Management of primary hypothyroidism: statement by the British Thyroid Association Executive Committee
If our bodies were indeed identical machines rather like the images on my website treatment would be simple, straightforward and unvaried – like a mechanic mending your car.
Unfortunately this is not the case, and my job as an endocrinologist is to help along the very individual road to wellbeing taken by my patients. To do this I use my expertise, the knowledge and experience of my peers worldwide and the results of ongoing research into our bodies and our medical challenges.
The 2015 position statement of the BTA
It was using all of these things that assisted with the positioning of the recent BTA Executive Committee statement on the management of primary hypothyroidism (underactive thyroid). This is based on a review of the recently published positions of the American Thyroid Association (ATA) and the European Thyroid Association (ETA); upon current literature and upon the best principles of good medical practice.
This statement has been endorsed by the Association of Clinical Biochemistry (ACB) the British Thyroid Foundation (BTF) the Royal College of Physicians (RCP) and the Society for Endocrinology (SFE). You may like to see this in full – in which case click here.
Part of the statement acknowledges a small proportion of patients who continue to suffer with symptoms despite receiving adequate biochemical correction. This has been the subject of controversy and great public interest – not least from the patients and their families.
The ATA and ETA position on combined therapy treatment
One particular area of debate is the role of combined treatment with L-T4 and L-T3. The ETA and ATA guidelines have looked at this and concluded that L-T4 remains the therapy of choice and does not support the routine choice of L-T4/L-T3 in combination therapy due to:
- insufficient evidence from controlled trials
- lack of long term L-T3 safety data and
- the unavailability of L-T3 formulations which accurately mimic natural physiology
- The ETA would consider a carefully monitored trial under specialist supervision with reassessment after 3 months.
- The ATA goes further by insisting any such trial must be rigorously implemented either as part of a clinical trial or with formal ethical and governance approvals.
The BTA position on continually unwell patients
In acknowledging that a proportion of individual on LT-4 are not satisfied with therapy and have persistent symptoms despite a normal serum TSH the BTA says:
- Such patients should be thoroughly evaluated for other conditions that could be modified
- In some cases a retrospective review of the original diagnosis of hypothyroidism may be necessary
- Symptom and lifestyle management support should be provided and further dose adjustments may be required
You will be well aware that under the Hippocratic Oath doctors are required “to do good or to do no harm” so any clinical judgement about treatments has to be based on the current understanding of the science and the evidence of those treatments.
Because of insufficient evidence, therefore, the BTA guidelines are that L-T4/L-T3 combination therapy should not be used routinely and due to the risks of such treatment and the risks of potentially adverse consequences you will not be surprised to know that many Clinicians will not currently agree to a trial.
However, the BTA is keeping an open mind. Future clinical trials on combination therapy for patients with specified genetic or clinical characteristics will be conducted and ultimately of course the aim of us all is for improved patient outcomes.