title: Treating Hypothyroidism with Thyroxine/Triiodothyronine Combination Therapy in Denmark: Following Guidelines or Following Trends?
abstract: BACKGROUND
  Five to ten percent of patients with hypothyroidism describe persistent symptoms despite being biochemically well regulated on levothyroxine (L-T4). Thyroxine (T4)/triiodothyronine (T3) combination therapy [L-T4/liothyronine (L-T3) or desiccated thyroid] are still regarded as experimental with no evidence of superior effect on persistent symptoms according to meta-analyses. However, some randomized controlled trials have demonstrated patients' preference for T4/T3 combination therapy as compared to L-T4 monotherapy. In 2013, attention to combination therapy increased in Denmark after a patient published a book describing her experiences with hypothyroidism and treatment.
  
  
  OBJECTIVE
  To investigate current Danish trends in the use of T4/T3 combination therapy.
  
  
  METHODS
  We used an Internet-based questionnaire, distributed as a link via two Danish patient fora. Further, information was obtained from the Division of Pharmacies and Reimbursement at the Danish Health and Medicines Authority and from the only pharmacy in Denmark producing desiccated thyroid and L-T3 tablets.
  
  
  RESULTS
  A total of 384 patients answered the questionnaire, and 293 responders were included. Sixty-nine percent of the responders had six or more symptoms, and 84% reported a treatment effect. Forty-four percent of the responders received their prescriptions from general practitioners; 50% received desiccated thyroid and 28% reported that they adjust their dose themselves. Responders followed by general practitioners more frequently received desiccated thyroid and adjusted their dose themselves.
  
  
  CONCLUSIONS
  Increased media focus has changed the prescription pattern of thyroid hormones; European guidelines on T4/T3 combination therapy are not always followed in Denmark and many patients adjust their medication themselves and may therefore be at risk of overtreatment.
authors.affiliation: Department of Endocrinology, Herlev Hospital, University of Copenhagen, Copenhagen, Denmark.
authors.forename: Luba Freja
authors.initials: LF
authors.lastname: Michaelsson
authors.affiliation: Department of Endocrinology, Herlev Hospital, University of Copenhagen, Copenhagen, Denmark.
authors.forename: Bjarke Borregaard
authors.initials: BB
authors.lastname: Medici
authors.affiliation: Department of Endocrinology, Herlev Hospital, University of Copenhagen, Copenhagen, Denmark ; Department of Clinical Physiology, Nuclear Medicine and PET, Rigshospitalet, University of Copenhagen, Copenhagen, Denmark.
authors.forename: Jeppe Lerche
authors.initials: JL
authors.lastname: la Cour
authors.affiliation: Department of Endocrinology, Herlev Hospital, University of Copenhagen, Copenhagen, Denmark.
authors.forename: Christian
authors.initials: C
authors.lastname: Selmer
authors.affiliation: Department of Medicine, Gentofte Hospital, University of Copenhagen, Copenhagen, Denmark ; Division of Pharmacies and Reimbursement, Danish Health and Medicines Authority, Copenhagen, Denmark.
authors.forename: Michael
authors.initials: M
authors.lastname: Røder
authors.affiliation: Department of Endocrinology, Bispebjerg Hospital, University of Copenhagen, Copenhagen, Denmark.
authors.forename: Hans
authors.initials: H
authors.lastname: Perrild
authors.affiliation: Department of Endocrinology, Bispebjerg Hospital, University of Copenhagen, Copenhagen, Denmark.
authors.forename: Nils
authors.initials: N
authors.lastname: Knudsen
authors.affiliation: Department of Endocrinology, Herlev Hospital, University of Copenhagen, Copenhagen, Denmark ; Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark.
authors.forename: Jens
authors.initials: J
authors.lastname: Faber
authors.affiliation: Department of Endocrinology, Herlev Hospital, University of Copenhagen, Copenhagen, Denmark.
authors.forename: Birte
authors.initials: B
authors.lastname: Nygaard
keywords: Hypothyroidism; Levothyroxine; Liothyronine; Thyroid; Triiodothyronine