Access to the Lancet?

[dolphin5]

Just wondering if Thyroid UK has access to the Lancet. There's a new article suggesting the overuse of levothyroxine. Worrying, but maybe the details are not as bad as the summary suggests???

thelancet.com/journals/land...

[Hidden]

Sorry, don't have an answer but really wish we could have access to that as well as the BMJ etc.

[SmallBlueThing in reply to Hidden]

You can, if you pay.

[Hidden in reply to SmallBlueThing]

Doesn't one have to work in the medical/health industry first and foremost?

[SmallBlueThing in reply to Hidden]

The Lancet has Consumer and Other options for its current registration process. I registered a few years ago for family history purposes, when I was scouring their archive.

[dolphin5 in reply to Hidden]

I would have thought that anyone can access it if they pay. I feel that it's enough to be paying for essential medication that the NHS should be funding.

I can live without the Lancet, but not without T3!!!

[shaws Administrator in reply to dolphin5]

Neither can I

[SmallBlueThing]

A related Abstract on shared decision making: thelancet.com/journals/land...

[shaws Administrator in reply to SmallBlueThing]

I liked this except:

With the available evidence, however, endocrinologists can now start to practice shared decision making, partner with their patients, and use their expertise to formulate treatment plans that reflect patient preferences and are more likely to fit into the context of patients' lives. In this Personal View, we describe shared decision making, the evidence behind the approach, and why and how both endocrinologists and their patients could benefit from this approach.

[SmallBlueThing in reply to shaws]

My prescribed amount of Levo is perhaps double what it would've been without the "shared decision making" when I almost blew my top in front of a student observer, when my GP was happy with a TSH of 4.3.

But all the people with thyroid issues that I know personally leave things in the hands of their GP (although one changed GPs) and don't know their test results.

So I doubt it's us lot (hopefully more informed) who are responsible for the nearly seven-fold increase in prescriptions for Levo since 1998. I never had any testing during the 1990s when, looking back, I feel I should've.

My GP allowed me to state my case for getting my TSH under 1.0 but didn't detail any concerns. Just squirmed a bit

[shaws Administrator in reply to SmallBlueThing]

I wonder if there is some truth that damage to thyroid gland could possibly be due to flouride in toothpastes and I assume flouride can also be in other things.

How many children are swallowing 'toothpaste' which contains flouride even on 'baby' teeth. There's certainly been lots of research:-

search.yahoo.com/yhs/search...

[shaws Administrator]

In the UK levo is prescription only, so I cannot see how it is 'overused'. It is practically impossible to be diagnosed as hypo in the UK as the impossible 'TSH must reach 10' before being prescribed whilst ignoring the patients' clinical symptoms. Other countries prescribe if around 3+.

I'd like to know how many prescriptions are given out to 'probable' hypo patients who remain undiagnosed due to their TSH whilst ignoring the clinical symptoms which the professionals appear not to know one. I would also like to know the 'extra' prescriptions given to hypo patients for remaining symptoms which are diagnosed as 'other' unconnected to hypo.

If undiagnosed/undertreated we are in danger of more serious illnesses, such as heart etc.

[Clutter]

Dolphin5,

Email [e-mail]

[diogenes Remembering]

I've sent the article through to Louise Roberts at TUK for those who'd like to read it.

[diogenes Remembering]

I've copied the Lancet text and here it is - sorry for the long post.

Despite the fairly low prevalence (about 0·2–2·0%) and stable incidence of overt hypothyroidism, use of levothyroxine is increasing. In the USA, the number of prescriptions for levothyroxine increased from 97 million in 2007 to 120 million in 2014, and in the UK from 2·8 million in 1998 to 19 million in 2007 and 29 million in 2014 (figure). Levothyroxine has become the most prescribed drug in the USA and the third most prescribed drug in the UK.1,2 What factors are driving the prescription and possible overuse of levothyroxine? What is the evidence? And what can be done to improve the quality of levothyroxine prescription.

