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Issues to discuss with MPs

regarding the Non-Prescribing of Liothyronine
under the category of

“Items which are clinically effective but where more cost-effective products are available, including products that have been subject to excessive price inflation.”


This template is in three parts
(1) Your story
(2) Points to mention/write about
(3) Research and questions to ask the Secretary of State for Health.

If you are writing a letter, make sure that you make it as personal as possible to you because mass letters which are exactly the same have less impact (which is why we really want you to visit your MP rather than write to them.)

Try not to make your letter too long – maximum two pages. 
Separate your story and the points you want to make from the research i.e. print them off separately (you can download the pdf version of the research separately here

 1) Your Story

When you speak/write to your MP mention the problems you are having such as:

  • Still being ill on levothyroxine - explain your symptoms and how miserable they are making you
  • Not being tested for T3 or the DIO2 polymorphism
  • Having to pay privately for testing your T3 or the DIO2 polymorphism
  • Having the DIO2 polymorphism
  • Having low T3 but nothing is being done about it
  • Being refused T3 and the reason why
  • Being prescribed T3 but then having it withdrawn – explain reason why
  • Having to pay for a private prescription and for your T3 – explain how much this is costing you
  • Having to purchase your T3 online – explain how much this is costing you
  • T3 has changed your life/is making you feel much better – explain how it has changed your life

 2) Some points to mention/write about:

[Figures in square brackets refer to research papers listed below]

  • The Clinical Commission Groups (CCGs) are informing GPs and endocrinologists not to prescribe liothyronine (T3) due to the cost of T3 which has risen from 16p per tablet to £9.22 per tablet over the past few years. However, they are misinterpreting the British Thyroid Association guidelines [1] which state that it should not routinely be prescribed but can be used on a trial basis and continued if the patient responds well.  
  • The British Thyroid Association has issued further guidelines stating that patients who are doing well on liothyronine should not have their liothyronine stopped. [2]
  • The BMA are not happy [3] about the fact that NHS England plan to stop prescribing drugs for patients:

 “The BMA’s GP committee recognises the need to prescribe in a cost-effective manner, but where prescribing is changed for any other reason than clinical benefit to the patient, the patient must be involved and the extra workload for GPs needs to be recognised. Any prescribing policy needs to include flexibility to allow GPs to continue to meet individual patient’s needs without having to negotiate bureaucratic hurdles.”


“GP’s have a contractual duty to prescribe drugs that their patients need and pressure must not be placed on them to act in a way that may contravene those regulations.”  

  • Professor Azeem Majeed has stated in the British Medical Journal [4] that, “However, this locally based approach is flawed.  Firstly, CCGs have no legal power to limit the prescribing of drugs by GPs.  As CCG policies on restricting prescriptions are not backed by statutory guidance, the inevitable result will be variation between GPS in the use of the drugs that CCGs are proposing to restrict – thereby leading to “postcode prescribing.” 
  • CCGs have no legal power to enforce doctors to stop prescribing drugs yet CCGs seem to be making their own policies in this regard in a snowball effect.  Professor Azeem has reported NHS Dudley CCG to the Advertising Standards Agency for misleading patients on over the counter prescribing, because 'CCGs have no legal right' to limit the drugs GPs can prescribe.[5] GPC clinical and prescribing policy lead Dr Andrew Green has warned that CCGs do not have the power to ban GPs prescribing medicines that patients need.  He told GPonline, “If faced with upsetting their CCG or complying with GMS [General Medical Services] requirements GPs ‘should upset their CCG every time' [6]
  • The savings that the CCGs want to make by refusing to prescribe T3 is a false economy because patients who are ill on levothyroxine will simply be returning to their clinician/GP/endocrinologist with their symptoms and find themselves going on a merry-go-round of specialists to find a cause of their symptoms.  This will cost the NHS much more money than they will be saving.
  • Some doctors are giving patients private prescriptions for their T3 and some NHS hospital trusts are informing patients to go private to obtain their T3 [7].  This goes against the ethos of the NHS.
  • Some people have a polymorphism that causes poor conversion. [8,9,10]
  • Recent research has found that hypothyroid patients on levothyroxine had lower levels of T3 than healthy individuals (poor converters) and were heavier and differed in other objective and subjective measures.  Some patients clearly did not convert at the same rate as others.  Everyone is not the same. [11,12,13,14,15,16 ,17,18,19,20,21]
  • 10-15% of all hypothyroid patients taking levothyroxine have impaired quality of life despite normal TSH concentrations. Could impaired conversion of thyroxine to T3 be the reason for this? [22]
  • Research also shows that long term use of T3 is safe. [23,24]
  • Studies investigating the efficacy of T3 substitution (liothyronine) gave varying results. However, some patients found improved quality of life under substitution therapy with T3 and preferred the combination treatment. [25,26,27,28,29]
  • More and more doctors are realising that levothyroxine alone is not sufficient for many patients. Patients in many of the studies much preferred combination treatment and it was associated with improved metabolic profiles. [30,31,32,33,34,35,36,37,38,39] How much more research do we need to make doctors listen? [40]
  • It’s not just the thyroid that is affected by low T3 – many patients may have hidden low T3 syndrome.  Research has shown that low fT3 was the most important predictor of cumulative death.  Also, depression is shown to be caused by low T3 levels.  If FT3 testing is not done, many patients could suffer unnecessarily. [41,42,43,44,45]
  • Recent research is being ignored [46,47,48,49] and the guidelines used by clinicians need to be updated, particularly the UK Guidelines for the Use of Thyroid Function Tests 2006 [50] as these were meant to be reviewed in 2009 and Healthcare Improvements. Scotland state in their Scoping Report dated 22nd February 2014 [51] that “UK guidelines for the use of thyroid function tests published in 2006 were based on a nonsystematic review of generally poor quality evidence from the United States (US) National Academy of Clinical Biochemistry (now archived).”


