A Cross-Sectional Analysis of Cardiovascular and Bone Health Care Utilization During Treatment With Thyroid Hormone

Overview

Journal J Clin Endocrinol Metab

Publisher Oxford University Press

Specialty Endocrinology

Date 2023 Oct 25

PMID 37878964

Authors

Gustavo C Penna

Antonio C Bianco

Matthew D Ettleson

Affiliations

Soon will be listed here.

Abstract

Context: Combination therapy with levothyroxine and liothyronine (LT4 + LT3) and desiccated thyroid extract (DTE) make up >10% of new thyroid hormone (TH) prescriptions in the United States.

Objective: To assess health care utilization related to cardiovascular disease (CVD) and bone health (BH) events (atrial fibrillation [AF], heart failure [HF], myocardial infarction [MI], stroke, and osteoporosis/fractures [FX]) in participants taking LT4+LT3 or DTE surveyed in the Medical Expenditure Panel Survey database.

Materials And Methods: Multi-year cross-sectional analysis examining 5437 participants (≥18 years old) treated with LT4, LT4+LT3, or DTE between 2016 and 2020. Health care utilization was assessed through outpatient, emergency, and hospital visits for AF, HF, MI, stroke, FX, and a composite index. A weighted analysis provided national estimates of health care utilization parameters. Utilization was re-analyzed following propensity score-based matching to balance sociodemographic and clinical covariates between treatment groups. Additionally, provider type and specialty data were obtained from visits associated with TH prescriptions.

Results: 5106 participants were treated with LT4 monotherapy, 252 with DTE, and 79 with LT4 + LT3. Prevalence of combined outpatient CVD and BH-related care utilization was lower among DTE/LT4+LT3 vs LT4 users (3.5% vs 7.7%; P = .008). There were no differences in emergency/hospital events. After covariate balancing, CVD and BH-related care utilization was similar between groups in outpatient and emergency/hospital settings. LT3 and DTE made up 7.6% of all TH prescriptions. For visits associated with DTE prescriptions, nurse practitioners and alternative medicine professionals were more likely to be identified as the primary provider type.

Conclusion: No significant differences in CVD- and BH-related health care utilization were identified between LT4 and DTE/LT4+LT3 users after covariate balancing. Non-MD providers were more likely to prescribe DTE.

Citing Articles

The Impact of Hypothyroidism on Cardiovascular-Related Healthcare Utilization in the US Population With Diabetes.

Ramirez M, Bianco A, Ettleson M J Endocr Soc. 2024; 9(1):bvae204.

PMID: 39669655 PMC: 11635454. DOI: 10.1210/jendso/bvae204.

References

Walsh J, Shiels L, Lim E, Bhagat C, Ward L, Stuckey B . Combined thyroxine/liothyronine treatment does not improve well-being, quality of life, or cognitive function compared to thyroxine alone: a randomized controlled trial in patients with primary hypothyroidism. J Clin Endocrinol Metab. 2003; 88(10):4543-50. DOI: 10.1210/jc.2003-030249. View

Leese G, Soto-Pedre E, Donnelly L . Liothyronine use in a 17 year observational population-based study - the tears study. Clin Endocrinol (Oxf). 2016; 85(6):918-925. DOI: 10.1111/cen.13052. View

Jonklaas J, Tefera E, Shara N . Physician Choice of Hypothyroidism Therapy: Influence of Patient Characteristics. Thyroid. 2018; 28(11):1416-1424. PMC: 6247977. DOI: 10.1089/thy.2018.0325. View

Shakir M, Brooks D, McAninch E, Fonseca T, Mai V, Bianco A . Comparative Effectiveness of Levothyroxine, Desiccated Thyroid Extract, and Levothyroxine+Liothyronine in Hypothyroidism. J Clin Endocrinol Metab. 2021; 106(11):e4400-e4413. PMC: 8530721. DOI: 10.1210/clinem/dgab478. View

Ladenson P . Recognition and management of cardiovascular disease related to thyroid dysfunction. Am J Med. 1990; 88(6):638-41. DOI: 10.1016/0002-9343(90)90532-i. View

Gross J, PITT-RIVERS R . The identification of 3:5:3'-L-triiodothyronine in human plasma. Lancet. 1952; 1(6705):439-41. DOI: 10.1016/s0140-6736(52)91952-1. View

