The PrescQIPP Recommendations - NOT A BAN on T3

[holyshedballs]

PrescQIPP has a bulletin for Liothyronine "recommending" that doctors switch patients using T3 to T4.

Here are the actual "recommendations".

Ensure that prescribing of thyroid hormones is in line with British Thyroid Association (BTA) guidance.2 british-thyroidaassociation...

• Commence new patients requiring thyroid replacement on levothyroxine.

• Review all patients taking liothyronine (alone or in combination with levothyroxine) for suitability for switching to levothyroxine. Switch all suitable patients to levothyroxine. For patients under the care of a relevant specialist, involve them in the decision to switch to levothyroxine.

• It may be necessary in some cases to establish patient is genuinely hypothyroid before swapping (historically confirmed on biochemistry in accredited NHS lab or if not stop treatment and show thyroid stimulating hormone (TSH) rise). In these cases, start with standard dose of levothyroxine and titrate.

• CCG Medicines Management Teams should liaise with local endocrinologists to ensure that prescribing is consistent across the interface between primary and secondary care.

• As with all switches, these should be tailored to the individual patient.

Note that the "recommendations" state that PrescQIPP recommend that only suitable patients are switched to levothyroxine. PrescQIPP further recommend that as with all switches, these should be tailored to the individual patient.

Important points.

These are RECOMMENDATIONS.

Even PrescQIPP say that swaps should be for SUITABLE patients and tailored to the individual patient.

THIS IS NOT A BAN.

IF you are already on T3 then you are not a suitable patient for a swap because T4 cannot in your case do what T3 does. Your medication has been individually tailored to you as PrescQIPP recommend.

The first recommendation they make is for the prescribing of T3 in line with the BTA statement. This is itself unlawful, by interfering with the doctors duty to comply with GMC guidance to work with the patient see Montgomery v Lanarkshire Health Board 2015 and also to use his/her skill and judgement see R (ex parte Pfizer Ltd) v. The

Secretary of State for Health. Case C/2002/0860. 6 November 2002. .

However, the BTA refute PrescQIPP's interpretation of their recommendations The BTA have issued a further statement advising that T3 should be prescribed for those that need it. british-thyroid-association...

This should nullify the recommendations because most of the them drawn from the BTA statement yet the BTA itself is correcting PrescQIPP.

Your doctor should not simply call you in to tell you that your T3 is being discontinued. According to the GMC

The doctor and patient make an assessment of the patient’s condition, taking into account the patient’s medical history, views, experience and knowledge.

The doctor uses specialist knowledge and experience and clinical judgement, and the patient’s views and understanding of their condition, to identify which investigations or treatments are likely to result in overall benefit for the patient. The doctor explains the options to the patient, setting out the potential benefits, risks, burdens and side effects of each option, including the option to have no treatment. The doctor may recommend a particular option which they believe to be best for the patient, but they must not put pressure on the patient to accept their advice.

The patient weighs up the potential benefits, risks and burdens of the various options as well as any non-clinical issues that are relevant to them. The patient decides whether to accept any of the options and, if so, which one. They also have the right to accept or refuse an option for a reason that may seem irrational to the doctor, or for no reason at all.

If the patient asks for a treatment that the doctor considers would not be of overall benefit to them, the doctor should discuss the issues with the patient and explore the reasons for their request. If, after discussion, the doctor still considers that the treatment would not be of overall benefit to the patient, they do not have to provide the treatment. But they should explain their reasons to the patient, and explain any other options that are available, including the option to seek a second opinion.

This is where you show your knowledge of your condition and your knowledge that the doctors are acting under recommendations not a ban. Those recommendations also require that only suitable patients are swapped and you are not suitable for swapping. Then you should produce the PrescQIPP document and the BTA document and tell the doctor that to swap you to T4 would be illogical based on incorrect interpretation of BTA guidance which the BTA itself refutes.

However the CCG could have taken a decision to "ban" T3 based on the PrescQipp bulletin but the same principles apply to the CCG as to the doctor. In my view it is so illogical and unlawful it is ripe for Judicial Review.

I haven't done this myself because I'm not on T3 yet.

[jimh111]

The liothyronine 'guidance' was written by a pharmacist with no expertise in treating hypothyroidism. This bulletin has done enormous damage to thyroid patients with no accountability. If a doctor refers to PrescQIPP refer them to the source of the 'information'.

