We are working with RMOC to clarify the guidance they published in November 2018

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Thyroid UK and other thyroid groups have been working with RMOC to clarify the guidance they published last November. We all felt that their guidance was not clear enough for CCGs and clinicians in respect of some patients needing T3.

We are pleased to say that this updated guidance has been published today.  Although the guidance is not exactly what we wanted, there has been compromise throughout and we think it will help not only patients who are currently on T3 but those new patients who wish to have a trial.

The updated guidance

“NHS England guidance states that prescribers in primary care should not initiate liothyronine (L-T3) for any new patient, and that individuals currently prescribed liothyronine should be reviewed by a consultant NHS endocrinologist with consideration given to switching to levothyroxine (L-T4) where clinically appropriate. Prescriptions for individuals receiving liothyronine should continue until that review has taken place.

The majority of patients suffering from hypothyroidism can be treated effectively with levothyroxine alone,  but liothyronine is perceived to be an important medicine for a small proportion of patients in order to  maintain health and wellbeing. The prescribing of liothyronine is only supported if initiated by, or  considered appropriate following a review by, an NHS consultant endocrinologist. The withdrawal or adjustment of liothyronine treatment should al only be undertaken by, or with the oversight of, an NHS consultant endocrinologist. Where General Practitioners (GPs) are involved in such treatment changes this should be with NHS consultant endocrinologist support. This advice applies to both liothyronine monotherapy and combination therapy with levothyroxine.

As noted by the British Thyroid Association (BTA) Executive Committee (1), ‘clinicians have an ethical responsibility to adhere to the highest professional standards of good medical practice rooted in sound evidence. This includes not prescribing potentially harmful therapies without proven advantages over existing treatments’. Also ‘If a decision is made to embark on a trial of L-T4/L-T3 combination therapy in patients who have unambiguously not benefited from L-T4 then this should be reached following an open and balanced discussion of the uncertain benefits, likely risks of over-replacement and lack of long-term safety data. Such patients should be supervised by accredited endocrinologists with documentation of agreement after fully informed and understood discussion of the risks and potential adverse consequences. Many clinicians may not agree that a trial of L-T4/L-T3 combination therapy is warranted in these circumstances and their clinical judgement must be recognised as being valid given the current understanding of the science and evidence of the treatments’.

The RMOC therefore recommends that strict criteria are applied to ensure that liothyronine is only prescribed in the situations where alternative treatments have been found to be inadequate. In such circumstances, an ongoing shared care arrangement may be appropriate if agreed by local commissioners. If a patient is initiated on treatment, prescribing responsibility should remain with the hospital consultant for at least 3 months.

Clinical and biochemical monitoring of treatment and for potential side-effects is to be undertaken by the  clinician supervising the treatment. TSH levels should be monitored, and free L-T4 / free L-T3 levels measured where clinically appropriate. The risks of over-treatment with thyroid hormones include atrial fibrillation, osteoporosis and bone fractures, and the risks of under treatment are also significant.”

Read the full guidance

We would like to thank all the thyroid groups that had an input into this work, especially the Thyroid Trust.

If you have had your T3 withdrawn without a referral to an endocrinologist you could try going back to your GP with this guidance and ask for it to be reinstated whilst you wait for a referral. Ensure that the endocrinologist you go to isn’t completely anti-T3 though. We think endo appointments will take a long time so use this to encourage your GP to put you back onto T3.