Nice guideline on thyroid disease: where does it take us with liothyronine?
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COMMENTARY
Open Access
Nice guideline on thyroid disease: where does it take us with liothyronine? Graham P. Leese
Abstract The new NICE guidelines on thyroid disease and its management do not recommend the routine use of liothyronine, but do not completely rule it out either. Guidelines from the British and European Thyroid Associations are open to a “trial of liothyronine” on an individual basis. Some patients do not feel well on L-thyroxine despite a serum TSH in the reference range. Key issues to consider in such patients include establishing whether the patient had established hypothyroidism initially, and whether the Lthyroxine has been titrated carefully enough, possibly using small increments, to achieve a careful balance between symptoms and serum TSH concentrations. Patients should also be considered for other causes of the symptoms which may be wide-ranging. Meta-analyses of several, but small, randomised control trials show no advantage, or disadvantage of liothyronine over L-thyroxine. However, detailed sub-analysis identifies some tantalising results eg on preferential weight loss, patient preference, and possibly genetic markers. Although linked with plausible theoretical explanations, these results may be over-interpreted. The key questions are whether a short-term trial treatment is worthwhile and safe, and whether in the future sub-groups of patients can be identified who may benefit from liothyronine. These questions remain divisive but require additional focussed research. It could be argued that inflated costs of liothyronine in some countries have either distracted from or helped focus on the science. Costs need to be addressed. However better biomarkers of tissue level thyroid action, and a better understanding of the impact of genetic polymorphisms will help to make progress when choosing if there is a place for liothyronine in the future. (words: 262) Keywords: Liothyronine, L-thyroxine, Thyroid, Guidelines
Background The debate on whether liothyronine has a role in managing hypothyroidism is akin to entering a cauldron where there is reasonably clear, but possibly weak, clinical evidence but with intriguing and tantalising questions in the detail, alongside a strong patient lobby, Pharmaceutical financial opportunism and Politicians who are conflicted between a popularist approach and a need for fiscal responsibility in health-care.
Correspondence: [email protected] Ward 5 Ninewells Hospital, Dundee DD1 9SY, UK
Sorting L-thyroxine prescribing first of all
Titrating the correct dose of L-thyroxine for patients with primary hypothyroidism is usually straight-forward but can be challenging in some patients, as around 5– 10% of patients on L-thyroxine have persistent symptoms after starting treatment [1, 2]. The goal is to achieve a balance between symptomatic improvement and maintaining a serum thyroid-stimulating hormone (TSH) concentration in the reference range so as to avoid adverse events [3]. Several patients do seem to prefer a dose of L-thyroxine that results in a serum TSH i
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