Pharmacy insights

Liothyronine: issues with cost and NHS prescribing

I recently came across a patient being privately prescribed 168 liothyronine tablets. This particular patients (like many others) was refused supply of this drug on NHS prescription and due to ‘Brexit’ happening, he decided to get some extra tablets ‘just in case’. He was about to be amused.

Price?

£1799

Left with no choice, he was forced to look elsewhere (abroad) for affordable pharmacies. Germany? Prices cheaper than UK. This particular patient went with pharmacy he found in Turkey, raising questions about the source of the supply and quality of liothyronine. Generally EU prices for liothyronine are significantly cheaper than UK prices ranging from 2 pence to 26 pence per tablet, as comparing to UK, where cost per tablet is more than £9 (Thyroid UK, 2018).

Concordia, the producer of liothyronine in UK is currently under investigation by The Competition and Markets Authority (CMA) for ‘abusing its dominant position to overcharge the NHS by millions’ when supplying liothyronine (Gov UK, 2017).

Difference between liothyronine (T3) and levothyroxine (T4)

Both T3 and T4 are produced in the body by the thyroid gland. Levothyroxine is the synthetic form of thyroxine (T4), the main hormone produced by the thyroid gland (about 80%-90%). Once in the body T4 is converted into the active form T3. Liothyronine is the synthetic version of T3 hormone.

Is liothyronine (T3) better than levothyroxine (T4)?

No. Liothyronine (T3) is more potent form of the hormone then levothyroxine (T4). It has a quicker onset of action (starts to work faster), but it is also metabolised quicker, meaning it disappears from the body in faster pace than T4 (PJ, 2011). Clinical trials involving patients who were ‘blinded’ (not knowing which form of hormone was given) showed no difference between both drugs in term how patients felt (JAPC, 2018). These results conflict with the fact that many patients report feeling better when being treated with T3, and as I was told number of times it is ‘life changing’ treatment for some.

Liothyronine can have bigger impact on pulse rate and cardiovascular effects (PJ, 2011) and due to more difficulties in terms of dose adjustments and monitoring in long term it may increase risks of stroke and osteoporosis (JAPC, 2018).

Cost of supply liothyronine to NHS

In 2016/2017 NHS spent more than £34 mln on supplies of liothyronine. In contrast in 2006 this sum was just £600 000 (NHS England, 2017). This is mainly due to the cost of liothyronine, which increased by 6000% in recent years. Although following consultation in 2017 NHS England decided to continue supplies of liothyronine where levothyroxine does not manage patient’s condition, local Clinical Commissioning Groups (CCGs) simply refuse this medication from being supplied on NHS. This is possibly because liothyronine was included on the list of ‘items not routinely prescribed in primary care’. This of course does not mean banning/refusing the supply, something that came into place in many areas after this consultation.

All of this bring the issues of cost effectiveness (high price of medication versus lack of evidence for effectiveness) of treatment with liothyronine.

Use of levothyroxine is a standard treatment for hypothyroidism (NICE, 2018) and most patients will have their condition controlled with this medication. In rare situations treatment with liothyronine can be initiated as combination therapy and only by consultant NHS endocrinologists on trial basis (RMOC, 2018).

Where to buy liothyronine in UK?

Almost all pharmacies will be able to supply liothyronine, however price of £250-£300 per box of 28 is standard price for this medication.

Where to buy liothyronine abroad (Thyroid UK)?

Please note you will need a private prescription from a GP or any registered UK prescriber. Although your GP will know what to write on private prescription, I would contact your chosen pharmacy, before getting your private script. This is just in case there are some specific/additional requirements for EU private prescriptions which are not in place in UK.

Examples of German pharmacies where liothyronine can be ordered. You can use Google translate to get a overview of each website, however some translation mistakes will be present.

References:

Gov UK (2017). Drug company accused of abusing its position to overcharge the NHS. Available at: https://www.gov.uk/government/news/drug-company-accused-of-abusing-its-position-to-overcharge-the-nhs Accessed on 22/02/2019

JAPC (2018). Liothyronine not recommended for hypothyroidism Levothyroxine is the only recommended treatment for hypothyroidism in Derbyshire. Available at: http://www.derbyshiremedicinesmanagement.nhs.uk/assets/Clinical_Guidelines/Formulary_by_BNF_chapter_prescribing_guidelines/BNF_chapter_6/Liothyronine_position_statement.pdf Accessed on 22/02/2019

NHS England (2017). Items which should not be routinely prescribed in primary care: Guidance for CCG. Available at: https://www.england.nhs.uk/publication/items-which-should-not-be-routinely-prescribed-in-primary-care-guidance-for-ccgs/ (Accessed on 22/02/19)

NICE (2018). Hypothyroidism. Available at: https://cks.nice.org.uk/hypothyroidism#!scenario (Accessed on 23/02/19)

Pharmaceutical Journal (2011). Thyroid disorders management. Available at: https://www.pharmaceutical-journal.com/download?ac=1065114 (Accessed on 22/02/19)

RMOC (2018). Regional Medicines Optimisation Committee: Guidance – Prescribing of Liothyronine. Available at: https://www.sps.nhs.uk/wp-content/uploads/2018/11/RMOC-Liothyronine-Guidance-v2.0-final-1.pdf (Accessed on 23/02/19)

Thyroid UK (2018). Improving T3 prescription in the UK – a joint campaign on behalf of thyroid patients. Available at: http://thyroiduk.org/tuk/campaigns/T3-Campaign/Improving%20T3%20Prescription%20in%20the%20UK%20for%20Submission%20to%20NHS%20%20England%20(1).pdf (Accessed on 22/02/19)

I am a community pharmacist working in UK. I blog about drugs, health and pharmacy.

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