6.9 Thyroid disorders

First line drugs

Second line drugs

Specialist drugs

Secondary care drugs

Traffic light status (TLS) explained:

Green: Routine prescribing within licensed indication
Amber 1: specialist recommendation followed by GP initiation and continuation
Amber 2: specialist or GP initiation in line with local guideline after 1st line failure followed by GP continuation
Amber 3: specialist initiation and stabilisation followed by GP continuation
Amber SCG: specialist initiation and stabilisation followed by GP continuation in line with an agreed shared care guideline
Red: Hospital or specialist prescribing only

6.9.1 Hyperthyroidism

Notes:

MHRA Drug Safety Update Carbimazole: increased risk of congenital malformations; strengthened advice on contraception Feb 2019
MHRA Drug Safety Update Carbimazole: risk of acute pancreatitis (Feb 2019)

Notes:

CSM warning: Neutropenia and agranulocytosis.
Doctors are reminded of the importance of recognising bone marrow suppression induced by carbimazole and the need to stop treatment promptly.
- Patients should be asked to report symptoms and signs suggestive of infection, especially sore throat or mouth ulcers.
- A white blood cell count should be performed if there is any clinical evidence of infection.
- Carbimazole should be stopped promptly if there is clinical or laboratory evidence of neutropenia.
Propylthiouracil is used where there is a known sensitivity to carbimazole, or in pregnancy.

Notes:

Liothyronine (oral) is not recommended for prescribing in Milton Keynes and is therefore classified Double Red for all new patients.
Liothyronine (oral) is not supported by local NHS endocrinologists and it is not included in the recommendations for the treatment of hypothyroidism from the Royal College of Physicians.
The British Thyroid Association recommends levothyroxine as the standard treatment for hypothyroidism. Treatment with combination L-T3 plus L-T4 should only be considered in exceptional cases and should be started and supervised by accredited endocrinologists.
The Milton Keynes Prescribing Advisory Group (MKPAG) does not recommend liothyronine (T3) as a treatment option for resistant depression in adults.
The only UK licensed liothyronine tablet is available as a 20mcg strength. Other strengths are available from special's manufacturers but are not licensed in the UK and should not be routinely prescribed. Liothyronine currently costs approximately £3000 per patient per year based on a 10 microgram twice daily dose. The equivalent daily dose of levothyroxine is 100 micrograms and costs the NHS approximately £20 per patient per year.
There are potential risks from liothyronine therapy (on the bone - osteoporosis and the heart - arrhythmia)
The NHS will only support continued prescribing in exceptional circumstances and only under recommendation from an NHS endocrinologist.
RMOC Guidance - Prescribing of Liothyronine (November 2018)

Traffic light status (TLS) explained:

Green: Routine prescribing within licensed indication
Amber 1: specialist recommendation followed by GP initiation and continuation
Amber 2: specialist or GP initiation in line with local guideline after 1st line failure followed by GP continuation
Amber 3: specialist initiation and stabilisation followed by GP continuation
Amber SCG: specialist initiation and stabilisation followed by GP continuation in line with an agreed shared care guideline
Red: Hospital or specialist prescribing only