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GPs should not alter liothyronine prescriptions without oversight, says NHS

NHS England has released new advice for prescribing liothyronine, clarifying its position after some CCGs ‘wrongly’ used official guidance to tell GPs to stop prescribing the drug.

The new advice has clarified that GPs should not change existing prescriptions – or administer new ones – without the oversight of an NHS consultant endocrinologist.

It follows guidance originally published in 2017, which set out how to reduce prescriptions for a number of routinely prescribed items in primary care - and after a period in which the price of liothyronine rose dramatically.

When NHS England issued the guideline at the end of 2017 the document said: ‘In most circumstances, the primary care prescribing of liothyronine is not supported for any patient.

‘Initiation for patients with hypothyroidism should only be undertaken by consultant NHS endocrinologists.’

However, CCGs were incorrectly using the guidance to tell GPs to end prescriptions for the drug, according to former BMA GP Committee prescribing lead Dr Andrew Green.

The cost of liothyronine increased by almost 6,000% in a decade - from £4.46 in 2007 to £258.19 by July 2017, as revealed in an investigation by the Competition and Markets Authority.

Dr Green said: ‘Some CCGs were wrongly using the guidance to tell GPs to stop these prescriptions, whereas the correct action for GPs is to refer back into NHS endocrinology services for assessment.

'Equally, patients cannot use opinions received from non-NHS sources to pressurise GPs to provide liothyronine prescriptions.’

In the new advice published last month by NHS England, the document states: ‘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 also only be undertaken by, or with the oversight of, an NHS consultant endocrinologist.’

It added: ‘Where GPs are involved in such treatment changes this should be with NHS consultant endocrinologist support.

‘This applies to both liothyronine monotherapy and combination therapy with levothyroxine.’

Dr Green welcomed the new advice, which he said makes clear the position for GPs.

He said: ‘This is welcome guidance as it clarifies what was the intention of last year’s guidance from NHS England’s Low Priority Prescribing Clinical Working Group.

‘It confirms that decisions regarding the care of patients who believe they need liothyronine should be made by an NHS endocrinologist, who would also be responsible for prescribing until stability is achieved.'

Readers' comments (14)

  • We are not endocrinologists and do not pretend to be. Stop pushing work to us!

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  • So to save money in primary care we have to spend unecessary money in secondary care. There is no evidence that liothyronine needs to be used. What are the onsultants going to do? See the patient, tell them to change and send them back to the GP. Madness

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  • Took Early Retirement

    Usual rubbish.

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  • Dear Dr Green,
    Firstly, liothyronine is NOT a 'routinely prescribed item' in primary care! it is, amd should remain, an exceptional item for prescription by Consultants only.
    Secondly, patients CAN, and DO, use private medical opinions to presurise GPs. We can only overcome this by education and guidelines and compulsory messages to the CONSULTANTS.
    Thankyou, GP

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  • Why has the cost gone up so much ?

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  • Instead of grouching about whose responsibility it is to prescribe T3, how about, as GPs, we listen to our patients. or is this now considered reactionary and we should all be good little civil servants and follow the algorithms set by our betters?
    My patients tell me that when T3 is stopped and they are put on T4, they feel tired and put on weight.
    When T3 is reinstated, the weight problems, along with the Diabetes and Hypertension, get better.
    I would like to think that colleagues listen to and advocate for their patients. What a shame we are reduced to squabbling over budgets and who should do the work.
    How will we progress if GPs no longer listen and think critically for themselves.
    Steve Hopkins

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  • Lots of patients think things work for them- homeopathy for instance. It doesn’t mean it’s anything beyond placebo. I’m not saying T3 doesn’t help just needs proof beyond “the patient thinks it works”

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  • @Steven Hopkins
    Levothyroxine 50 mcg per day = £30 per year
    levothyroxine 100 mcg per day = 30 per year
    Liothyronine 20mcg daily= £3,000 per year
    My T shirt might seem to look better with the word Nike on it, but all it might have achieved is just ripping me off and making someone else rich.
    Proper evidence is needed, as is lacking at the moment.
    Also have heard of private medical opinions being used - these endocrinologists should know better.

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  • So those patients who have seen the endocrinologist and complained that they can't tolerate levothyroxine do what exactly what when the endocrinologist doesn't care about their side effects?

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  • How about some blind randomised controlled trials for starters?

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