New paper probing rT3 test value

[diogenes]

New paper in Thyroid describing possible use of and prescribing of rT3 tests in the US:

Clinical Utility? An Analysis of Practice Variation Based on Order Data from a National Reference Laboratory

Schmidt Robert L. , LoPresti Jonathan S. , McDermott Michael T. , Zick Suzanna M. , and Straseski Joely A.

Published Online:1 Jul 2018doi.org/10.1089/thy.2017.0645

Abstract

Background: Clinical laboratories are under pressure to increase value by improving test utilization. The clinical utility of reverse triiodothyronine (rT3) is controversial. A study was conducted to identify order patterns that might suggest inappropriate utilization of rT3.

Methods: All orders for thyroid tests placed over a period of one year at a national reference laboratory were reviewed. Order patterns by client (hospital) and by provider were analyzed. A Pareto analysis was conducted to determine the percentage of orders placed as a function of the percentage of providers. A systematic review of the indexed literature and an informal review of the web were conducted to identify indications for rT3 testing.

Results: There were 402,386 orders for 447,664 thyroid tests, including 91,767 orders for rT3. These orders were placed by 60,733 providers located at 1139 different organizations. Only 20% of providers who ordered thyroid tests placed an order for rT3. Of those who placed an order for rT3, 95% placed two orders or fewer for rT3. One hundred providers (0.1% of the 60,733 providers who placed orders for thyroid tests) accounted for 29.5% of the orders for rT3. Of the 100 providers, 60 with the highest order volumes for rT3 were classified as practitioners of functional medicine. A systematic review of Medline found little evidence to support the high volumes of orders for rT3. A survey of Web sites for functional medicine suggests that rT3 is useful for the diagnosis of rT3 dominance and can be used to direct triiodothyronine replacement therapy.

Conclusions: There is wide practice variation in rT3 testing. A high proportion of tests are ordered by a relatively small proportion of providers. There is little evidence to support high volumes of rT3 testing placed by some practitioners.

This indicates someuse for rT3 testing, but only for certain conditions.

[Judithdalston]

Interesting- I got the impression from US members of this forum that RT3 tests were more of a 'norm' there - obviously not! Wonder what the 'certain conditions' were that dominated the need to request RT3 that couldn't be confirmed by rest of thyroid results?

[LAHs in reply to Judithdalston]

Hi Judith, no it is not the norm (in the US) but it is included in private labs' "complete thyroid panel" blood tests. My sweet doctor once did as I asked and requested to have rT3 included in their (the hospitals) blood tests - gosh I was so happy. When I got to the hospital's lab I was told by the receptionist that they didn't have that one in their repertoire, in fact they had never heard of it!

[Judithdalston in reply to LAHs]

Ok- you will have gathered lots of Gb members think it is a waste of money. Some Us members seem to test for everything under the sun because medical insurance allows it sometimes- Our NHS is struggling on the 'basics' re thyroid health!

[LAHs in reply to Judithdalston]

Oh my gosh no, our insurance situation is far worse than the NHS. Health insurance for the majority of people is not affordable, for some of my friends it is about $700 per month per person. That is twice my mortgage. I pay $280 for a full thyroid panel about once a year. If nothing changes, that is good. My doctor does an obligatory TSH and T4 every year and we both ignore the results - well, he tells me my TSH is too low and I say, "That doesn't matter", we both ignore each other and nothing changes - including my excellent health. If you are prepared to pay the $280 and study the results, you are OK. It all hinges upon the education of medics, perhaps it will change in the future, I do not know. For the time being I am all right Jack but I dread the day when I will be dependent upon the knowledge of an Endo because, so far, I have been amazed at their ignorance.

[UrsaP in reply to LAHs]

That sounds like a good relationship with your dr. He is voicing concerns but as long as the meds are working for you, he has done his duty and given you the responsibility. Treating you like an adult. I am totally amazed and angry that so many Endo's are so ignorant, that is bad enough but they impose their ignorance onto patients. They will not admit they are not 'expert' enough. Patients are being treated according to the low level of training - which means that these Dr's and specialists are able to cover themselves for their poor understanding and abilities in this area as they can claim that they are treating according to their training and knowledge. They don't seem to care that it is 'p' poor training and understanding. Have they no desire to improve their knowledge and understanding? Is there not a duty for them to continue to keep up to date with all the new thinking coming out?