Doctors need to be aware that T3 testing is important in the treatment of hypothyroidism and not dismiss patients’ concerns, especially since the research referenced in the following paper (Patients’ attitudes and perceptions towards treatment of hypothyroidism in general practice: an in-depth qualitative interview study by Rosie Dew, PhD et al in the BJGP journal - http://bjgpopen.org/content/bjgpoa/early/2017/06/26/bjgpopen17X100977.full.pdf) is out of date –

“Patients that felt unwell also believed that TSH levels were too crude a measure to gauge optimal thyroid hormone replacement. Some more informed patients had approached their GP and asked for further tests to check their triiodothyronine (T3) and thyroxine (T4) readings, as they felt unwell and dissatisfied with their treatment. However, since T3 measurements have limited value in the management of hypothyroidism[32] these tests are not routinely offered.” (32. Carter JN, Corcoran JM, Eastman CJ, et al. Effect of severe, chronic, illness on thyroid function. The Lancet - 1974; 304(7887): 971–974. doi: 10.1016/S0140-6736(74)9207)[52]

3) Ask your MP to look at the research below (which you can download here) and:

Write to the Secretary of State for Health/Minister of State for Health and ask them:

  1. Why is it that, when the British Thyroid Association guidance states that endocrinologists can prescribe liothyronine for patients on a trial basis and also that the British Thyroid Association has issued guidelines stating that patients who are doing well on liothyronine should not have their liothyronine stopped, the CCGs can carte blanche withdraw T3 from so many patients due to cost?  
  1. To clarify who has overall responsibility and decision making about a patient’s treatment - the CCGs who do not know the patient or the clinicians who actually know the patient and what their needs are.  Patients’ needs should come before cost. 
  1. Can a Clinical Commissioning Group override the British Thyroid Association guidelines?
  1. Why can’t doctors give a prescription for T3 from outside of the UK as has happened in the past when there has been a supply problem?  T3 in Europe is extremely cheap and can be purchased for just a few euros. It would save the NHS a lot of money and ensure that patients get the thyroid medication they need to have a good quality of life.

For further information on hypothyroidism from Thyroid UK go to: www.thyroiduk.org



  1. Management of Primary Hypothyroidism: statement by the British Thyroid Association Executive Committee (May 2015) -
    http://www.british-thyroid association.org/sandbox/bta2016/
  1. Switching from Liothyronine (LT-3) to Levothyroxine (LT-4)? – 2016
  1. BMA responds to NHS England action plan on wasteful drug use

