In response to: 'Thyroid hormone replacement - a counterblast to guidelines'

[helvella]

Just saw an alert for a new item - in response to Toft's Thyroid hormone replacement - a counterblast to guidelines.

Not yet published and I cannot find it online. Please, if anyone does find it, let us all know!

I wonder how they have responded?

J R Coll Physicians Edinb. 2018 Mar;48(1):93. doi: 10.4997/JRCPE.2018.120.

In response to: 'Thyroid hormone replacement - a counterblast to guidelines'.

Leese GP, Flynn RV, MacDonald TM, Schofield C, Mackie AD.

PMID: 29741539

DOI: 10.4997/JRCPE.2018.120

ncbi.nlm.nih.gov/pubmed/297...

[diogenes Remembering]

I think it was a submission by Toft which the wise and good rejected, but I'll ask him and found out its fate.

[thyras]

here - share your thoughts

rcpe.ac.uk/sites/default/fi...

[helvella Administrator in reply to thyras]

Thank you!

[diogenes Remembering in reply to helvella]

Here is the link to Toft's paper which he did succeed in publishing

rcpe.ac.uk/college/journal/...

[thyras]

In response to: ‘Thyroid hormone

replacement – a counterblast to guidelines’

Dr Toft’s paper(1) describes our paper from 20102 as being

flawed; we think results may be over-interpreted but

not fl awed. In our paper, people on thyroid replacement

with a TSH of less than 0.1 mU/L had increased risk of

cardiovascular disease and fractures after 4.5 years followup.

Most of the 17,684 patients only took L-thyroxine, but

patients on liothyronine were included. Additionally, our

paper showed the risks of having a TSH between 0.1–0.4

were low,(2) allowing clinicians to make a judgement on the

risks of prescribing thyroid replacement with a serum TSH in

this range, even though some people may describe this as

‘over-treatment’. We never claimed to distinguish between

those on thyroxine and liothyronine, or to use serum T4 or

T3 measurements as predictors, or to address symptoms.

These are valid research questions requiring further studies,

but do not invalidate the association of adverse outcomes

with a TSH < 0.01 mU/L.2

More recently we looked at the safety of patients taking

liothyronine alone or in combination (n = 400), compared

to patients only taking L-thyroxine (33,955), followed up for

9 years.(3) There was no additional risk of atrial fi brillation,

cardiovascular disease or fractures, although there was an

increased incident use of antipsychotic medication during

follow up. Patients had serum TSH titrated according to

current guidelines,(4) although again data on serum T3 were

not available.

Furthermore, we believe that Dr Toft should be proud of his

and the College’s pioneering role in the use of evidencebased

guidelines. However, guidelines need to be used

fairly and wisely. Evidence-based guidelines describe a

foundation of knowledge, but should not be the ceiling

of clinical practice. They allow confi dent clinical practice

where there is high quality evidence, but make clinicians and

patients aware of uncertainty when evidence is lacking. For

example, further clinical trials for thyroid replacement are

required, which address appropriate clinical issues. Far from

restricting the development of evidence-based guidelines,

we need to be educated to use them constructively and to

ensure they are not misinterpreted or misused by people

who do not have a patient-focused agenda.

Graham P Leese1, Robert VW Flynn2, Thomas M MacDonald3,

Christopher Scho eld4, Alasdair D Mackie5

1,4,5Consultant in Endocrinology, 2Superintendent Pharmacist,

3Professor of Clinical Pharmacology, Department of

Endocrinology and Medicines Monitoring Unit, Ninewells

Hospital and Medical School, Dundee, UK

Email: [e-mail]

References

1 Toft AD. Thyroid hormone replacement – a counterblast to guidelines.

J R Coll Physicians Edinb 2017; 47: 307–9.

2 Flynn RV, Bonellie SR, Jung RT et al. Serum thyroid stimulating

hormone concentration and morbidity from cardiovascular disease

and fractures in patients on long-term thyroxine therapy. J Clin

Endocrinol Metab 2010; 95: 186–93.

3 Leese GP, Soto-Pedre E, Donnelly L. Liothyronine use in a 17 year

observational population-based study – the TEARS study. Clin

Endocrinol 2016; 85: 918–25.

4 Okosieme O, Gilbert J, Abraham P et al. Management of primary

hypothyroidism: statement by the British Thyroid Association

Executive Committee. Clin Endocrinol 2016; 84: 799–808.

[silverfox7]

Having shown slidesat such meetings in the dim and distant past it sounds very much like the normal procedure at these meetings. Many give papers on no end of subjects which in broad terms puts things in the public domain and basically others can then question it, point out irregularities or whatever. These meeting are held often and those interested in the topic for whatever reason can go and question it. The paper then can be accepted, discarded or suggested where it should go next. So an exchange of ideas can be the positive outcome if working broadly towards the same goal or it can I expect end in disaster. It must also be realised that drug companies put a lot of monies into research so it can in itself promote what it wants/hopes but then no guarantees that's how it works out. I knew of someone who spent years of trying to prove something that never quite succeeded so tried the converse and got that to be successful and the sponsers still got a successful drug out of it so a win win situation for them. Then in turn they could find someone else to take on a cause.