Deprescribing Levothyroxine in Subclinical Hypothyroidism: Which Barriers and Enablers Do GPs Identify?

Annika Rettich, Sandy Scheibe, Stefan Hager, Melanie Rennert, Tobias Deutsch, Markus Bleckwenn, Karen Voigt, Jeannine Schübel

Keywords: Levothyroxine, deprescribing, subclinical hypothyroidism, participatory research, qualitative research, focus group discussions, general practitioners

Background:

Subclinical hypothyroidism (SH) is a condition which, according to current evidence, generally does not require medical treatment. The prescription of levothyroxine (LTX) in patients with SH can therefore be regarded as medical oversupply. According to the DEGAM guideline for German general practitioners (GPs), a controlled deprescription of LTX can be considered in cases of SH. Yet, no structured deprescription strategy for LTX has been established in primary care.

Research questions:

Which barriers and enablers do German GPs identify regarding the deprescription of LTX? Which conditions are considered essential for the development of a deprescription strategy?

Method:

In DELTA-PIA, collaboration project between Universities of Leipzig and Dresden, Germany, we used a qualitative participatory approach involving GPs and patients. We aimed to explore key barriers, enablers and conditions of deprescribing LTX to derive indications for a deprescription strategy. Three GP focus groups were conducted in March 2024 (N = 15 GPs).

Results:

As main enablers for deprescribing LTX, participating GPs identified (1) a potential reduction of side effects through LTX, (2) depathologization of patients with SH, and (3) a reduction of (multi)medication burden. As main barriers, GPs identified (1) anticipated patient resistance, (2) elevated short-term effort required to implement the deprescription procedure, and (3) suspected conflicts with other medical professionals (e.g., endocrinologists, alternative practitioners, dieticians). Reported necessary conditions for deprescribing were: (1) the presence of patient’s willingness, (2) a low initial LTX dose, and (3) the availability of an effective deprescription strategy including a decision-making tool covering different social and medical factors.

Conclusions:

The focus groups revealed a general willingness of GPs to deprescribe LTX in patients with SH. In order to enable an implementation of LTX deprescription in primary care, a structured deprescription strategy is required that incorporates all conditions identified by GPs and provides a decision-making tool on the appropriate handling of the identified barriers.

Points for discussion:

What types of material could facilitate the LTX deprescription process for GPs? (e.g. information sheets as handouts for patients on possible consequences of deprescribing/not deprescribing)

How could GPs handle potential conflicts with other medical professionals over the deprescription of LTX?

Which other areas of general medicine research could benefit from participatory involvement of GPs?

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