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Physician Choice of Hypothyroidism Therapy: Influence of Patient Characteristics.
Thyroid. 2018 11; 28(11):1416-1424.T

Abstract

BACKGROUND

Most endocrinologists encounter patients who are dissatisfied with their current hypothyroidism therapy and request combination therapy with either liothyronine (LT3) or thyroid extract.

METHODS

A survey of American Thyroid Association members was conducted in 2017. Respondents were presented with 13 scenarios describing patients with hypothyroidism and were asked to choose among six therapeutic options. The index patient was satisfied taking levothyroxine (LT4) therapy. Twelve variations introduced parameters that potentially provide reasons for considering combination therapy (presence of symptoms, low serum triiodothyronine concentration, documentation of deiodinase polymorphisms). Therapeutic options included (i) continuing LT4, (ii) increasing LT4, (iii) adding LT3 to a reduced LT4 dose, (iv) adding LT3 to the current LT4 dose, (v) replacing LT4 with thyroid extract, and (vi) replacing LT4 with LT3. Repeated-measures logistic regression analysis was performed to examine both the prescribing of LT4 (options i and ii) versus all other therapies and the choice of continuing LT4 (option i) versus either increasing LT4 (option ii), adding LT3 (options iii and iv), or replacing LT4 with thyroid extract or LT3 (options v and vi).

RESULTS

Of the 389 survey respondents, 363 physicians prescribed therapy for hypothyroidism. For the index patient, 98% of physicians continued current LT4 therapy. However, as the patient scenario incorporated other patient characteristics, physicians opted to increase LT4 dose or prescribe other therapies. The tendency to prescribe alternative therapies was powerfully increased by patient symptoms (odds ratio = 25.6 [confidence interval 9-73], p < 0.0001). Older age and the presence of a comorbidity reduced the likelihood that an alternative therapy was prescribed (p = 0.0002 and <0.0001, respectively). All other characteristics, except athyreotic status, patient sex, and body mass index, significantly increased the likelihood that alternative therapies would be prescribed in multivariate analyses (p < 0.0001).

CONCLUSIONS

Even with the acknowledged limitations of survey methodology, this analysis appears to show a marked increase in the willingness of physicians to prescribe combination therapy in specific circumstances. If current prescribing patterns do incorporate the use of therapies other than LT4, there is a critical need for more research into the benefits and risks of these therapies.

Authors+Show Affiliations

1 Division of Endocrinology, Georgetown University , Washington, DC.2 Department of Biostatistics and Biomedical Informatics, MedStar Health Research Institute , Washington, DC.2 Department of Biostatistics and Biomedical Informatics, MedStar Health Research Institute , Washington, DC.

Pub Type(s)

Journal Article
Research Support, N.I.H., Extramural

Language

eng

PubMed ID

30289349

Citation

Jonklaas, Jacqueline, et al. "Physician Choice of Hypothyroidism Therapy: Influence of Patient Characteristics." Thyroid : Official Journal of the American Thyroid Association, vol. 28, no. 11, 2018, pp. 1416-1424.
Jonklaas J, Tefera E, Shara N. Physician Choice of Hypothyroidism Therapy: Influence of Patient Characteristics. Thyroid. 2018;28(11):1416-1424.
Jonklaas, J., Tefera, E., & Shara, N. (2018). Physician Choice of Hypothyroidism Therapy: Influence of Patient Characteristics. Thyroid : Official Journal of the American Thyroid Association, 28(11), 1416-1424. https://doi.org/10.1089/thy.2018.0325
Jonklaas J, Tefera E, Shara N. Physician Choice of Hypothyroidism Therapy: Influence of Patient Characteristics. Thyroid. 2018;28(11):1416-1424. PubMed PMID: 30289349.
* Article titles in AMA citation format should be in sentence-case
TY - JOUR T1 - Physician Choice of Hypothyroidism Therapy: Influence of Patient Characteristics. AU - Jonklaas,Jacqueline, AU - Tefera,Eshetu, AU - Shara,Nawar, PY - 2018/10/6/pubmed PY - 2019/8/27/medline PY - 2018/10/6/entrez KW - combination therapy KW - hypothyroidism KW - liothyronine KW - physician prescribing KW - thyroid extract SP - 1416 EP - 1424 JF - Thyroid : official journal of the American Thyroid Association JO - Thyroid VL - 28 IS - 11 N2 - BACKGROUND: Most endocrinologists encounter patients who are dissatisfied with their current hypothyroidism therapy and request combination therapy with either liothyronine (LT3) or thyroid extract. METHODS: A survey of American Thyroid Association members was conducted in 2017. Respondents were presented with 13 scenarios describing patients with hypothyroidism and were asked to choose among six therapeutic options. The index patient was satisfied taking levothyroxine (LT4) therapy. Twelve variations introduced parameters that potentially provide reasons for considering combination therapy (presence of symptoms, low serum triiodothyronine concentration, documentation of deiodinase polymorphisms). Therapeutic options included (i) continuing LT4, (ii) increasing LT4, (iii) adding LT3 to a reduced LT4 dose, (iv) adding LT3 to the current LT4 dose, (v) replacing LT4 with thyroid extract, and (vi) replacing LT4 with LT3. Repeated-measures logistic regression analysis was performed to examine both the prescribing of LT4 (options i and ii) versus all other therapies and the choice of continuing LT4 (option i) versus either increasing LT4 (option ii), adding LT3 (options iii and iv), or replacing LT4 with thyroid extract or LT3 (options v and vi). RESULTS: Of the 389 survey respondents, 363 physicians prescribed therapy for hypothyroidism. For the index patient, 98% of physicians continued current LT4 therapy. However, as the patient scenario incorporated other patient characteristics, physicians opted to increase LT4 dose or prescribe other therapies. The tendency to prescribe alternative therapies was powerfully increased by patient symptoms (odds ratio = 25.6 [confidence interval 9-73], p < 0.0001). Older age and the presence of a comorbidity reduced the likelihood that an alternative therapy was prescribed (p = 0.0002 and <0.0001, respectively). All other characteristics, except athyreotic status, patient sex, and body mass index, significantly increased the likelihood that alternative therapies would be prescribed in multivariate analyses (p < 0.0001). CONCLUSIONS: Even with the acknowledged limitations of survey methodology, this analysis appears to show a marked increase in the willingness of physicians to prescribe combination therapy in specific circumstances. If current prescribing patterns do incorporate the use of therapies other than LT4, there is a critical need for more research into the benefits and risks of these therapies. SN - 1557-9077 UR - https://www.unboundmedicine.com/medline/citation/30289349/Physician_Choice_of_Hypothyroidism_Therapy:_Influence_of_Patient_Characteristics_ L2 - https://www.liebertpub.com/doi/full/10.1089/thy.2018.0325?url_ver=Z39.88-2003&amp;rfr_id=ori:rid:crossref.org&amp;rfr_dat=cr_pub=pubmed DB - PRIME DP - Unbound Medicine ER -