  2. NHS England’s plan to reduce wasteful and ineffective drug prescriptions
    Azeem Majeed BMJ 2017;358:j3679

  3. CCG reported to advertising watchdog for 'misleading' patients on OTC prescribing
  1. GPC warning ignored as CCGs roll out bans on GPs prescribing OTC drugs
    David Millett - 27 July 2017
  1. Brighton and Sussex University Hospitals NHS Trust
    Information for Patients Currently treated with T3 (liothyronine).
  1. Common variation in the DIO2 gene predicts baseline psychological well-being and response to combination thyroxine plus triiodothyronine therapy in hypothyroid patients.
    Panicker V, Saravanan P, Vaidya B, Evans J, Hattersley AT, Frayling TM, Dayan CM
    J Clin Endocrinol Metab. 2009 May;94(5):1623-9.
  1. Hypothyroid Patients Encoding Combined MCT10 and DIO2 Gene Polymorphisms May Prefer L-T3 + L-T4 Combination Treatment – Data Using a Blind, Randomized, Clinical Study.
    Carlé A, Faber J, Steffensen R, Laurberg P, Nygaard B
    Eur Thyroid J 2017;6:143–151
  1. Genetic variation in deiodinases: a systematic review of potential clinical effects in humans
    Herman Verloop, Olaf M Dekkers, Robin P Peeters, Jan W Schoones and Johannes W A Smit
    European Journal ofEndocrinology (2014) 171, R123–R135
  1. Variation in the biochemical response to L-thyroxine therapy and relationship with peripheral thyroid hormone conversion efficiency.
    John E M Midgley, Rolf Larisch, Johannes W Dietrich, and Rudolf Hoermann
    Endocrine Connections (2015) 4, 196–205

  2. Is a Normal TSH Synonymous With “Euthyroidism” in Levothyroxine Monotherapy?
    Sarah J. Peterson, Elizabeth A. McAninch, Antonio C. Bianco
    J Clin Endocrinol Metab. 2016 Dec;101(12):4964 4973
  1. Is pituitary TSH an adequate measure of thyroid hormone-controlled homoeostasis during thyroxine treatment?
    Rudolf Hoermann, John E M Midgley, Rolf Larisch and Johannes W Dietrich
    J Clin Endocrinol Metab. 2016 Dec;101(12):4964-4973
  1. Homeostatic equilibria between free thyroid hormones and pituitary thyrotropin are modulated by various influences including age, body mass index and treatment.
    Rudolf Hoermann, John E.M. Midgley, Adrienne Giacobino, Walter A. Eckl, Hans Gunther Wahl, Johannes W. Dietrich and Rolf Larisch
    Clin Endocrinol (Oxf). 2014 Dec;81(6):907-15
  1. Levothyroxine monotherapy cannot guarantee euthyroidism in all athyreotic patients. 
    Gullo, D., Latina, A., Frasca, F., Le Moli, R., Pellegriti, G., & Vigneri, R. (2011
    PLoS One6(8), e22552. 
  1. Levothyroxine therapy and serum free thyroxine and free triiodothyronine concentrations.
    Woeber, K. A. (2002).
    Journal of endocrinological investigation25(2), 106-109.
  1. Integration of Peripheral and Glandular Regulation of Triiodothyronine Production by Thyrotropin in Untreated and Thyroxine-Treated Subjects.
    Hoermann R, Midgley JE, Larisch R, Dietrich JW
    Horm Metab Res. 2015 Aug;47(9):674-80
  1. Dual control of pituitary thyroid stimulating hormone secretion by thyroxine and triiodothyronine in athyreotic patients
    Rudolf Hoermann,  Johannes W. Dietrich, Rolf Larisch
    Therpeutic Advances in endocrinology and metabolism.  Volume: 8 issue: 6, page(s): 83-95
  1. Adult hypothyroidism. Thyroid Disease Manager. Accessed: Nov, 16, 2011.  See section 9.8 "Treatment of Hypothyroidism".
    Wiersinga, W. M., & DeGroot, L. J.
  1. Does normal TSH mean euthyroidism in L-T4 treatment (Summary)
    Orgiazzi Jacques.
    Clinical Thyroidology. November 2016, 28(11): 325-328.
  1. No Effect of the Thr92Ala Polymorphism of Deiodinase-2 on Thyroid Hormone Parameters, Health-Related Quality of Life, and Cognitive Functioning in a Large Population-Based Cohort Study.Wouters HJ, van Loon HC, van der Klauw MM, Elderson MF, Slagter SN, Kobold AM, Kema IP, Links TP, van Vliet-Ostaptchouk JV, Wolffenbuttel BH.
    Thyroid. 2017 Feb;27(2):147-155 
  1. The History and Future of Treatment of Hypothyroidism
    Elizabeth A. McAninch, MD and Antonio C. Bianco, MD, PhD
    Ann Intern Med. 2016 Jan 5; 164(1): 50–56.
  1. Liothyronine use in a 17 year observational population-based study - the tears study.
    Leese GP, Soto-Pedre E, Donnelly LA
    Clin Endocrinol (Oxf). 2016 Dec;85(6):918-925
  1. Safety review of liothyronine use: a 20 year observational follow up study
    Enrique Soto-Pedre & Graham Leese
    Endocrine Abstracts (2015) 38 OC5.6
  1. Effect of combination therapy with thyroxine (T4) and 3,5,30-triiodothyronine versus T4 monotherapy in patients with hypothyroidism, a double-blind, randomised cross-over study.
    Nygaard B1, Jensen EW, Kvetny J, Jarløv A, Faber J.
    European Journal of Endocrinology (2009) 161 895–902

