Use of liothyronine (T3) in hypothyroidism: Joint British Thyroid Association/Society for endocrinology consensus statement (June 2023)

This joint consensus statement aims to provide practical guidance to clinicians on treating patients who have persistent symptoms when being treated with thyroid hormone replacement. 

Consensus statement

Patient leaflet about the use

Liothyronine (T3) prescribing report (June 2022)

The price of T3 has come down by 75% since 2017 to a current price of £63 per packet. However, many patients deemed to have a clinical need for this drug by an NHS endocrinologist still struggle to get it prescribed on the NHS.

A recent survey conducted by thyroid patient organisations has revealed that 58% (61) of CCGs are continuing to withdraw, refuse or reduce liothyronine prescriptions across England. This is primarily due to Clinical Commissioning Groups (CCGs) either not following or misinterpreting national guidance on T3 prescribing which is set out in the Regional Medicines Optimisation Committee (RMOC)  liothyronine prescribing guidance and referenced in the National Institute for Health and Care Excellence (NICE) NG145 guideline: Thyroid disease: assessment and management. Patient groups have submitted a report recommending that: 

1. All CCGs, and Integrated Care Boards in future, adopt national guidance on T3 prescribing

2. National guidance for thyroid drug prescribing (including T3) is simplified to ensure CCGs correctly interpret its formulary policies

3. T3 is no longer classified as a high-cost drug 

We hope this report will lead to widespread adoption of the national prescribing guidance to end the current postcode lottery on T3 prescribing. 

Advanz Pharma and partners fined for ‘excessive and unfair price’ of liothyronine - July 2021

We welcome the decision by the Competition and Markets Authority (CMA) to fine pharmaceutical company Advanz Pharma and its private equity partners £100 million for inflating the price of liothyronine tablets. 

The firms were found to have taken advantage of the lack of competition in the market and inflated the price of liothyronine. The price increases could not be attributed to investment or innovation nor changes in production costs or sales volumes. This resulted in the price paid by the NHS for the drug sky-rocketing from £4.46 in 2007 to £258.19 in 2017. This price inflation of more than 6,000% made the drug unaffordable to the NHS. From 2015 many doctors were subsequently no longer able to prescribe liothyronine to patients. This resulted in many patients’ liothyronine treatment being withdrawn causing unnecessary suffering, and often expense, for patients. 

We hope this decision will mean the price will now come down in line with other countries where it costs a minimal amount and that patients with a clinical need for this medication will be able to obtain it more easily on the NHS wherever they live in the UK. 

GOV.uk statement  

ATA/BTA/ETA consensus document on evidence-based use of levothyroxine (T4)/liothyronine (T3) combinations in treating hypothyroidism.

We are grateful to the doctors and patients who met to discuss the current evidence for the use of combination therapy (T4/T3) for hypothyroidism and have produced this important consensus document. We look forward to future clinical trials that will improve understanding and patient care in this area.

ATA/BTA/ETA consensus document

July 2020 – Norfolk Thyroid Group 

The Norfolk Thyroid Group successfully campaigned to have L-T3 reinstated as a treatment option for hypothyroidism following its withdrawal by their CCG in 2016. Norfolk and Waveney CCG’s guidance now states hospital specialists can initiate prescribing L-T3 in patients where it may be deemed clinically necessary. Furthermore, the guidance provides a clear pathway for the small number of patients who do not benefit from levothyroxine (L-T4), which is offered as the first line of treatment. 

Norfolk Thyroid Group campaign 

Norfolk and Waveney CCG Liothyronine Pathway

RMOC guidance

• 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. 

https://www.sps.nhs.uk/articles/updated-rmoc-guidance-prescribing-of-liothyronine/

NICE guideline 2019 Thyroid disease: assessment and management

• Section 1.3.4 states 'Do not routinely offer liothyronine for primary hypothyroidism, either alone or in combination with levothyroxine, because there is not enough evidence that it offers benefits over levothyroxine monotherapy, and its long-term adverse effects are uncertain.'
• However, the committee noted that the use of combination therapy is a critical issue in hypothyroidism and some committee members suggested beneficial effects of combination treatment with levothyroxine and liothyronine in small subgroups of patients. They could not recommend liothyronine either alone or in combination treatment based on the evidence available and its current list price but agreed a research recommendation to help inform future guidance in this important area. The NICE guideline directs readers to the advice on prescribing liothyronine produced by NHS England's specialist pharmacy service (see RMOC guidance above). 

https://www.nice.org.uk/guidance/ng145/chapter/Recommendations#managing-primary-hypothyroidism

Switching your patient from liothyronine to levothyroxine

• Most health authorities now advise GPs to switch patients on liothyronine (L-T3) to levothyroxine (L-T4). The British Thyroid Association has produced guidance for GPs in these circumstances. 

Switching your patient from liothyronine to levothyroxine: answering GPs' frequently asked questions

When a trial of L-T3/L-T4 might be considered for treatment of hypothyroidism

(Video shared with kind permission from CoMICS bit.ly/SimbaComics)

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