that liothyronine should not be used?

There are perhaps 10% or more who have issues which seem to require liothyronine but the proposal would appear to be a blanket ban. (And would, I am sure, become a de facto ban even if the words don't actually say that.)

10 Replies

Considering people diagnosed as hypothyroid are given free prescriptions for life, it can't be classed as unnecessary! I'm sure that's the main reason getting a diagnosis is so difficult!

I think that the proposal is not that the medicine should no loner be used but that the medicine should no longer be available on the NHS by prescription. Some of the medicines are already available over the counter and so perhaps liothyronine will still be available but at the users cost.

Clutter profile image
Clutter in reply to genetix


Liothyronine is prescription only in the UK.

helvella profile image
helvella in reply to Clutter

Further, because of the incompetence of NHS procurement the product is so ridiculously over-priced that most patients couldn't afford it. If the price were sensible such that patients could reasonably be expected to be able to afford it, the NHS would not be so keen to abandon prescribing it.

It would be the wrong side of madness for NHS doctors to have to write private prescriptions for essential medicines. Especially as many would fully exploit their right to charge for writing such prescriptions.

Many, many patients already buy their own - but have to do so from abroad. (Many countries offer perfectly good products but international medicine supply is hardly ideal - especially when instead of the NHS paying, patients often end up having to pay for their medicines plus VAT.)

Clutter profile image
Clutter in reply to helvella


I don't think it is a coincidence that since Concordia has increased cost to stratospheric levels NHS has started saying there is no evidence to support use of T3 despite many patients being prescribed it for years because they weren't well on Levothyroxine.

I don't understand how NHSCC can claim it is not a blanket ban when we are told that Liothyronine will not be available on prescription. It's not as if we can buy it over the counter unless we're prepared to travel to Greece or Turkey.

helvella profile image
helvella in reply to Clutter

I think there are weasel words.

The specific statement is "for underactive thyroid" which, theoretically, leaves the door ajar for use in reduced sensitivity to thyroid hormone.

Therefore we will end up with liothyronine technically being prescribable - just not for anyone without proved reduced sensitivity...

So - their words will be true but ever so misleading. I have no doubt this is 100% intentional.

Clutter profile image
Clutter in reply to helvella


So much easier to withdraw what has become an expensive medication rather than close the loopholes which allowed Concordia to price gouge Liothyronine out of our reach.

I think the rationale is there are cheaper, more effective, alternatives, such as levothyroxine


Clutter profile image
Clutter in reply to Gez_Blair


No argument that Levothyroxine is a cheaper thyroid replacement but it most certainly is not as effective, or even effective at all, for some hypothyroid patients.

helvella profile image
helvella in reply to Clutter


Thank you for responding.

I have lots and lots of arguments with that document.

For a start, its title says Management of Primary Hypothyroidism. But we are seeing liothyronine being withdrawn without any reference to the rationale for its prescription. Could have been prescribed for secondary or tertiary hypothyroidism, reduced sensitivity to thyroid hormone, depression resistant to other treatment, or several other things.

The amount of active ingredient in different suppliers liothyronine products may not be standardised so can vary from batch-to-batch, providing variable control.

Where did this come from?

Is there any evidence whatsoever that liothyronine products are not standardised? That they vary from batch to batch? For any UK medicine that did vary beyond the established criteria, the MHRA would get involved. For USA products, the FDA would get involved. And typically USA potency criteria are tighter than those in the UK. I doubt the German or French products are any less satisfactory but do not have ready access to their standards.

It is the proposed switch-to product levothyroxine that has failed and been withdrawn repeatedly. In 2013 one sub-standard levothyroxine product (Teva) was allowed to remain in circulation because issues with another make (Mercury Pharma) were already causing shortages!

No reference provided so cannot see why they came up with that.

It is recognised that some patients on levothyroxine remain symptomatic despite treatment leading to TSH levels in the therapeutic range. The reasons for this are not fully understood and such patients should be under the care of an endocrinologist [2].

This is utter nonsense as a justification. For a start, untold thousands of patients are refused referrals to endocrinologists because hypothyroidism is usually classed as something GPs should be able to manage.

And if it is the endocrinologist to whom you have been referred who prescribes liothyronine?

The Royal College of Physicians does not recommend the prescribing of additional liothyronine in any presently available formulation, including Armour Thyroid, as it is inconsistent with normal physiology, has not been unequivocally proven to be of any benefit to patients, and may be harmful.

Pray tell, in what universe is levothyroxine monotherapy consistent with normal physiology?

One of the main references in that document [2] is that most unacceptable document from the RCP. Purports to be about the diagnosis and management of primary hypothyroidism but nowhere explains how to distinguish primary from any other form of hypothyroidism!

Finally, I wanted real evidence rather than a highly derivative document. This is pretty much a word for word copy of what so many groups around the country have put out.