REDUCING INAPPROPRIATE SERUM T3 LABORATORY TEST ORDERING IN PATIENTS WITH TREATED HYPOTHYROIDISM.
Sue LY, Kim JE, Oza H, Chong T, Woo HE, Cheng EM, Leung AM
Abstract
Objective: Choosing Wisely is a campaign of the American Board of Internal Medicine that aims to promote evidence-based practices to reduce unnecessary ordering of tests or procedures. As part of this campaign, the Endocrine Society advises against ordering a serum total or free triiodothyronine (T3) level when assessing levothyroxine dosing in hypothyroid patients. This study was performed to assess and reduce inappropriate laboratory ordering practices among providers who manage patients with hypothyroidism within a large U.S. academic health system. Methods: A best practice alert (BPA) in the health record was developed and implemented following the collection of baseline data. This alert consisted of a pop-up window that was triggered when a serum T3 laboratory test was ordered for patients prescribed levothyroxine. The alert required user acknowledgement before the serum T3 laboratory test could be ordered. Results: During the six-week period prior to launching the BPA, serum T3 tests were ordered a mean of 162.3 ± 15.4 [standard deviation] occurrences per 10,000 patients per week. Over a 15-week period following implementation of the BPA, the frequency of serum T3 orders steadily decreased and resulted in >44% fewer inappropriate tests being ordered. Conclusion: Although national societal guidelines recommend against ordering serum T3 concentrations while monitoring patients with hypothyroidism managed with levothyroxine, these laboratory tests are frequently ordered. Development of a triggered alert in the health record may reduce inappropriate monitoring practices, decrease costs, and improve utilization of limited healthcare resources for this common clinical condition. Abbreviations T3 = triiodothyronine; BPA = best practice alert; ATA = American Thyroid Association; U.S. = United States; TSH = thyroid stimulating hormone.
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Is Big Pharma in their pockets? After all if all of our symptoms are resolved, we wont need so many more prescriptions, neither would we need so many blood tests nor consultations. I only get one a year now.
Dr Lowe stated that it was due to corruption amongst the pharma companies/professionals that NDT was eventually withdrawn and replaced with levothyroxine (T4 alone|) even if many patients recovered with NDT replacement.
I doubt there is 'evidence-based' results as each and every one of us would have 'different' numbers/doses . The pharma companies may not like the fact that their profits would drop if we didn't need 'extras' to control pain/symptoms.
Good grief!😳 How on earth can measuring the ACTIVE hormone be deemed 'inappropriate'? And patients treated with thyroxine are the very ones that need it testing. A 'Best Practice Alert'? They wouldn't know best practice if it jumped out on them! Only best for them and big pharma! If we'd all had 'best practice' we wouldn't be on this forum...appalling. I shall be 'choosing wisely' and staying well away from these idiots who seem to stop at nothing to keep us ill! 😕 x
I Couldn't Agree With You More greygoose . It's beyond shameful and irresponsible and yes even criminal the way the thyroid community is being treated or *Not* by Dr's . This has to *Stop*. Unfortunately Big Pharma has tremendous lobbyists working for them . And we as thyroid patients are paying a very high price for this . In more ways than one .
Total b*ll*cks. I’m beginning to think there is a conspiracy against hypos. We are becoming a shunned and mistreated community across the world! 🤸🏿♀️🥛
What a load of crap!!!!! When I was rushed in to hospital with thiyroid Storm my sister in law was with me I was out of it in A&E she said the person dealing with me requested immediate blood TSH and T3 T4.....they started me on drugs and I did recover, thiyroid was removed several months later..after the removal the day before I was discharged they took blood surgeon request TSH.T3 T4 full pannel...he recived the results that day the next day I was discharged saw him six weeks later he requested full pannel TSH T3 T4 being as I wanted to know everything about my care I asked what these bloods show he told me and did point out that T3 was the one he was concerned with then he also said the thyriod was considered the second heart it deals with ever cell in the human body..either my surgeon was doing the right blood work and didn't care about NHS guidelines or they just do these in hospital because my GP misses out the T3 as does the endo...but on seeing a GP at my surger she had only been their a week she diagnosed me on seeing me!!!! then requested the nurse to get blood work prepared she requested T3 T4 TSH...the only two she was concerned with on my return was the T3 and TSH..of course I had hyperthiyroidism ,,I think it needs to be addressed they can't miss out a relivent blood test like T3 no wonder thiyroid pacients don't get better if were missing out on the one important blood test....😡😡😡😡😡😡
Looks to me like they just want to kill us all off!with a very slow and painful death. I just don't understand why? It's hard enough getting your t3 tested already without this rubbish it's not like it's an expensive test cost is around 92p...
