The management of primary hypothyroidism with Levothyroxine (L-T4) 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/liothyronine (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. 

In recent years we have been aware that a large number of patients have been advised by their doctors that L-T3 is no longer available for the treatment of hypothyroidism and that they should use L-T4 as an alternative treatment. We understand that this was a direct result of the sharp increase in price of L-T3, which made the drug largely unaffordable.

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 This resulted in many patients’ liothyronine treatment being withdrawn causing unnecessary suffering, and often expense, for patients.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

November 2019 – NICE guidance on the assessment and management of thyroid disease 

This states levothyroxine (L-T4) should be offered as standard treatment for hypothyroidism. It also states liothyronine, either in mono- or combination therapy, should not be routinely offered to patients with hypothyroidism. However, the guidance refers to the RMOC guidance which recognises that L-T3 is an important medicine for a small proportion of patients in order to maintain their health and wellbeing. Furthermore, the NICE guideline places emphasis on shared decision making and the importance of clinical judgement in reaching decisions about patients’ individual care. 

 NICE guidance on thyroid disease 

November 2019 - T3 prescribing patterns survey 

UK thyroid groups carried out a T3 Prescribing Patterns Survey in November 2019. Its aim was to gain a greater understanding of how liothyronine (L-T3) is being prescribed in England since NHS England clarified its RMOC guidance in July 2019  

The report highlighted that many patients continue to have their liothyronine prescriptions either denied or reduced across CCGs in England. Only 5% of respondents had had their T3 prescription reinstated by their local CCG following the updated RMOC guidance in July 2019. Worryingly a proportion of respondents also reported sourcing T3 outside the NHS. The survey indicates that whilst some progress has been made, access to L-T3 varies hugely by individual CCG.  

T3 Prescribing Patterns Survey  

July 2019 - Updated RMOC guidance - prescribing of liothyronine (L-T3) 

Following publication of the Liothyronine Dossier, NHS England Regional Medicines Optimisation Committee (RMOC) clarified the guidance issued to Clinical Commissioning Groups (CCGs) on the prescribing of L-T3. This updated guidance was published in July 2019. It clearly states that L-T3 can be prescribed to the small minority of patients with hypothyroidism where their symptoms persist despite optimal dosage with levothyroxine (L-T4). It also states that GPs cannot withdraw or adjust a patient’s L-T3 prescription without the oversight of an NHS consultant endocrinologist. 

 RMOC guidance – prescribing of liothyronine 

October 2018Liothyronine Dossier 

To address the problems around L-T3 prescribing in England, UK thyroid patient groups have been working in partnership with the British Thyroid Association (BTA). In 2018, at the request of the Department of Health, they produced and published the Liothyronine Dossier which was presented to NHS England. The dossier contained evidence of patient cases where NHS England guidance to continue to make L-T3 available on prescription in exceptional cases was not being followed. The authors highlighted their concern for patients’ health in cases where L-T3 is being denied or reduced. They subsequently called for clarification of these guidelines to address this inequality across England’s CCGs. 

Liothyronine Dossier 

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)

Further information 

BTA Statement on the management of primary hypothyroidism 2015 

Liothyronine (T3): Answering patients' questions 2016 

We rely on donations to fund our work supporting and informing people living with thyroid disorders. Please consider making a donation or becoming a member

Donate

Become a member