A leading US endocrine society has kicked off a yearlong campaign designed to improve awareness of thyroid disease among the public and to educate physicians of many disciplines and pharmacists to the many nuances of diagnosis and treatment of these conditions.
“10 Questions to Ask About Your Thyroid Health” (see end of story) has been created to encourage dialogue between patients, their physicians, and pharmacists and is available for public download at www.thyroidawareness.com, a website that contains general information about thyroid conditions and diseases, including thyroid cancer.
The awareness campaign is run by the American College of Endocrinology (ACE) — the educational and scientific arm of the American Association of Clinical Endocrinologists (AACE).
“Thyroid hormone is the leading prescription drug in our country, and there are a lot of misconceptions about what thyroid disease is and what the thyroid does,” AACE president Dr R Mack Harrell (Memorial Healthcare System, Florida), who is a thyroid specialist, told Medscape Medical News.
“One of our jobs is to make sure that patients have access to correct information and not just hearsay that is written by nonexperts.”
Pharmacists Included to Try to Reduce “Switching” of Levothyroxine
One new aspect of the campaign this year is the inclusion of pharmacists, Dr Harrell noted.
When it comes to the treatment of hypothyroidism, the most common thyroid condition, he explained, keeping patients’ thyroid-stimulating hormone (TSH) within a tight normal range is imperative. Measuring TSH is the single most important tool that physicians can use to regulate thyroid-hormone dosing, he added.
Consistent TSH levels are best achieved by patients remaining on the same thyroid-hormone product (T4, levothyroxine), rather than switching from one to another. Even tiny variations in the amount of levothyroxine between different manufacturers’ products may make it difficult for patients to maintain their TSH in the proper range, and this is something that many patients don’t really understand, Dr Harrell stressed.
“One of the constant problems that endocrinologists in this country run into is this problem of switching — from one brand [of levothyroxine] to another brand, from one generic to another generic, from generic to brand, or back again. This detrimental practice is technically allowed as long as the products are [Food and Drug Administration] FDA approved.”
Patients will often be switched by their pharmacist without notification, and such changes may cause them to feel differently “because their TSH is a bit too low or too high. We want our patients to understand what is happening,” he noted.
“Switching creates a kind of constant ‘scramble’ by the physician in charge to keep the TSH level within a reasonable range, so patients and physicians are always adjusting for these pharmacist-generated changes.”
Pharmacists are generally driven by financial incentives to switch patients from one levothyroxine product to another, “so we wanted to bring the pharmacist into the counseling mix — since they are the ones making the substitutions, we believe they should explain themselves,” he added.
“Our belief is if the patients understand the consequences of substitution, then they will make better decisions, possibly choosing higher cost in the interest of product consistency and certainly notifying their doctors in the event of unforeseen changes.
“Patient education creates understanding, and understanding creates empowerment. Ultimately, patient empowerment has impact — even when the law doesn’t protect thyroid patients that much, patient activism influences the pharmacist and the system.”
Pharmacists Can Help Educate Patients About Interactions
Pharmacists can also play an immensely important role in helping to educate thyroid patients on other matters, Dr Harrell said.
“We [endocrinologists] should be doing it too, but it’s a second opportunity. We hope to use the educational background of pharmacists to instruct patients: we want pharmacists to reiterate the fact that you can’t take levothyroxine with many nutritional supplements and to remind patients that there are often issues with other medications.
“For example, you can’t take thyroid hormone with iron, and it doesn’t mix with calcium supplementation, and soy products may cause a problem.”
And certain medications, such as antacids and proton-pump inhibitors (PPIs), decrease the absorption of levothyroxine, Dr Harrell explained.
“We think the reiteration of that kind of information at the pharmacy is essential.”
There are also many physician groups who need reminding of these issues, Dr Harrell says.
“We don’t think it hurts for GPs, family practitioners, and internal-medicine doctors to be exposed to these messages, because it just reinforces their previous training, and they may need a little refresher.”
To T3 or Not? AACE Believes More Research Needed
Dr Harrell also touched on the topic of recent American Thyroid Association (ATA) guidelines on hypothyroidism, issued at the end of last year, which recommend that levothyroxine as monotherapy should remain the standard of care for the treatment of the condition.
Despite this overriding conclusion, the ATA did alter its stance on adding another treatment, triiodothyronine (T3), into the mix for the small minority of patients who don’t fare well on levothyroxine treatment alone.
The ATA had previously recommended against use of T3, but the new guidelines now don’t rule out its use, although they still conclude there is insufficient evidence to routinely combine T3 with levothyroxine in the treatment of hypothyroidism.
The issue is hugely contentious and was discussed in detail at the 2014 Annual Meeting of the American Thyroid Association
Dr Harrell says AACE normally endorses the ATA guidelines, but in this instance, it did not feel that it could.
“The ATA new hypothyroidism guidelines are just loaded with speculation on whether adding T3 is the right thing to do,” he told Medscape Medical News.
“It was a difficult decision for our organization when we saw the new guidelines, because it’s a double-edged sword: we think there may be a small subgroup that does better with T3 — everybody who does thyroidology for a living has a few patients who may benefit from T3 — but you have to be very careful, because it’s much easier to make people mildly hyperthyroid with these preparations.”
“We were afraid that [the new guidelines] gave too much publicity to the T3 movement without any real science to back it up. The problem is that people are just going out and getting T3 preparations or Armour thyroid [desiccated thyroid, a combination of porcine T4 and T3] and using them in a relatively unsupervised fashion.
This can be problematic because there is a subgroup of people who become a “little bit ‘hyper’ on T3 and who feel pretty good that way, but feeling good doesn’t mean you are always doing good,” Dr Harrell explained.
“If TSH is suppressed from too much T3, that’s not a good thing; the problem is with side effects such as atrial fibrillation and bone loss, and these are real long-term risks.”
“There needs to be carefully designed research in the T3-supplementation area, not just speculation,” he concluded.