[holyshedballs in reply to jimh111]

I cant be certain but it appears to me that all she has done is trawl the internet for information to support swapping T3 for T4. It appears to me that she has purposefully misinterpreted the BTA statement. As i said, even the BTA are up in arms bout the statement's misuse.

The opening recommendation - to only follow the BTA statement is unlawful

the fourth - to check that patients are genuinely hypothyroid - is outrageous and will drag many back to the tyranny of the TSH NORMAL range it seems to me.

It is so badly written and researched yet many CCG are using it with no critical appraisal, in my view.

I wish we had the resources to Judicially Review this document or any decision based on it. I'm sure we would win hands down. Unfortunately a JR has to be commenced by a person affected by it.

In the intervening period, we should fight it where ever and however we can, and in my view empowered patients challenging doctors is a good first step.

[holyshedballs in reply to jimh111]

From its own site, PrescQIPP was a group of pharmacists who set it up in one CCG. The express purpose was to find drugs that are cheaper replacement drugs for some expensive drugs.

They have no business "recommending" to doctors which guidance they should follow. That is for the doctor and the "empowered" patient to decide in accordance with GMC guidelines and recent case law. This document rides rough shod over those important (legal) principles.

PrescQIPP has widened its own scope and, as you have suggested, I believe to areas outside its expertise such as managing hypothyroidism.

However, the patient in the consulting room doesn't normally have this forum to hand so its important to give the form members as much information as possible to take with them into the consulting room.

[holyshedballs in reply to jimh111]

Finally, the accountability is via Judicial Review in my view. PrescQIPP, although it states that it is a Community Interest Company, is acting as a public body and therefore is open for JR but it has to be taken by a person affected by their decision.

[helvella Administrator Thyroid UK in reply to jimh111]

It gives me a distinctly uneasy feeling that the author is, apparently, living in Australia while writing things for the UK.

[holyshedballs in reply to helvella]

Blumming Hummer !!!

That is pretty bad in the accountability stakes.

[helvella Administrator Thyroid UK in reply to holyshedballs]

Summary

I am currently living in Australia and offering a remote consultancy business as a UK registered pharmacist. With expertise in a range of healthcare settings, I have managed successful NHS healthcare projects and have experience in a range of areas. Consequently, I am able to deliver high quality, bespoke pieces of work.

au.linkedin.com/in/gemma-do...

[holyshedballs in reply to helvella]

PFT!! That's outrageous. She cant possibly respond to concerns raised about UK issues properly. Certainly by remote control.

[jimh111 in reply to helvella]

It's not so much her location but the fact she has no knowledge of hypothyroidism. Doesn't even understand the difference between triiodothyronine, liothyronine and NDT. The blame is also shared with PresCQIPP and the CCGs who fail to check the credentials of the people they hire.

[holyshedballs in reply to jimh111]

As I said before even the BTA are unhappy about her use of their statement.

Perhaps someone could give his Noble Lordship a nudge?

[humanbean]

Create a document for doctors to read called a DROP List and many of those same doctors will read that as a definite instruction to end prescription for anything given on the list.

The fact that "DROP" stands for "Drugs and Devices to Review for Optimised Prescribing" will be forgotten and the word "DROP" will be remembered - as was quite clearly intended when the acronym was decided upon.

prescqipp.info/droplist/pro...

[Zephyrbear]

'It may be necessary in some cases to establish patient is genuinely hypothyroid before swapping (historically confirmed on biochemistry in accredited NHS lab or if not stop treatment and show thyroid stimulating hormone (TSH) rise). In these cases, start with standard dose of levothyroxine and titrate.'

STOP TREATMENT??? So years of being treated with thyroid hormones to stabilise this bloody condition could be withdrawn altogether just to prove to some numpty that a patient is hypothyroid if their TSH rises... Especially those who have been on T3 for a long time and whose TSH is no longer released.

These ignorant idiots are going to end up killing people!

[holyshedballs in reply to Zephyrbear]

Yes its totally outrageous, requiring people to be ill again just so that an Endo can see TSH rise. iI is my view that PrescQIPP have acted completely ultra vires i.e. beyond their self designated remit. PrescQIPP are pharmacists not Endocrinologists and should not be making treatment recommendations.