84th Annual Meeting of the American Thyroid Association:

Clinical Evaluation of Hospital In-patient Use of Intravenous Levothyroxine

Dr. K. Mizokami-Stout from the University of Colorado Hospital at Aurora presented the results of a six-month retrospective study related to the use of intravenous (IV) lexothyroxine during the American Thyroid Association’s (ATA) annual meeting. Dr. Mizokami-Stout indicated IV lexothyroxine is an expensive medication compared to the oral form. She and her colleagues wanted to see if any cost savings could be realized by trying to reduce the number of patients who receive IV lexothyroxine.

Chart Review/Data Evaluated
The study involved a chart review of six months of data and evaluating hospital in-patients who received IV lexothyroxine, where they were being prescribed the medication, and what were the indications.

  • N=76
  • Mean age: 65
  • Gender: 56% female

Endocrinologists Surveyed
Dr. Mizokami-Stout stated, “We also surveyed our clinical endocrinologists at the University of Colorado Hospital to evaluate basically what indications they thought IV levothyroxine was indicated for. We came up with indications, including suspected short gut syndrome, malabsorption, cardiogenic shock, or suspected or confirmed myxedema coma, and used those as our compelling indications and compared that to the data that we collected with a chart review to see whether or not the patients who were actually prescribed the medication had met one of those indications.”  The evaluation revealed that about 80% of the time the patients were not being administered IV levothyroxine for one of the compelling indications (n=10, below).

  • Myxedema: 5 (5%)
  • Malabsorption: 3 (4%)
  • Cardiogenic shock: 2 (2.5%)

Safety Analysis
The study included a safety analysis to evaluate whether or not the patients’ doses were being correctly converted. It was found that about 20% of patients were incorrectly dosed from their oral (PO) to IV form and were often receiving 1:1 dosing. Dr. Mizokami-Stout stated, “Whereas, we recommended anywhere from 50% to 80% of a dose reduction from the PO to IV form.”  

Cost Analysis
Dr. Mizokami-Stout indicated the study included a cost analysis because a vial of IV levothyroxine (100 mcg) at the University of Colorado Hospital costs is $75 compared to pennies for the oral form. It was determined the hospital could save upwards of $60,000 per annum if IV levothyroxine was restricted to patients with a compelling indication for the IV medicine.

Adverse Events
The study revealed 21% of patients experienced either new onset arrhythmias or atrial fibrillation or atrial flutter in the past. Dr. Mizokami-Stout stated, “This was a surprising finding, although it could be correlated to patients in the Intensive Care Unit often are very sick. We don’t know if the medicine is causation, but is something to evaluate.”

  • New onset arrhythmia: 8 (10.5%)
  • Total number of arrhythmias: 16 (21%)
  • Percentage of patients with arrhythmias without compelling indication: 9 (75%)

Conclusion
Dr. Mizokami-Stout concluded by stating that not every patient, "who is NPO [nothing by mouth] needs to be started on IV medication right away." Physician awareness of medication cost, whether it is PO or IV, can influence savings for the hospital and the patients served.

 

January 27, 2015

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