Shared Decisionmaking in the Treatment of Hypothyroidism - new from Bianco AC

[helvella]

I suggest you read this line to your OWN benefit:

Guidelines from leading endocrinology organizations now recommend considering combination therapy for patients with persistent symptoms despite adequate LT4 dosing.

That is, if the endocrinology organization your doctor is referring to does NOT recommend the consideration of combination therapy, then they are obviously NOT a LEADING organization. They are some rather second-rate outfit that is out of date...

Shared Decisionmaking in the Treatment of Hypothyroidism.

Bianco AC 1

Author information

Clinical Endocrinology, 12 Mar 2025,

doi.org/10.1111/cen.15228 PMID: 40077932

Abstract

Hypothyroidism, a condition characterized by an underactive thyroid gland, affects millions worldwide, leading to cognitive and metabolic slowdowns. It is most prevalent in women and older adults, with causes including autoimmune thyroiditis, surgical thyroidectomy, and certain medications. The standard treatment involves synthetic levothyroxine (LT4) monotherapy, which alleviates symptoms by converting to the active hormone, T3. However, some patients continue to experience symptoms such as fatigue, mood disturbances, and poor quality of life despite normalized TSH levels. This persistence of symptoms may stem from misdiagnosis, inadequate dosing, or incomplete normalization of thyroid hormone signaling. Research suggests that LT4 monotherapy may not fully restore T3 levels, leading to suboptimal symptom control. Consequently, combination therapy with LT4 and liothyronine (LT3) has been proposed as an alternative, aiming to balance T4 and T3 levels more effectively. Although randomized controlled trials have not identified significant differences in patient-reported outcomes between LT4 monotherapy and combination therapy, they indicate that patients may prefer the latter. Guidelines from leading endocrinology organizations now recommend considering combination therapy for patients with persistent symptoms despite adequate LT4 dosing. A patient-centered approach, emphasizing shared decision-making and individualized treatment plans, is essential for optimizing outcomes in hypothyroidism management. Further research is needed to refine dosing strategies and identify the patients who would benefit most from combination therapy.

Open access:

doi.org/10.1111/cen.15228

europepmc.org/article/MED/4...

onlinelibrary.wiley.com/doi...

PS I'd use a hyphen to make it Decision-making - but I'd rather quote absolutely accurately.

[JoJoloveschocolate]

Thank you for posting this helvella .

[healthkiwi]

"if the endocrinology organization your doctor is referring to does NOT recommend the consideration of combination therapy, then they are obviously NOT a LEADING organization. They are some rather second-rate outfit that is out of date.."Love it!! Can we circulate to the ICBs? Extra copies to certain high profile departments of dinosaurs who are removing T3 as an option?

Bianco turning out to be a knight on charger, armed with the sword of solid research analysis.

[helvella in reply to healthkiwi]

I'd be delighted to see a story where the email inboxes of every ICB had filled up due to people doing precisely that!

(Note: This is not meant to support spamming. but if every single registered member of this forum sent it to just their ICB, and maybe the neighbouring ones, that would be an awful lot of email. That is, members simply expressing themselves using their own names and emails.)

[helvella in reply to healthkiwi]

Just to be clear - those words are MY interpretation! Not Antonio Bianco's!

I wouldn't wish anyone to mis-attribute as my words go further than he was willing and he might disagree with me. (Entirely his choice - of course. )

[Star13]

That’s rather nice for a change! Thanks for posting Helvella.

[AKatieD]

Hopefully a step in the right direction.

I don't like the "patient preferred" usage as I think that will make the naysayers go, oh they "preferred" the expensive treatment did they, well tough. Just because they "preferred" it, we don't need to prescribe it.

I also don't believe the "Although randomized controlled trials have not identified significant differences in patient-reported outcomes between LT4 monotherapy and combination therapy" as there must be loads of us who can identify significant differences in outcomes when on T3.

[Bearo in reply to AKatieD]

Nearly all the studies I’ve looked at say they couldn’t find benefits for adding Lio to therapy in randomised trials. But I think that’s because they had no idea on starting low and slow, so obviously there would be lots of failure. That and continuing to focus on TSH .

[helvella in reply to Bearo]

That, plus the widespread tendency to drop L-T4 by a significant amount - sometimes far more than we would estimate/guess for the L-T3 dose being added.

[AKatieD in reply to Bearo]

Yes agree, if they ask the right questions and look at the right measures, they would get different answers as we are starting to see

[BB001]

Thanks for posting helvella.

Although randomized controlled trials have not identified significant differences in patient-reported outcomes between LT4 monotherapy and combination therapy

It would be good if this bit had said why the randomized controlled trials don't highlight differences. The reasons I can think of are:

1) insistence in dosing T3 by TSH when T3 has a more suppressive effect on TSH than T4. This has the effect of under- dosing people on T3. A better way would be to dose by fT3 and fT4 levels.

2) the statistical 'hiding' of the effects on the minority of patients who continue to have symptoms on T4. There needs to be research using only this cohort of patients. That way the effects on them would be identified and could be explored.

3) the lack of measurement of fT3 levels and their relationship to fT4.

[helvella in reply to BB001]

I think because they don't use the necessary techniques.

For example, we all know that questionnaires can very easily mislead - the subjects and the researchers.

I'd be interested to see very detailed interview approaches to people who have had to switch between combination and LT4-monotherapy - preferably several times. After all, they are among the few who will undoubtedly have spent some considerable time trying to understand the differences. And that will lie behind their choice to repeatedly try combination. And - all too often - their going to LT4-monotherapy will have been perforce - not a free choice. Cost. Availability. Having a prescriber.

[Regenallotment Ambassador]

I think my NHS Endo must have just read this - lucky me 👏

Thanks for sharing.

[RedApple in reply to Regenallotment]

Let's hope your GP reads and understands it to!

[Regenallotment Ambassador in reply to RedApple]

Yes I will send her a copy I think