Forbidding FT3 and FT4 in British Columbia as of late 2018

Thyroid Laboratory testing policy in BC, CanadaSomeone asked for more info on the guidelines in British Columbia (BC) to prevent FT3 and FT4 testing, so I supply links and summaries of policies here.

These barriers became active in BC health policy October 2018, they were being enforced by physicians and laboratories in January 2019, according to posts on our support group.

Document 1

This is the main British Columbia Health policy document, “Thyroid Function Testing in the Diagnosis and Monitoring of Thyroid Function Disorder” (PDF): link: https://www2.gov.bc.ca/assets/gov/health/practitioner-pro/bc-guidelines/thyroid-function-testing.pdf

The final page, “Appendix 1: BC Laboratory Algorithm for Thyroid Tests,”  shows in red all the places where “Cancel FT3 if ordered” or “Cancel FT4 if ordered” occurs at the laboratory.

All diagnosis and treatment of hypothyroidism is completely blind to FT3 levels.

FT3 testing is only indicated in subclinical hypER when TSH is low and FT4 is normal.

Lower FT3 levels during thyroid therapy are not listed under their “Controversies in Care” heading.

There is NO mention of various thyroid therapy types and whether or not T3-based thyroid therapy requires FT3 or FT4 testing for safety.

Their overall approach presumes that low T3 is benign and temporary and not of concern at all during thyroid therapy.

There is no mention of Atrophic Thyroiditis and its TSH-receptor blocking antibodies that cause hypothyroidism.

References cite the Choosing Wisely Canada toolkit on FT3 and FT4 and the ATA hypothyroidism guidelines published in 2012 and 2014 (Jonklaas et al, Gerber et al).

In subclinical hypothyroidism (where FT4 is normal but TSH is above range), thyroid therapy is only recommended when TSH rises above 10 mU/L or when TSH is elevated along with high TPO antibodies, hypo symptoms, cardiovascular disease or pregnancy.

These guidelines also incorrectly imply that low T3 is only found in “Sick Euthyroid Syndrome,” (an alternative label for Low T3 Syndrome), which they incorrectly define as only occurring in patients without a thyroid disease diagnosis. They also falsely presume that such patients will all recover from their low FT3 (research shows no, they can and do often die or remain ill if FT3 is too low and stays too low). They also teach that in recovery from sick euthyroid syndrome, T3 levels are insignificant compared to their return to normal TSH: “As patients recover from their illness, TSH may normalize or become elevated.” This presumes of course that patients have a thyroid gland for TSH to stimulate.

“Table 2. Potential Causes of Abnormal Hormone Levels (TSH, fT4 and fT3)” classifies abnormal thyroid test results primarily under the categories “Causes of low TSH” and “Causes of high TSH” as if these are the most significant abnormalities. In Sick Euthyroid Syndrome, it says “testing not usually indicated,” so if it is suspected, it will now be ignored on the basis that “Any abnormality in levels is possible; Usually: TSH low or normal, fT4 low or normal, fT3 low; As patients recover, TSH may normalize or become elevated.”

Document 2

PDF from BC Guidelines, “Hormone Testing – Indications and Appropriate Use” https://www2.gov.bc.ca/assets/gov/health/practitioner-pro/bc-guidelines/hormone_full_guideline.pdf

This has rows on Free T3 and Free T4 and TSH, listing prices and when testing is indicated or not.  FT3 is never indicated in hypo, only to confirm suspected hyper.

As of the date of the policy document, May 2016,

  • TSH $9.90,
  • Free T4 $12.12,
  • Free T3 $9.30 per test.

 

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