Should have asked more questions ! I have always read here that the T3 test is under a pound ! I assumed it was the lab that made the individual test charges.
Maybe we should all ask our GPs how much it costs for a T3 test and other awkward questions about it, (whilst pretending we know nothing) like why we can't have it, etc. then come back with our answers. Might be amusing, and at the very least will make them feel uncomfortable about it. We should all offer to pay for it too, if they blame cost.
It annoys me that we always have to be so subservient and just accept our lot. We need to stand up for ourselves more... and not just for ourselves, but for others in the future. I worry about how bad it will be for my daughters and granddaughters, should they become hypo if this nonsense is allowed to carry on. x
When I had TSH, FT4 and FT3 done by one of the private labs, it was just one sample required. I suspect the same is true for all labs.
Further, the lab cannot suddenly decide that FT4 and/or FT3 are also required (e.g. with very low or very high TSH) and measure in the same sample if an extra vial is required, can they?
So my NHS TSH test the other day would have cost exactly the same, with respect to blood draw, as if FT4 and FT3 were included.
I have t3, t4 and TSH done via my endo now and it's all just one vile of blood so as far as I can see no extra cost for blood draw! Think they just say that to fob you off
Huh! Welcome home Marz...thyroid related fibs on your first visit. At least you knew what to expect 😕 Perhaps they are placing an extra 'charge' on even asking for T3 tests now, although they needn't bother, because the labs usually outrightly refuse to do them anyway! Once the bloods' have been taken for their sainted TSH test, the draw has been paid for surely?
I actually saw a lovely GP recently who was leaving the practice two days after I found him (I didn't even know he was there, as I never go) he said 'oh yes, many people do a lot better on T3...I'm only sorry we can't test for it...they've stopped that for some unknown reason' shaking his head.
He won't last long in the system. He knew how the body worked. When I went to my local chemist and mentioned to the pharmacist how nice he was, and what a shame he was leaving, etc., she said if she had a pound for every person who had said that, she could leave work without her pension and not bother with marches anymore😳 Wow! Britain today...😂 x
So sad ! Yes I was well prepared for our GP visit ! She saw we were both on T3 and quickly said she was happy for us to self-medicate as she was unable to prescribe ?? !! I pointed out to her that we do not take any other meds - which at 80 and 73 she had to agree was unusual ! Of course the penny never drops !
Well that wasn't too bad if she was happy for you to carry on as you are...some GP's go into fits. Yes, sadly it's very unusual now for older people to not have the carrier bag sized haul of pharma drugs each month. I feel so sorry for them😢 Nobody bothers to explore alternatives or discover the root cause of their problems. They are even given poor advice about their diet, and make themselves worse.
I was disturbed a while ago when I spotted an elderly couple in M&S ~ he was loitering with a packet of organic Cornish salted butter in his hand (which I was trying to get to😂) and the woman left the trolley, tutted, and said 'put that down, you know what the Dr said...there's no point taking all those tablets and then eating that' etc. etc. He was dismayed. She then picked up a tub of Benecol and tossed it in the trolley. Of course, she thought she was doing the right thing... Dr's and the 'free' NHS are often revered by their generation, and quite rightly too, it's a wonderful service, but it's the growing tentacles of big pharma that they just don't understand...
Yes the unicorn GP was great, and he gave me hope for a brief moment. On speaking to an elderly woman who also thought him great, she said she'd been able to come off some of her meds, because he thought she was taking too many, and they didn't 'go together' ~ he won't last five minutes!😂 x
Sadly the Food Industry are like BigPharma - well supported by governments - sadly. We have to keep working through the maze of information to find the truth
Think of the cost saving if all the people who are also taking cholesterol medication and anti-depressants had their prescriptions for those drugs withdrawn because the doctor figured out that treating the hypothyroidism properly obviates the need for them. NHS would save a bundle (along with U.S. Medicare and Medicaid (program for the poor). But the drug companies would be quite unhappy.
Stupid systems run by stupid people....I bet if one of these power players had a family member without a thyroid or with severe thyroid disease they would do every thyroid test and medication combo under the sun without batting and eye.
When I lost my thyroid 3 yrs ago I never thought for 2 seconds that I would lose my health in the process and then be forced to deal with its aftermath alone without proper medical testing and care.
