Richtlijn L-T4 plus L-T3: een moeizame stap in de goede richting

Al jaren was het een wens van patiënten en in 2012 is hij verschenen: een richtlijn voor de behandeling van L-T4 (Thyrax / levothyroxine / Euthyrox) met L-T3 (Cytomel / liothyronine). Voor de behandeling van mensen met hypothyreoïdie betekent deze ETA-richtlijn een enorme vooruitgang. ETA staat voor European Thyroid Association.


Petros Perros is endocrinoloog en hij schreef als editorial in de European Thyroid Journal bij het verschijnen van de nieuwe richtlijn:

ETA Guidelines on L-T4 + L-T3 combination for hypothyroidism:
a weary step in the right direction

‘I made a few rather cynical remarks during my presentation, which got me some laughs by the audience. Unaware that I was speaking to anyone but colleagues, I was confronted at the end of my talk by an angry lady, who turned out to be a patient representative. She made sure I noted that her views and personal experience were very different to what I had portrayed. I had unintentionally offended a hypothyroid patient, which I regretted terribly, but after a lengthy discussion with her, which continued with occasional emails for several months, I was delighted to be asked to act as medical advisor for her thyroid patient-led organization. We remain friends and respect each other, though our views are still different.’

‘On balance, I cautiously welcome the ETA guideline. It is patient centred and will encourage clinicians and disenfranchised patients to engage with each other. This can only be a good thing. The authors have had the courage to take a stance on L-T4 + L-T3 and that is admirable, though it will be perceived as controversial by many of their peers for not being based on evidence. In my view, the proposition to ‘experiment’ with a trial of L-T4 + L-T3 treatment comes with a responsibility that befalls upon the ETA and clinicians who adopt the guideline: to audit it and report back over the next 1–2 years.’

The thyroid community needs to know:

1. what proportion of patients presenting with unresolved symptoms while on L-T4 have an alternative diagnosis;
2. how often are the target biochemical parameters achieved on L-T4 + L-T3 using the recommended formulae;
3. does the conversion from L-T4 monotherapy to combination L-T4 + L-T3 cause periods of instability of the thyroid status;
4. how many additional consultations and measurements of thyroid function are generated by conversion to L-T4 + L-T3;
5. is L-T4 + L-T3 associated with documented episodes of cardiac arrhythmias or other adverse effects;
6. what proportion of patients decide to abandon the L-T4 + L-T3 ‘experiment’, and finally and most importantly,
7. what is the patients’ opinion and level of satisfaction with the ‘experiment’?

This is not difficult to do and although it will never answer the important remaining questions about the L-T4 + L-T3 story, it will be hugely valuable for everyday management of patients with hypothyroidism. I expect the guideline will change our practice and will stimulate more research on this fascinating topic.’