Hegedus L, Bianco A, Jonklaas J, Pearce S, Weetman A, Perros P . Primary hypothyroidism and quality of life. Nat Rev Endocrinol. 2022; 18(4):230-242. PMC: 8930682. DOI: 10.1038/s41574-021-00625-8. View

Ettleson M, Ibarra S, Wan W, Peterson S, Laiteerapong N, Bianco A . Demographic, Healthcare Access, and Dietary Factors Associated With Thyroid Hormone Treatments for Hypothyroidism. J Clin Endocrinol Metab. 2023; 108(12):e1614-e1623. PMC: 10655529. DOI: 10.1210/clinem/dgad331. View

Wekking E, Appelhof B, Fliers E, Schene A, Huyser J, Tijssen J . Cognitive functioning and well-being in euthyroid patients on thyroxine replacement therapy for primary hypothyroidism. Eur J Endocrinol. 2005; 153(6):747-53. DOI: 10.1530/eje.1.02025. View

10.

Solomon B, Wartofsky L, Burman K . Prevalence of fractures in postmenopausal women with thyroid disease. Thyroid. 1993; 3(1):17-23. DOI: 10.1089/thy.1993.3.17. View

11.

Lan H, Wen J, Mao Y, Huang H, Chen G, Lin W . Combined T4 + T3 therapy versus T4 monotherapy effect on psychological health in hypothyroidism: A systematic review and meta-analysis. Clin Endocrinol (Oxf). 2022; 97(1):13-25. DOI: 10.1111/cen.14742. View

12.

Yi W, Kim B, Kim M, Kim J, Im M, Ryang S . Heart Failure and Stroke Risks in Users of Liothyronine With or Without Levothyroxine Compared with Levothyroxine Alone: A Propensity Score-Matched Analysis. Thyroid. 2022; 32(7):764-771. DOI: 10.1089/thy.2021.0634. View

13.

Sawin C, Geller A, Wolf P, Belanger A, Baker E, Bacharach P . Low serum thyrotropin concentrations as a risk factor for atrial fibrillation in older persons. N Engl J Med. 1994; 331(19):1249-52. DOI: 10.1056/NEJM199411103311901. View

14.

Braverman L, Ingbar S, Sterling K . Conversion of thyroxine (T4) to triiodothyronine (T3) in athyreotic human subjects. J Clin Invest. 1970; 49(5):855-64. PMC: 535757. DOI: 10.1172/JCI106304. View

15.

Gross J, PITT-RIVERS R . Physiological activity of 3:5:3'-L-triiodothyronine. Lancet. 1952; 1(6708):593-4. DOI: 10.1016/s0140-6736(52)90104-9. View

16.

Jonklaas J, Bianco A, Bauer A, Burman K, Cappola A, Celi F . Guidelines for the treatment of hypothyroidism: prepared by the american thyroid association task force on thyroid hormone replacement. Thyroid. 2014; 24(12):1670-751. PMC: 4267409. DOI: 10.1089/thy.2014.0028. View

17.

Saravanan P, Roberts N, Vedhara K, Greenwood R, Dayan C . Psychological well-being in patients on 'adequate' doses of l-thyroxine: results of a large, controlled community-based questionnaire study. Clin Endocrinol (Oxf). 2002; 57(5):577-85. DOI: 10.1046/j.1365-2265.2002.01654.x. View

18.

Gross J, PITT-RIVERS R, TROTTER W . Effect of 3:5:3'-L-triiodothyronine in myxoedema. Lancet. 1952; 1(6717):1044-5. DOI: 10.1016/s0140-6736(52)90695-8. View

19.

Kuye R, Riggs C, King J, Heilmann R, Kurz D, Milchak J . Thyroid Stimulating Hormone Stability in Patients Prescribed Synthetic or Desiccated Thyroid Products: A Retrospective Study. Ann Fam Med. 2020; 18(5):452-454. PMC: 7489980. DOI: 10.1370/afm.2545. View

20.

McAninch E, Bianco A . The History and Future of Treatment of Hypothyroidism. Ann Intern Med. 2016; 164(1):50-6. PMC: 4980994. DOI: 10.7326/M15-1799. View