[LAHs in reply to UrsaP]

Yep, agree with every word. My very first GP was good in as much as neither of us knew anything about endocrinology but we learned together, he was interested, he studied up on things and was delighted that I was willing to change doses, have as many blood tests as needed and change things if necessary. He let me experiment as I wanted too and finally WE got me very well. Of course, he retired about the same time as Forest Pharma (my Levo source) went out of business, this was a double whammy. I then had to be managed by an ignorant Endo... But the rest is history, I'm OK now.

[UrsaP in reply to LAHs]

Glad you are ok now. But sadly the days of understanding Dr's has long gone, not the fault of the Dr's, on the whole, due to lack of training and perhaps the incorrect training which seems to leave Dr's thinking they know all there is to know? Science is only as good as the knowledge of the day. Also due to lack of time to focus on specific patients. How often do we go to GP or Endo and see the same person twice? There is no continuance. Dr's no longer remember your history as they have too many patients to deal with. They don't get the big picture as most appointment times allow for only one symptom to be discussed. etc...etc...

[Katepots]

It seems to be a pointless test here as even if you have high RT3 there is no help available anyway. Most GP’s haven’t even heard of it. 😳

[UrsaP in reply to Katepots]

And some Endo's have not heard of it either, as one said last year at an appointment. Nor did he know what NDT is??? What ARE they taught? Diabetes only! Or maybe it is only Diabetes that features in any testing.

[Katepots in reply to UrsaP]

My Endo even asked me what K2 was, the mind boggles!

[UrsaP in reply to Katepots]

My local CCG chap told me that they were doing an 'audit' of those of us on T3 still, to see when we last saw Endo's with a view to sending us back, if we have not been recently (WHY? -surely only with a view to tell us we don't need t3 -because the Endo 'doesn't believe in it' ???) I told him I would not be happy being sent to an Endo that had such little knowledge of thyroid conditions that they do not even know of rT3 or NDT. He did say that it was something they were also looking into, the 'right' Endo's...hummmm! Will be interesting to see who they will want us to see. I'm likely to be telling them to take a jump!

Why do I need to go to an Endo when my meds are reasonably stable and have been for years. And taking the T3 has had no adverse effect? Time wasting.

Hopefully they will realise how futile this all is.

[shaws Administrator in reply to UrsaP]

I agree. GPs and Endocrinologists are as much good at treating - once diagnosed - as getting a diagnosis can take quite a long time because symptoms are unknown.

The medical profession prefer TSH and T4 against patients' clinical symptoms. Therefore it can be years before someone is, finally, diagnosed but who have been prescribed other medications i.e. anti-depressants or pain relief etc in the meantime. Patients may lose their livelihoods etc. maybe even marriages etc.

Some may be driven to distraction with clinical symptoms as was Lorraine Cleaver who wanted to end it all but thankfully saw Dr Skinner who saved her sanity and life.

The professionals should return to diagnosing upon clinical symptoms then thousands woud be saved on blood tests - patients allowed to try different methods of replacement if levo doesn't improve their health.

[UrsaP in reply to shaws]

Yes shaws It took me over a decade, following a 2 year stint with an Endo, to get a diagnosis, 'there was, wasn't' evidence in the bloods. - To my simple mind - surely common sense should have told them there was a problem, even if intermittent, something was causing problems. Instead he just dismissed me with a condescending wave of his hand. When diagnosed 10 years later, all because they got a blood test whilst the goitre was visible, they put me on T4 and spent 20 more years ignoring me saying it wasn't working. Offered and given Anti-D's at one point - did nothing - as not the problem. Eventually read about T3 and fought to see an Endo to get it. Got a small amount and then after 18mths when things went downhill again, Endo started focusing back on the blood tests. I ended up giving up my teaching job as just so wiped out. Know now that was the knock on effect on the adrenals, making things worse. So dropped Endo and saw Dr P. Only wish I'd seen him 30 years earlier! Been on T3 only for 8 years and just let anyone tell me they are taking it off me!!!

[shaws Administrator in reply to UrsaP]

I know exactly what you mean but they all seem to be so insensitive to people who cannot and do not recover with hormones that don't suit their bodies and they still insist that levo is all that is to be prescribed. Some poor people who don't have internet access will die through being neglected by those who are supposed to have studied about hypothyroidism and might well have developed other more serious illnesses.

[UrsaP in reply to shaws]

I wonder how many deaths there have been from heart, diabetes, mental health and who knows what else, all these people who die, from 'nondescript' illness that no one seems to be able to pin a diagnosis on, deaths that may have been avoided if thyroid health was better understood.

