16 July 2019
Updated RMOC Guidance - Prescribing of Liothyronine
The Regional Medicines Optimisation Committee (RMOC) have clarified the guidance issued to Clinical Commissioning Groups (CCGs) on the prescribing of liothyronine. This updated guidance was published in July 2019 and can be found on this link.
14 July 2019
Repeat NHS prescriptions
In a bid to increase patient safety and reduce medicines waste, health commissioning groups across the country are changing the way repeat prescriptions can be ordered. In many areas, pharmacies will no longer be able to order medications from GPs on behalf of patients. Instead you will need to order your repeat prescriptions from your GP practice yourself.
You can request a repeat prescription in one of the following ways:
- Order online via GP Online Services (the safest and easiest way)
- Via the repeat prescription box at your GP practice. Just tear off part of your repeat prescription and hand in to your surgery
- Via post to your GP practice
- Email (this service is only available at some GP practices)
More information about how to register to use GP online services can be found here www.nhs.uk/GPonlineservices
Alternatively, if you feel you might need extra support ordering your repeat prescription, or you have more questions, please contact your GP practice or pharmacy.
Please note you will still be able to arrange for a high street or internet pharmacy to collect your repeat prescriptions from your GP practice and deliver medication to your door. However, you will need to order it from your GP yourself first.
21 October 2017
Over the last few months the availability of liothyronine (T3) has been in the spotlight and for some BTF members this has caused considerable concern. In August 2017 the British Medical Journal (BMJ) invited the BTF to contribute to an article which has now been submitted for publication. Below is the article which was submitted to the BMJ and which is also the front page story in BTF News 96.
For many years a small but significant number of patients have told us that despite having ‘normal’ TFTs they do not feel well on levothyroxine (L-T4) alone. Whilst the evidence for its use has always been disputed, some patients, usually under the guidance of their endocrinologist, have had the opportunity to try liothyronine (L-T3). Although not a solution for all patients there are undoubtedly significant numbers who feel that L-T3 has given them their life back again and that life without it is unthinkable.
An online petition calling for improved treatment protocols for hypothyroid patients currently has almost 20,000 signatures.
The current situation – triggered by what would appear to be an unjustifiable cost increase – has left patients, and many of their doctors, in a very difficult position. We are hearing from patients who have been treated with L-T3 for many years who feel they have now been abandoned without care, and whose doctors, no longer able to prescribe it, are leaving them to their own devices and in some cases even advising them to buy L-T3 on the internet (where it is available from other countries, and at much lower prices than in the UK). Sadly the relationship of trust between doctor and patient has been seriously compromised. Patients are confused as to the reason why their doctor’s decision to prescribe L-T3, based on clinical judgement, is now being blocked. Is the real reason for the restriction due to recent price increases or to sudden doubts about the strength of evidence for its use? Should clinical need not come before financial considerations? Who should have the final say about whether there has been an improvement in patient well-being?
The proliferation of online health information and forums has added to the confusion. Access to peer support is often beneficial but unfortunately patients sometimes find misleading and false information about their condition and the treatment options, and the consequence of this can lead to faith in their own doctors being undermined, and they are left concerned and confused.
We would welcome:
- market controls that prevent suppliers being in a position to dominate the market and cause such upset in the future
- a greater consensus of medical viewpoints with the aim of providing a clear message to patients, and reducing the current ‘postcode’ lottery of care and the need that some patients feel to have to ‘shop around’
- more research to clarify the effectiveness and long-term safety data of L-T3 and combination therapy and to help determine which patients may benefit from such treatments
- greater empathy for the thyroid patients who do not feel well, including helping them to understand their diagnosis and treatment, and signposting to quality patient information which may avoid the confusion that can arise when patients research the available treatments on the internet
20 December 2016
Liothyronine (L-T3) and Levothyroxine (L-T4)
Answering patients’ questions
The management of primary hypothyroidism with Levothyroxine is usually simple, effective and safe, and most patients report improved well-being once they have started treatment. However medical professionals recognise that a proportion of individuals continue to suffer with symptoms despite apparently having thyroid function tests falling within the normal range.
For patients who have clearly not derived benefit from L-T4, endocrinologists (thyroid specialists) sometimes decide to begin a trial of L-T4/L-T3 combination therapy. Such patients should be supervised by accredited endocrinologists after a fully informed and understood discussion of the risks and potential adverse consequences.
We are aware that a number of patients have been advised by their GPs that L-T3 is no longer available for the treatment of hypothyroidism and that they use L-T4 as an alternative treatment. We understand that this is as a direct result of the sharp increase in price of L-T3, which the NHS does not believe is sustainable. The sudden non-availability of L-T3 has caused considerable concern and we therefore feel that some clear advice would be helpful. The BTA has produced a similar FAQ sheet for GPs which you can print off and take with you to an appointment if you believe it would be useful.
What is the BTA and the BTF’s position as regards the withdrawal of L-T3 therapy?
The BTA and BTF believe that clinical need should come before financial considerations and they therefore do not support the practice of sudden withdrawal of L-T3 therapy. Patients established on L-T3 who continue to derive benefit from its use should continue to use it. However, patients with uncertain benefits should be considered for a switch to L-T4 and advice should be sought on how this can be safely done.
I have been on Liothyronine (L-T3) a long time. Is there any problem with switching me to Levothyroxine (L-T4)?
Your doctor should have made you aware of the risk to your thyroid stability. A change in treatment can unfortunately result in a significant instability in thyroid status, which can take some time to address.
Is there a resource to which I can refer with regard to the use of Liothyronine (L-T3)?
Yes there is a 2015 BTA Statement on the Management of Primary Hypothyroidism. This summarises the evidence for the use of Liothyronine and states that we have yet to see conclusive evidence regarding its efficacy for this condition. Therefore combination treatments of Liothyronine and Levothyroxine should be started and supervised by an accredited endocrinologist rather than a GP.
Is there any problem in switching me to just Levothyroxine from combined Liothyronine (L-T3) /Levothyroxine (L-T4) or from Liothyronine?
This has to be made gradually with the aim of avoiding under- or over- replacement. The final L-T4 requirement is likely to be around 1.6mcg/kg. If there is any information about a previous L-T4 dosage that achieved a normal TSH this will be a useful guide. Gradual reduction of L-T3 starting at the same time as introducing L-T4 may be a preferable alternative. Careful monitoring of the patient during the transition period is essential.
Can I be switched from Liothyronine (L-T3) to Levothyroxine (L-T4) if I have been diagnosed with thyroid cancer?
Switching from L-T4 to L-T3 is part of a standard protocol used in patients with a history of thyroid cancer in preparation for radioiodine ablation, radioiodine therapy, iodine scanning or stimulated thyroglobulin test, so access to L-T3 is imperative.
Are there any particular patients who merit extra caution?
If you are over the age of 60, or have known heart disease, additional care is required to avoid over-replacement and L-T4/L-T3 combination therapy or L-T3 only therapy. L-T4/L-T3 combination therapy or L-T3 only therapy are not recommended if you are pregnant.
What is your advice concerning the use of desiccated animal thyroid extracts?
This issue is addressed in the 2015 BTA Statement on the Management of Primary Hypothyroidism. These thyroid hormone preparations are not currently recommended in the management of hypothyroidism.
Adverse side affects to thyroid medication
Have you had any adverse side effects to your medications? If so you can report them to the Yellow Card Scheme. The scheme, run by the MHRA and the Commission on Human Medicines, is used to collect information from both health professionals and the general public on suspected side effects. Find more information on their website.