I totally agree with you Batty1. In fact I said it a long time ago we should only look for Dr's that they themselves or their family members/loved ones have thyroid issues . Maybe then they would be more understanding of our thyroid insufficiencies . Labs and Meds T3/NDT/T4 etc. included .
Why? Well, during that very slow and painful death, and in a vain attempt to keep ourselves going, we will no doubt require lots of pharma drugs, which they will be more than happy to supply. We will try them in desperation, unless we know better. It's very difficult for anyone not to come to the conclusion that it is entirely financially based. Imagine all the profits made from those with fibromyalgia and CFS too, who haven't even had a diagnosis of low thyroid, because only TSH is tested. It's fraudulent and criminal. x
This happened to me 20 years ago. I had been on levothyroxine for 10 years then over the following two years everything went wrong with me. My TSH was 1.6 I was deemed to be OK on the levothyroxine I was taking. Could not possibly be thyroid. Was told it must be all in my head and to take antidepressants. I would have been left to rot and die. I had a private blood test done for T3 which turned out to beunder range. A private doctor prescribed T3 and I became well again. I have had a good quality of life for 20 years because of T3. All those years all the doctors and consultants could/would do was go appopleptic because my TSH was suppressed but STILL nobody did a T3 test. It took years of groups like this to get more T3 testing and just as it seems we were getting somewhere, it looks like we are all going to be back to square one again.
Actually, this is happening in the US. (Maybe they are using the NHS as their model to follow?). Here are the Author affiliations:
Author information
1. From: 1Division of Endocrinology, Diabetes & Metabolism; Department of Medicine; University of California Los Angeles (UCLA) David Geffen School of Medicine and VA Greater Los Angeles Healthcare System.
2. Division of Endocrinology and Metabolism, University of California San Francisco School of Medicine.
3. UCLA Health Information Technology.
4. Department of Pathology, UCLA David Geffen School of Medicine.
5. Department of Medicine, UCLA David Geffen School of Medicine.
6. Department of Neurology, UCLA David Geffen School of Medicine.
Also, we saw in the Abstract: "a campaign of the American Board of Internal Medicine"
Sent an email to the principal researcher, A Leung:
"Disappointed" would be the mildest word I can think of to describe my feeling upon reading the abstract of your study: REDUCING INAPPROPRIATE SERUM T3 LABORATORY TEST ORDERING IN PATIENTS WITH TREATED HYPOTHYROIDISM. REDUCING INAPPROPRIATE SERUM T3 LABORATORY TEST ORDERING IN PATIENTS WITH TREATED HYPOTHYROIDISM. - PubMed - NCBI
Can you please explain why the Endocrine Society advises against ordering a serum total or free triiodothyronine (T3) level when assessing levothyroxine dosing in hypothyroid patients. Take a levothyroxine-treated hypothyroid patient who has lingering symptoms--sometimes severe--despite having a TSH within the reference range. How can the provider determine whether or not that patient has adequate peripheral deiodination without measuring the patient's FT3?
And if the patient does NOT have adequate peripheral deiodination, elevating the T4 treatment will not bring the serum T3 values into range.
But of course, the provider will never know this, since s/he has been advised not to test the serum T3 levels.
The patient will know, however, that she or she is still very ill.
Your Abstract states that the American Board of Internal Medicine aims to promote evidence-based practices to reduce unnecessary ordering of tests or procedures. There may well be a problem with the evidence they are using. Take this example:
Sawka AM, Gerstein HC, Marriott MJ, MacQueen GM, Joffe RT. Does a combination regimen of thyroxine (T4) and 3,5,3′-triiodothyronine improve depressive symptoms better than T4 alone in patients with hypothyroidism? Results of a double-blind, randomized, controlled trial. J Clin Endocrinol Metab. 2003;88(10):4551–5.
The study appears to provide evidence that adding T3 to treatment is totally ineffective. However, when you dig a little deeper, you learn "The dose of T3 was titrated by one of the investigators (H.C.G.), who had no contact with either the participants or those assessing psychological outcomes, to maintain the TSH concentrations within the normal range (0.52–5.0 mU/liter)."
Did the researchers think they were supposed to treat the patient's pituitary?
What we do NOT know from this experiment is what the effect on symptoms would have been if the dose of T3 had been titrated to maintain the FT3 concentrations within the normal range. So if studies like this are what the Endocrine Society and the American Board of Internal Medicine are using to justify their recommendation, they need to reconsider.
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