Just how many deaths that are borne out of failing thyroid health but not allocated to thyroid disease?

It seems to be a tactic in the UK - don't keep records, that way they can ignore what those records would have shown...i.e. the benefit of T3... Where are the figures of failing T4 treatment?

That is why so much documentation quotes 'little or no evidence of benefit' of T3. The evidence is there in the patients who are using it and benefiting from it but they have not recorded that anywhere.

If patients can find all this new information that is helping them, through researching the internet and reading, why are Dr's not looking or ignoring it? They should be doing the research themselves, especially Endo's - as specialist they should be keeping up with all developments in this area. They are failing in their professionalism if not.

They should be held accountable for their ignorance.

[UrsaP in reply to UrsaP]

That said the NHS do say they have a 'No blame' ethos. How very convenient for them!!!

[shaws Administrator in reply to UrsaP]

The same applies to the doctor who told my mother - years after being diagnosed with pernicious anaemia - and after a blood test was told she no longer needed B12 injections and my sister and I, in our confidence in doctors, thought and said 'that's great Mum'.

Little did we know of the awful consequences of this decision by a doctor. My Mum died an awful death with undiagnosed/untreated stomach cancer.

She was being given a myriad of antacids (I assume) instead - being undiagnosed.

When first she was admitted to hospital I phoned and said 'my mother had Pernicous Anaemia' little knowing that once diagnosed it is for life. I too have PA now.

There's no looking back and it is one of life's worst memories. It needn't have happened.

[UrsaP in reply to shaws]

How awful. And yes the victims of of this poor attitude and understanding is not just the patient themselves but all those left behind. I suspect my mother was HypEr all her life, the signs were there, lots of HypEr in the family. And I suspect her mother also had thyroid problems as they say she went a bit 'odd'. My mother was never diagnosed with HypO or HypEr despite goiters being obvious 15 years ago. She died two years ago, she had two different types of thyroid cancer. One quite rare. By the time they found it it had spread to her lungs and who knows where else.

She was 90 when she died, and despite the advanced stages she survived well and fought it mentally for over 2 years from diagnosis. Her attitude was 'I've got it, can't do anything about it...just get on with life. The end was quick and as she wanted, she died in her own bed. If she was in pain she insisted she was not. I took a lot of comfort in that.

I can't begin to imagine how awful it must have been to watch your mother suffer so. Made so much worse by knowing it could have been so different. As I said there is no accountability. The Dr's hide behind their own ignorance and poor knowledge. My heart goes out to you.

[shaws Administrator in reply to UrsaP]

It is 25 years ago so you come to terms with things that happen in life and not become embittered. It makes you more aware not to take 'diagnoses' without getting second opinions at least.

I'm sorry about your Mum too but when you have a family that care about you it makes such a difference than being alone.

[UrsaP in reply to shaws]

I would imagine that the horrors of the situation with your Mum will never fade, but as you say, you have to find a way of coming to terms. Yes, always research and look into options and never just accept what one Dr says. I recall a friend from 30+ years ago - lovely young lad, so much potential. He had a pain in his leg, ongoing, Dr kept saying it was where he had been kicked playing football. Eventually he asked for a second opinion to find he had tumours, secondary cancer, 18 months later he was gone. Aged 22. So incredibly sad. Dr can make too many and too easy assumptions!

We were lucky, we had Mam for a long time and she was an amazing lady. She always saw the good in everyone. I am from a big family but sadly split. I had one close sister (out of 5!) and was lucky enough to have another find us about 3 years ago. We have become very close and she has an amazingly lovely family too.

I count my blessings. I had some great quality time with Mam as I spent those last two years with her, I had the honour of being her carer for that time, and I got a new and lovely sister to boot.

[UrsaP]

linda96

[UrsaP]

"A study was conducted to identify order patterns that might suggest inappropriate utilization of rT3." Think this says it all!

I notice is does not mention the ratio of positive test results as opposed to negative. It should not be about the number of tests ordered, or whom ordered by, and no surprise most requests from functional medics, as we all know, most general medics do not even know what T3 is these days, never mind rt3, so not surprising all the test requests from a limited - knowledgeable source. It should be about the need for the rt3 - how many of those tests showed high rt3 levels?

This sort of research makes my blood boil - what a waste of time and money - it is all about cost saving at the cost of patient health. Proving they are not testing it enough to allow them to stop testing all together maybe.

Again, if that is the case we have to start questioning what it is they don't want us to know about thyroid health.