Subclinical hypothyroidism affects up to 12% of the adult population or roughly 1 billion adults worldwide. Some evidence supports use of levothyroxine to improve cardiovascular events, quality of life, and cognitive function in patients with subclinical hypothyroidism, but the evidence of benefit is scant (appendix).3 Guidelines, however, indicate treatment with levothyroxine for people with subclinical hypothyroidism with thyroid- stimulating hormone concentration of 10 mIU/L or higher and people with thyroid-stimulating hormone between 5·5 mIU/L and 10 mIU/L who have symptoms attributable to hypothyroidism, positive autoantibodies, or cardiovascular disease (appendix). Accordingly, nine of every ten women with subclinical hypothyroidism with a thyroid-stimulating hormone concentration between 5·5 mIU/L and 10 mIU/L could receive levothyroxine.4 As a result, the prevalence of untreated subclinical hypothyroidism in Norway has decreased by 64% in women and 54% in men between 1995–97 and 2006–08.5 Additionally, people in the UK with thyroid- stimulating hormone concentration of 10·0 mIU/L or lower were prescribed levothyroxine 1·3 times more in 2009 than in 2001,6 and 31% of treated patients in this cohort had a thyroid-stimulating hormone concentration of 10 mIU/L or less, normal thyroxine values, and no symptoms of hypothyroidism or abnormal cardiovascular risk factors.

The American Thyroid Association recommends screening asymptomatic men and women older than 35 years for thyroid dysfunction every 5 years, which translates into testing about 3·5 billion adults world- wide. Expert panels, however, disagree about the criteria for screening the general population for hypothyroidism

and have proposed different cutoffs (appendix).Despite the counterarguments, the enthusiasm for this practice has resulted in a surge of thyroid tests in otherwise healthynon pregnant people.In the UK,about 25%of the adult population are estimated to have their thyroid function measured every year.6

In a population-based study, 62% of thyroid- stimulating hormone values between 5·5 mIU/L and 10 mIU/L normalised without intervention. Thyroid- stimulating hormone pulsatility, concomitant transient illness, drugs, environmental and stress factors, and other factors might explain this reversal. Thus, the prescription of levothyroxine should require evidence of persistently abnormal levels of thyroid-stimulating hormone. Current practice, however, places one of every three patients with subclinical hypothyroidism on levothyroxine treatment with only one abnormal thyroid-stimulating hormone test result.6 Additionally, healthy elderly people might generally have increased thyroid-stimulating hormone levels. Some researchers have suggested increasing the upper boundary of the normal range of thyroid-stimulating hormone to 7·5 mIU/L or 8·5 mIU/L in normal adults aged 65 years and older. Ideally, to avoid misclassification and overtreatment, clinicians should receive population- specific reference limits.

Dry skin, hair loss, constipation, myalgia, fatigue, menstrual irregularities, low energy, and weight gain are all challenging but non-specific symptoms of subclinical and overt hypothyroidism. The probability of hypothyroidism in the presence of one of these symptoms is about 10%. In fact, 20–25% of people with normal thyroid hormone levels report one or two hypothyroidism-related symptoms. Therefore, symptoms might not reliably identify those who can benefit from levothyroxine treatment. Evidence supporting levothyroxine treatment for patients with subclinical hypothyroidism with non-specific symptoms is lacking. In selected cases, patients and clinicians might consider a brief therapeutic trial with levothyroxine with the goal of improving symptoms with reassessment and discontinuation of treatment if proven ineffective. Such explorations, however, can be affected by clinician and patient expectation, including the placebo effect.

Levothyroxine 3-month out-of-pocket cost to patients in the USA varies considerably, from US$4 to US$100. Synthroid,with21·5millionannualprescriptions,isthe leading prescribed brand-name medication in the USA, with revenues greater than US$1billion annually. In the UK, the annual amount of thyroid replacement therapy has tripled from 1998 to 2007 and the cost per day increased from less then £5000 to more than £40 000. In assessments of the economic effects of current practice, the costs to patients and other payers of thyroid testing, clinical follow-up of abnormal test results, clinical visits, and possible lifelong monitoring, follow-up, and levothyroxine use must be taken into account.

