Dr Kerbel speaks the truth

[Guest guest]

I apologise for the poor deal patients are getting.

Unfortunately you are not alone and frustrations are clear and anger the

outcome.

I think there are a number of reasons or factors at play.

Perhaps you can help by identifying others.

1) Prodromal phase - symptoms of hypothyroidism come on slowly & insidiously.

Initially they are very non-specific and often misdiagnosed or ignored by

doctors. They often mimic typical presentations of depression so patients are

told they have depression. (This can actually end up being the case because of

failure to diagnose and treat - chicken or egg scenario, and depression can be a

symptom of hypothyroidism.)

All this leads to a fracturing of Dr / patient relationship and loss of trust &

faith in previously trusted professionals.

Frustrations and anger builds.

Anyone with any symptoms lasting > 3 months should probably have thyroid

function tests.

Obviously mostly they will end up normal but this is what I teach GP registrars.

2) Starting treatment and getting to a therapeutic dose.

Many doctors were taught to start levothyroxine (T4) at 50mcg. This supplements

your natural thyroxine but often will not block production. The pituitary picks

up that there is now adequate T4 in system so slows its own production -

negative feedback. Your Dr checks TFTs and finds you need more T4 so increases

by 25mcg - this intensifies negative feedback and lowers your own T4 production

further...

It should now be standard practice to " block and replace " . This means using a

large enough dose of T4 to block the bodies own production and provide enough

for the body. The trouble is that we are all different with different T4

requirements.

Current standard practice & teaching is to start at 100mcg of T4 - in BNF

(British National Formulary) now, unless patient has angina or is elderly when

should start at 50mcg for 2w & increase to 100mcg after 2w.

T4 is slow to build up in body & it takes 3 months for new steady state to

establish itself. My local thyroid clinic guidelines are to only repeat TFTs in

3m after any increase and this is standard practice except in pregnancy (monthly

TFTs advised).

These guidelines apply to all patients - so thin eldery ladys may only need

50-75mcg & will end up having their doses reduced. Most however will need higher

doses. Larger " traditionally build " ( McCall - No 1 Ladies

Detective) ladies (hypothyroidism affects F:M 10:1)

As many patients need 175mcg - 200mcg this will take a year to build up to

therapeutic doses in an ideal world. The reality is that blood tests may be done

late, some may be inconclusive, results go astray or dosages not increased

immediately or medication not be available etc. It took my wife 2 years to get

to a steady state... (2 yrs of hell feeling tired all the time.)

Can things be done better?

I did read that an Evidence Based Medicine expert looked at literature & there

isnt actually evidence supporting current guidelines on increasing T4, practice

is based on expert guidance & clinical experience. He took as much T4 as he felt

he needed - then checked TFTs 3m later and his levels where normal. The problem

is he was a physician & new what he was doing. What do I as a GP tell patients

to take when they ask how much to take? We desperately need some new ideas &

guidance on getting T4 to therapeutic levels earlier (perhaps a formular based

on weight or BMI) - perhaps the BTF can help commission some?

I have some other issues I would like to discuss but will post later.

I apologise for not directly answering your question -

Current recommended treatment and advice is to use levothyroxine & get to a

therapeutic dose biochemically.

Generally patients do feel better on proper therapeutic doses.

Unfortunately a small percentage don't.

Referral to an endocrinologist specialising in thyroid problems may be necessary

as this will now be beyond GP management skills.

I saw a patient yesterday who I referred to endocrinology who did start T3, she

is feeling a lot better. (When she came to see me she was frustrated and angry &

it took quite a lot of talking and listening until we could sort it out over a

few appointments.)

The vast majority of my patients are stable and feel well on standard T4 - I

review and ask them regularly. (She is my only patient on T3 so this isnt the

norm).

Yes - T4 is cheap and T3 extremely expensive.

There are currently extreme pressures on GPs to reduce spending - we have to

reduce our drug overspend by 50%.

But most of us put patients care first and justify spending to our clinical care

groups.

I would insist that a patient first tried T4 and that there TFTs were in normal

range before referring for T3 treatment.

British Thyroid Foundation has a policy statement on T3 which does reflect

accepted current medical understanding / practice.

This is an evolving field and I am sure things will evolve and change.

As a generalist, I do follow advice from my specialist colleagues.

This is probably the most honest reply i have seen! I have respect for this guy!

Steve