GLASGOW, Scotland – Although the cost of liothyronine tablets has fallen significantly in the UK, it remains 10 times higher than 2009 levels. Notably, the low-dose tablets are more than double the cost of the high-dose ones. Earlier this year, the British Thyroid Association (BTA) had suggested that patients with persistent symptoms, despite levothyroxine treatment for overt hypothyroidism, could receive a trial of combined levothyroxine and a daily dose of 5-10 μg liothyronine split over the day.
“The lower dose of liothyronine (5-10 μg) recommended by the BTA is 240% of the cost of the 20 μg dose. So if we, as doctors, follow the BTA guidance, then we incur extra costs,” said Adrian Heald, endocrinologist at Salford Royal Hospital, speaking at the annual meeting of the Society for Endocrinology (SfE BES) 2023.
Together with his co-investigators from Cardiff University, Heald reported data that illustrate the changes in the amounts and costs of liothyronine (T3) prescribed across the UK at different dosages over the last 6 years, highlighting a widening of the gender health inequity gap.
“Because just under 90% of patients with an underactive thyroid are women, these prohibitive costs mean women bear the burden of not being able to access the treatment that their doctor recommends,” said Heald.
The EU-UK Divide
Outside of the UK, where the price is lower, liothyronine is prescribed more often, and some UK patients find they can only access the drugs they need by purchasing their medication online.
“While the evidence base for the validity of prescribing a combination of T3 (triiodothyronine) and T4 (thyroxine) is growing, the cost in the UK needs to be seriously looked at in comparison to elsewhere in Europe, where liothyronine can be bought online for £100s rather than £1000s,” Heald pointed out.
“There needs to be a level playing field in terms of what is prescribed, and we recommend that the tablets should all be the same price for whatever dosage, so that clinicians can prescribe according to a patient’s needs,” added Heald. “We call for the regulatory authorities to look into this again,” said Heald.
In 2017, the Competition and Markets Authority (CMA) determined that the price paid for liothyronine tablets in the UK rose from £15.15 in 2009 to £258.19 in 2017. As such, the CMA imposed a fine on the suppliers (previously Goldshield, now largely supplied in the UK by Advanz Pharma) of £101 million. Advanz lost its appeal against the CMA decision in August this year.
Changes Since 2016
Heald and his team analysed monthly primary care prescribing data for liothyronine, levothyroxine, and natural desiccated thyroid by dose levels to examine price changes from 2016 to 2022. They assessed outcomes including the number of GP practices issuing prescriptions in England, the number of prescriptions, the actual costs, the dosage (μg) of liothyronine, and the cost per prescription and per μg of liothyronine.
From 2016, liothyronine prescriptions fell by 30%, then started to grow in 2020, reaching 61,000 in 2022, but this was still 18% below 2016 levels.
In 2020, the percentage of 5 and 10 μg prescriptions began to rise from 7% to 30%.
In 2019, the average cost started to fall, reaching £146/prescription in 2022 (37% of the 2016 value).
However, by 2022, the cost of the 20 μg tablet fell by 80% of its 2016 value (from £404 to £101/prescription), while that of the 10 μg tablet fell by 35% (from £348 to £255/prescription) and that of the 5 μg tablet fell by 38% (from £355 to £242/prescription [£0.64/μgT3]).
The total annual cost of liothyronine fell by 70% to £9m/year between 2016 and 2022. The percentage of practices in the UK prescribing liothyronine fell from 49% to 36%.
Professor Karim Meeran, MD, Department of Metabolism, Digestion and Reproduction, Imperial College London, commented at the session and spoke to Medscape UK afterwards: “The only solution is for a charity to make the drug; as seen with insulin in the US to make it cheaply, at cost price, for the US market.” Meeran was describing a new not-for-profit partnership in the US that will lead to $30 insulin vials on the market by 2024.
Robert Semple is a professor of translational molecular medicine at the University of Edinburgh, as well as a practising endocrinologist. “Whether or not to add T3 to T4 in the treatment of hypothyroidism is one of the perennial issues in endocrinology, and people continue to disagree about this,” he told Medscape UK. “One of [the arguments] is around clinical efficacy, while another is about health economics because of the very high price of T3, and this is why this study is so pertinent.”
Heald, Meeran, and Semple have declared no relevant conflicts of interest.