In the past few decades, the incidence of thyroid cancer has tripled in the USA. Additionally, screening of pregnant women for thyroid dysfunction has also increased the number of thyroid function tests. Whereas in patients with cancer there is a definite need for levothyroxine use (eg, as replacement in patients undergoing total thyroidectomy), in pregnant women, at least in those with small increases in thyroid- stimulating hormone levels, there is still substantial uncertainty.9

The safety of levothyroxine is also an issue. In a study of patients older than 65 years taking levothyroxine, 40–50% had a thyroid-stimulating hormone concentration of less than 0·45 mUI/L.10 At these concentrations, patients can exhibit hyperthyroidism, increasing the risk for arrhythmias, angina pectoris, bone loss, and fractures. As well as the potential harms, levothyroxine contributes to treatment burden. Once started, about 90% of patients continue levothyroxine therapy in the long term. Taking this drug often demands modification of daily habits—eg,

dosing 30–60 min before a meal, monitoring of effects, and clinic and laboratory visits—as well as financial costs tothepatient.

The question is how to start doing better? In the consultation, clinicians and patients must deliberate together, armed with the evidence to determine whether thyroid-stimulating hormone testing followed by levothyroxine treatment is the best way to address their situation.11 In view of the existing evidence, we propose several strategies to improve the quality of levothyroxine use. First, the reason to explore the possibility of subclinical hypothyroidism should be determined with each patient individually. If symptoms are non-specific, physicians and patients should carefully consider the potential benefit versus the burden of treatment. Second, for people with abnormally high thyroid-stimulating hormone concentrations consistent with subclinical hypothyroidism (based on age-dependent thyroid-stimulating hormone cutoff values), the thyroid-stimulating hormone test should be repeated, ideally in the same laboratory, 3–6 months after the abnormal test, before treatment is considered. Third, clinicians need to recognise that patients with non-specific symptoms and normal thyroid function tests do not benefit from levothyroxine therapy. Finally, if subclinical hypothyroidism is confirmed and the patient agrees with a treatment trial, the lowest dose of a generic levothyroxine preparation should be used (to achieve an on-range thyroid-stimulating hormone concentration) at first, and reassessed periodically (eg, once or twice a year) to determine the efficacy of levothyroxine use. Treatment should be discontinued if ineffective (ie, no response to symptoms), and the dose lowered if toxic effects become evident.

There is substantial uncertainty and complexity associated with the technical aspects of identifying otherwise healthy people affected by mild, non-specific symptoms, who would benefit from levothyroxine. This uncertainty and complexity calls for policies that invite patients and clinicians to enrol in clinical trials to assess the effectiveness of levothyroxine use, rather than to the routine, expanding, and prolonged use of a treatment of uncertain value.

In conclusion, there is evidence of substantial overuse of levothyroxine. The treatment of individuals with mild, non-specific symptoms and the overdiagnosis of subclinical hypothyroidism, imprecise screening recommendations, and misinterpretation of normal thyroid-stimulating hormone variability could be contributing to levothyroxine overuse, imposing a substantial economic and treatment burden on millions of people. A prudent and patient-centred approach11 might mitigate the effect of the prevailing uncertainty on the quality of levothyroxine prescription, while much needed research accrues.

Rene Rodriguez-Gutierrez, Spyridoula Maraka, Naykky Singh Ospina, Victor M Montori, *Juan P Brito

Knowledge and Evaluation Research Unit in Endocrinology (KER-Endo), Division of Endocrinology, Diabetes, Metabolism and Nutrition, Department of Medicine, Mayo Clinic, Rochester, MN 55905, USA (RR-G, SM, NSO, VMM, JPB); Division of Endocrinology, Diabetes, Metabolism and Nutrition, Department of Medicine, Mayo Clinic, Rochester, MN, USA (RR-G, SM, NSO, VMM, JPB); and Division of Endocrinology, Department of Internal Medicine, University Hospital “Dr Jose E Gonzalez”, Autonomous University of Nuevo Leon, Monterrey, Mexico (RR-G) [e-mail]

We declare no competing interests. We thank the Patient Research Advisory Group, a group of patients from the community that has met with investigators of the Knowledge and Evaluation Research Unit at Mayo Clinic for the past decade to help to direct their work on what matters to patients.