  2. Combined Therapy with Levothyroxine and Liothyronine in Two Ratios, Compared with Levothyroxine Monotherapy in Primary Hypothyroidism: a Double-Blind, Randomized, Controlled Clinical Trial
    Bente C. Appelhof, Eric Fliers, Ellie M. Wekking, Aart H. Schene, Jochanan Huyser, Jan G. P. Tijssen, Erik Endert, Henk C. P. M. van Weert and Wilmar M. Wiersinga. The Journal of Clinical Endocrinology & Metabolism Vol. 90, No. 5 2666-2674

  3. Thyroid Hormone replacement therapy in primary hypothyroidism: a randomized trial comparing L-thyroxine plus liothyronine with L-thyroxine alone.
    Escobar-Morreale HF, Botella-CarreteroJI, Gomez-Bueno M, Galan JM, Barrios V, Sancho J Archives of Intern Med 2005 Mar 15;142(6)155. - https://www.ncbi.nlm.nih.gov/pubmed/15767619

  4. T3/T4 Combination Therapy
    AD Toft.
    Endocrine Abstracts (2002) 3 S40 
  1. Effects of thyroxine (T4) as compared with thyroxine (T4) plus triiodothyronine (T3) in patients with hypothyroidism.
    Benevicius R, Kazanavicius G, Zalinkovicius R, Prange AJ
    New England Journal of Medicine.1999; 340: 424-9.
  1. Paradigm shifts in thyroid hormone replacement therapies for hypothyroidism.
    Wilmar M Wiersinga
    Nature Reviews Endocrinology 10, 164-174 (2014)www.nature.com/nrendo/journal/v10/n3/abs/nrendo.2013.258.html
  1. Combination Treatment with T4 and T3: Toward Personalized Replacement Therapy in Hypothyroidism?
    Bernadette Biondi, and Leonard Wartofsky
    J Clin Endocrinol Metab. 2012 Jul;97(7):2256-71

  2. Thyroid Insufficiency: Is Thyroxine the Only Valuable Drug?
    Baisier, W.V., Hertoghe, J., and Eeckhaut, W.
    Journal of Nutritional and Environmental Medicine, 11:159-166, 2001.  http://www.tandfonline.com/doi/abs/10.1080/13590840120083376

  3. Metabolic effects of liothyronine therapy in hypothyroidism: a randomized, double-blind, crossover trial of liothyronine versus levothyroxine. 
    Celi, F. S., Zemskova, M., Linderman, J. D., Smith, S., Drinkard, B., Sachdev, V., et al 
    The Journal of Clinical Endocrinology & Metabolism,96(11), 3466-3474

  4. Treatment for primary hypothyroidism: current approaches and future possibilities.
    Chakera, A.J., Pearce, S.H., Vaidya, B.
    Drug Des Devel Ther.; 6: 1-11.  

  5. Does synthetic thyroid extract work for everybody?
    Gautam Das, Shweta Anand & Parijat De (2007). 
    Endocrine Abstracts (2007) 13 P316. 

  6. Thyroid Hormone Transport into Cellular Tissue. 
    Holtorf, K.
    Journal of Restorative Medicine3(1), 53-68. Chicago. 

  7. Does Combination Therapy T3/T4 Make Sense? 
    McDermott, M.
    Endocrine Practice. American Association of Clinical Endocrinologists

  8. Bioidentical thyroid replacement therapy in practice: Delivering a physiologic T4:T3 ratio for improved patient outcomes with the Listecki-Snyder protocol.
    Snyder, S., Listecki, R.E
    International Journal of Pharmaceutical Compound; 16(5): 376-378.

