Dog eat dog: how to identify your six wrongly-managed thyroid patients

Sarah Cathcart Evans is a retired GP, public health trained, and a creative arts student. She is on Instagram: sallyev

Levothyroxine (T4) is one of the most prescribed medicines in the UK. Before 1984, when I qualified, endocrinologists routinely managed and maintained hypothyroidism. Then, combined replacement was used; levothyroxine with liothyronine (T3). Pete Taylor, in a British Thyroid Foundation (BTF) webinar for GPs in 2021, explained that one study put an end to combined replacement. With 86 participants, as slightly over half prefered treatment with T4 alone, T3 was largely abandoned for everyone.¹

As GPs, we see over a hundred blood results in any working day. Checking which of the thyroid results are for people on replacement, when this is a high proportion of patients, is hard labour. Taylor’s work confirms that 30%–50% of hypothyroid patients are not biochemically corrected.¹

Of those who are well managed — on T4 with TSH in the target range,² comorbidities such as other auto-immune disorders identified — 10%-15% continue to have symptoms and signs of hypothyroidism.¹ Frustrated, performing less than their best at work, skipping tasks at home, letting social and family networks slip, unable to maintain their best health and lifestyle; difficult-to-convey malaise.

Biological causality for T4 monotherapy not working for some is now established. We can’t now attribute the 10%–15% of people with hypothyroidism not feeling better on T4 as wimps, laggards, or requiring psychological attention.³ As someone who has suffered this debility, I no longer need to hide in shamed silence. Fifteen percent of us lack the tissue enzyme to convert circulating T4 to T3, the active ingredient.¹ Offering combined treatment for this minority is now accepted, requiring individual selection and specialist monitoring, say the European 2012 guidelines.⁴ British 2015 guidelines and American guidance are in line with this.³ Prescribing guidelines in the UK are up-to-date.^2,5

When the price of T3 rose exponentially 10 years ago, with manufacture of appropriate doses for combination maintenance, NHS prescriptions for T3 plummeted further, on grounds of cost. Evidence for this withdrawal of treatment with a clear clinical need was, and still is, flimsy.⁶ After moving house, when I requested to continue with combined replacement, I found that in Buckinghamshire T3 prescribing is restricted. At least in the formulary — there is now an algorithm with updated guidance buried in the Integrated Care Board website.²

What causes us to take such punitive approaches to patients? Not having evidence is different from having established evidence of harm or no benefit. A medical student spent a session with me, through one morning surgery. The student reflected that my role appeared combative, delivering a firm no to patient after patient. General practice may be a less toxic branch of medicine, nevertheless, we could accumulate hefty ‘masculine contest culture’ (MCC) scores. Social sciences research shows higher MCC scores are associated with poorer outcomes in the workplace. Dog Eat Dog; Strength and Stamina; Show No Weakness; Work Comes First.⁷

Five percent of people over 60 have hypothyroidism. Aside from those of us diagnosed but poorly managed, as many as half of cases remain undetected among older, socially deprived, or non-White British people.⁸ Grinding to a halt through lack of active liothyronine in the tissues or the brain doesn’t have the glamour of a new cancer, an acute abdomen. Maybe, as GPs, we don’t have the patience or the interest. As a medical academic friend said recently about adult ADHD; ‘it’s complicated’, we ‘just don’t have the time for this’.

Not all patients with hypothyroidism are women, otherwise I would be tempted to wonder aloud whether our exceptionally poor management of this deceptively simple disorder could be evidence of systemic misogyny within our beloved accessible, equality-based NHS. Rather, by dismissing patients’ complaints; considering their symptoms to be somehow psychologically generated,³ or evidence of entitlement, or dependency — lack of ‘resilience’; we are feeling good at someone else’s expense, like boys in the playground.⁷ We are, despite ourselves, enmeshed in MCC, creating a tide of toxic masculinity for ourselves, our colleagues, and our patients.

I had intended to keep working as a GP until at least my mid-60s. I left partnership in 2016 and struggled with every medical role after that. I have comorbidities, sure; however, adequate, well-managed thyroid replacement might have allowed me still to contribute, to remain at the coalface.

There are 9 million people in the UK like me, some with hypothyroidism, many more with many other chronic conditions, economically inactive and of working age.⁹ Perhaps, with emphasis on ‘pro-social’ masculine traits at work⁷ — positive leadership, putting others first, friendship through teamwork, rationality, ability to take risks, and staying calm in adversity — medicine can begin to catch-up with the debilities that are affecting our patients’ lives and our nation’s wealth.

Pete Taylor in Cardiff and Kristien Boelaert in Birmingham are among those working to put this right for the few of us who require combined thyroid replacement.^1,3,5,6,10 As GPs, you need the agreement of the Integrated Care Board to prescribe² and to find support to identify and monitor this poorly served group among your list, 15% of 3%: six each.

References

1. British Thyroid Foundation. ‘T3 or not T3 webinar debate’ – September 2021. https://www.btf-thyroid.org/t3-or-not-t3-webinar-debate-september-2021 (accessed 15 Apr 2024).
2. Buckinghamshire, Oxfordshire and Berkshire West Integrated Care Board, Buckinghamshire Healthcare NHS Trust. 725FM.2 liothyronine review algorithm.  https://www.bucksformulary.nhs.uk/docs/Guideline_725FM.pdf (accessed 15 Apr 2024).
3. Okosime O, Gilbert J, Abraham P, et al. Management of primary hypothyroidism: statement by the British Thyroid Association Executive Committee. Clin Endocrinol (Oxf) 2016; 84(6): 799–808.
4. Wiersinga WM, Duntas L, Fadeyev V, et al. 2012 ETA guidelines: the use of L-T4 + L-T3 in the treatment of hypothyroidism. Eur Thyroid J 2012; 1(2): 55–71.
5. British Thyroid Foundation. Liothyronine. https://www.btf-thyroid.org/liothyronine (accessed 16 Apr 2024).
6. Stedman M, Taylor P, Premawardhana L, et al. Trends in costs and prescribing of liothyronine and levothyroxine in England and Wales 2011–2020. Clin Endocrinol (Oxf) 2021; 94(6): 980–989.
7. Glick P, Berdahl JL, Alonso NM. Development and validation of the masculinity contest culture scale. Journal of Social Issues 2018; 74(3): 449–476.
8. National Institute for Health and Care Excellence. Context. In: Thyroid disease: assessment and management. NG145. 2023. https://www.nice.org.uk/guidance/ng145/chapter/Context (accessed 15 Apr 2024).
9. Office for National Statistics. Economic inactivity. 2024. https://www.ons.gov.uk/employmentandlabourmarket/peoplenotinwork/economicinactivity (accessed 15 Apr 2024).
10. Heald A, Stedman M, Okosieme B, et al. Correspondence: Liothyronine prescribing in England; costs versus needs. Lancet 2023; DOI: 10.1016/S0140-6736(23)01792-0.

Featured Photo by National Cancer Institute on Unsplash.