BACKGROUND
Levothyroxine is one of the most prescribed medications, currently the 4th most prescribed medication in the United States. The most common reason for prescribing levothyroxine is hypothyroidism, which happens when the thyroid gland does not make enough thyroid hormone. More people have started taking thyroid hormones in recent years, possibly because mild or unclear thyroid problems are treated more often. However, many prescriptions appear to be written for individuals without strong indications for therapy. For example, some reasons thyroid hormone has been prescribed in the past are no longer indicated, such as for suppression of thyroid nodules (subsequently shown to be not helpful) or for treating fatigue or promoting weight loss with normal thyroid hormone levels. While most forms of hypothyroidism require lifelong treatment, there are some types of hypothyroidism that resolve on their own, such as some forms of thyroiditis. Finally, even when indicated, many patients are overtreated, which can cause heart problems, weaker bones, and anxiety, especially in older people.

Deprescribing is a medical practice that began in older adult care. It means stopping or lowering a medication when it might no longer be needed or could even cause harm. It’s always done under a doctor’s guidance. For thyroid hormone, this means checking if the medication is still needed, and if not, lowering the dose carefully. However, there are no clear recommendations on how and when to do this, and many doctors may not feel comfortable bringing it up.

The researchers wanted to find out why doctors don’t always discuss this option with older patients and what helps them when they do.

THE FULL ARTICLE TITLE
Moretti B, et al. Physician-reported barriers and facilitators to thyroid hormone deprescribing in older adults. J Am Geriatr Soc. Epub 2024 Oct 11; doi: 10.1111/ jgs.19219. PMID: 39392046.

SUMMARY OF THE STUDY
The researchers interviewed 19 doctors from different parts of the US, including 6 in primary care, 5 in geriatrics, and 8 in endocrinology. All of them had treated at least 10 patients aged 65 or older with thyroid hormone in the past year. Most of the doctors were women (12, 63%) and practiced in the Midwest (14, 74%).

The doctors gave several reasons for not talking about stopping the thyroid medicine with their patients. The main reason was that patients themselves didn’t want to stop. Some felt they needed it to feel better, feared feeling worse if the dose was decreased, or didn’t understand why the doctor wanted to stop it. Some patients had heard wrong or confusing information about stopping thyroid pills. Doctors were also worried about upsetting or worrying their patients. Many said the visits were too short to have detailed conversations. Some didn’t feel confident about how to stop the medicine safely. Other challenges included difficulty keeping track of changes if follow-up wasn’t easy, and many said electronic medical records made the process more complicated to manage.

The doctors were more likely to deprescribe if the patient had recently started the medicine, had other health problems that made the medication riskier, or if the dose was low. They also felt more comfortable when they had support, like better information and more time, and when their patients had good information and were open to talking. Trust and good doctor-patient communication made these talks easier.

WHAT ARE THE IMPLICATIONS OF THIS STUDY?
This study showed that many doctors hesitate to deprescribe thyroid hormone in older adults. They worry about upsetting the patient, often don’t have enough time, and lack clear guidance on how to do it safely. However, they were more open to the idea when they had a trusting relationship with the patient and felt supported with clear steps and follow-up. Even though the study was small and included doctors mostly from one region, it raises important questions and helps bring more attention to this issue. Future guidelines can help address some of the key points. This study is especially important for older adults who take thyroid hormone. It is a reminder to talk with their doctor about their medication. Sometimes, stopping or lowering the dose can be healthier, but should always be done together and with careful guidance from their care team.

— Ebru Sulanc, MD

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