  9. New insights into the variable effectiveness of levothyroxine monotherapy for hypothyroidism
    Elizabeth A McAninchemail, Antonio C Bianco
    The Lancet - Volume 3, No. 10, p756–758, October 2015
  1. The diagnosis and treatment of hypothyroidism: a patient’s perspective
    Mel Row, Rudolf Hoermann, Peter Warmingham
  1. Low-T3 Syndrome - A Strong Prognostic Predictor of Death in Patients with Heart Disease
    Giorgio Iervasi, MD; Alessandro Pingitore, MD, PhD; Patrizia Landi, BSc; Mauro Raciti, BSc; Andrea Ripoli, PhD; Maria Scarlattini, BSc; Antonio L’Abbate, MD; Luigi Donato, MD
    Circulation - February 11, 2003, Volume 107, Issue 5
  1. Low-dose T3 replacement restores depressed cardiac T3 levels, preserves coronary microvasculature, and attenuates cardiac dysfunction in experimental diabetes mellitus. 
    Weltman, N. Y., Ojamaa, K., Schlenker, E. H., Chen, Y. F., Zucchi, R., Saba, A., ... &
    Gerdes, A. M.
    Molecular medicine (Cambridge, Mass.).  

  2. The role of thyroid hormones in anxiety and depression.
    R. Larisch, S. Schulte, G. Hildenbrand, R. Hörmann.
    Deutsche Gesellschaft für Nuklearmedizin e.V.
    Samstag, 25. April 2015 8:30-10:00
  1. Combined treatment with sertraline and liothyronine in major depression: a randomized, double-blind, placebo-controlled trial. 
    Cooper-Kazaz, R., Apter, J. T., Cohen, R., Karagichev, L., Muhammed-Moussa, S., Grupper, D., et al
    Archives of general psychiatry64(6), 679-688. 
  1. T3 augmentation in major depressive disorder: safety considerations. 
    Rosenthal, L. J., Goldner, W. S., & O'Reardon, J. P.
    American Journal of Psychiatry168(10), 1035-1040.  

  2. Differences in hypothalamic type 2 deiodinase ubiquitination explain localized sensitivity to thyroxine.
    Joao Pedro Werneck de Castro, Tatiana L. Fonseca, Cintia B. Ueta, Elizabeth A. McAninch, Sherine Abdalla, Gabor Wittmann, Ronald M. Lechan, Balazs Gereben and Antonio C. Bianco
    J Clin Invest. 2015;125(2):769–781. doi:10.1172/JCI77588

  3. The pharmacodynamic equivalence of levothyroxine and liothyronine. A randomized, double blind, cross-over study in thyroidectomized patients.
    Francesco S. Celi, Marina Zemskova, Joyce D. Linderman, Nabeel I. Babar, Monica C.
    Skarulis, Gyorgy Csako, Robert Wesley, Rene Costello, Scott R. Penzak, and Frank Pucino
    Clin Endocrinol (Oxf). 2010 May ; 72(5): 709–715.

  4. Of rats and men: thyroid homeostasis in rodents and human being
    Johannes W Dietrichemail, John E M Midgley, Rolf Larisch, Rudolf Hoermann.
    The Lancet - Volume 3, No. 12, p932–933, December 2015

  5. Calculated Parameters of Thyroid Homeostasis: Emerging Tools for Differential Diagnosis and Clinical Research
    Johannes W. Dietrich, Gabi Landgrafe-Mend, Evelin Wiora, Apostolos Chatzitomaris, Harald H. Klein, John E. M. Midgley and Rudolf Hoermann
    Front. Endocrinol., 09 June 2016
  1. UK Guidelines for the Use of Thyroid Function Tests 2006
  1. Healthcare Improvements Scotland state in their Scoping Report dated 22nd February 2014 http://www.healthcareimprovementscotland.org/our_work/technologies_and_medicines/
  1. Patients’ attitudes and perceptions towards treatment of hypothyroidism in general practice: an in-depth qualitative interview study
    Rosie Dew, PhD, Kathryn King, PhD, Onyebuchi E Okosieme, MD, FRCP,Simon Pearce, PhD, MD, FRCP, Gemma Donovan, MSc, Peter Taylor, MSc, MBChB, Graham Leese, MD, FRCP, Janis Hickey, BA,Salman Razvi, MD, FRCP, Colin Dayan, PhD, FRCP, Scott Wilkes, PhD, FRCGP.
    Journal of General Practice; DOI:10.3399/  bjgpopen17X100977 http://bjgpopen.org/content/bjgpoa/early/2017/06/26/bjgpopen17X100977.full.pdf

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