[humanbean in reply to diogenes]

Levothyroxine has become the most prescribed drug in the USA and the third most prescribed drug in the UK.

I am curious about which drugs are numbers 1 and 2 in the UK. If I had to bet I might put £1 on anti-depressants and statins being in the number 1 and 2 slots, but I wouldn't like to say which way round I thought they were.

[humanbean in reply to humanbean]

Turns out I'd probably be wrong. It's more likely to be statins and PPIs.

[dolphin5 in reply to humanbean]

That doesn't surprise me. I've had both of those prescribed, and I now refuse to take them because they are so bad for your health!!!!!

I wish that doctors would learn the facts about what they prescribe, and instead of prescribing loads of harmful drugs, they could try prescribing T3 to those who need it. Or would that be way too sensible???

[humanbean in reply to dolphin5]

I agree about prescribing T3 where appropriate. But before even getting that far I would want vitamin and mineral testing to be more common and for doctors to understand that levels should be optimal, not just in range.

[dolphin5 in reply to humanbean]

I've got a good idea - let's train doctors to understand how the body works - at least in the areas where they treat patients.

If they don't know the details, they should pass the patient to a doctor who does understand, and if there's no-one who understands, then they'd better get some emergency training courses organised.

[humanbean in reply to dolphin5]

Sounds like an excellent idea to me. But doctors think they do know how the body works so you might encounter some resistance.

[SilverAvocado in reply to diogenes]

Interesting that the 'ideal' guidelines are trotted out without a mention of evidence.

As I was reading this I was thinking 'you'd never see a paper like this about over-prescription of anti-depressants or statins'. But then I realised that of course you do all the time. So I suppose it's just to be expected.

[dolphin5]

It seems to me that these researchers need to understand about how individuals all have their own set point for thyroid hormone levels. Also, I wonder if they have considered the possibility that much of the apparent lack of effectiveness is due to use of the TSH levels alone, and under-treatment of patients?

They need to read the work of Diogenes!!!!!

[Rapunzel]

' The question is how to start doing better? In the consultation, clinicians and patients must deliberate together, armed with the evidence to determine whether thyroid-stimulating hormone testing followed by levothyroxine treatment is the best way to address their situation.'

Until clinicians will deliberate together with their patients and consult instead of tell; until the reliance on the holy miracle of the TSH is once and for all discounted; until being 'in range' is considered the litmus test instead of how the patient is feeling...we are doomed to a world in which many of us will remain unwell. Thanks for the insight, diogenes

My hubby went to his GP today and asked at the end of the consultation about the possibility of him taking me on to his list. 'She's hypothyroid and self medicates. She's not an idiot.' GP 'What does she need to see a doctor for, then ?' They're all the same where I am, where I wash around, I have to add, with a larger than average number of pond life: smug, arrogant barstewards. Not for the first time...feck em all

[crimple]

Since joining this site nearly 4 years ago I have done a lot of reading and on line research in my quest for health! (Hypo, with TPO's and on levo only and still not fully well- low T4 and T3) I asked myself the following questions: Why was my iodine level low, why do I see more women with goitres etc.

I am not medically qualified but I did work in a scientific environment where I learned to look at cause and effect. Yes the use of fluoride in tooth paste is relevant in my opinion, my grandchildren all swallow theirs- not good. Also since the last world war how much radioactivity has been released into the enviroment? From warheads, nuclear power stations etc etc. I grew up in the north and remember the Sellafield debacle when sheep could not be sold for the meat market and I think milk had to be poured away. In 1985 we had Chernobyl which also affected UK. The Russians doled out Iodine tablets at the time in the hope that healthy thyroids would take up Iodine rather than radioactive Iodine!!

Diets lack Iodine because of farming methods etc. If you put alll this information together I come up with the answer that a toxic environment and lack of Iodine is leading to the increase in numbers of hypo patients. But I am a mere female, retired and clearly barking mad!!