During the coronavirus pandemic, health care access, policies and procedures are swiftly changing.
Hardly anyone in the media is talking about restrictions on managing our chronic health conditions like thyroid disease. It’s our job to talk about thyroid care from the patient’s point of view.
This post offers a Canadian perspective on the pressures on thyroid lab testing, thyroid care from our physicians, and thyroid medication availability at pharmacies as of March 24, 2020.
For each set of challenges, I provide a list of some things that we as patients can do to prepare ourselves.
Today, we can do a lot to secure our thyroid therapy and health. We may need to act on some of these things swiftly, in case the situation worsens or endures for a long time. Not everything is outside our control, at least not at this stage.
Doctor appointments
Many doctors are moving to telehealth appointments.
On March 24, the Montreal Gazette reported “Family doctors across Montreal have switched to telemedicine to examine as many as 90 per cent of their patients. … Patients with abdominal pain and other serious conditions are still being examined in doctors’ offices. But in most cases, doctors, nurses, dietitians and social workers are relying on the phone, and to a lesser extent video calls, to communicate with patients.”
The use of technology will change how medicine is practiced. Some manifestations of thyroid imbalance present themselves in heart rate, body temperature, and puffy skin. Video appointments may communicate emotional and mental symptoms in a way that audio telephone calls or email messages may not.
Telehealth can be fabulous in some ways, but our doctors are not invulnerable, and neither are the technologies. It requires expertise and technical equipment as well as internet bandwidth to do videoconferencing with a doctor. As more services move online, our systems may need to expand to meet demand. Software programs will undergo transition.
What can you do?
- Prepare for appointments so that when you are distracted by this alternative mode of delivery, you don’t forget your main questions, concerns, goals, and what symptoms you want to report.
- List the priorities for the consultation — both your own as well as what your doctor may consider priority information at this time.
- If you can, learn how to use technologies that are involved in video teleconferencing. Learn and get set up in advance so you aren’t presented with an overwhelming IT challenge when you’re sick.
Changing doctors
Our doctors may themselves become ill with this infection or another condition. Doctors may need to retire or go part-time due to stress on themselves or their families.
As a result of such unexpected situations, we may need to change health care providers. Future doctors may make changes in our thyroid therapy for better or worse.
What can you do?
- Make sure your medical record is complete in your province’s online system so that it can be taken into account by future doctors and emergency physicians.
- Ask whether there is a clear record of any distinctive aspects to your thyroid condition, such as thyroid nodules, an adverse response to a certain thyroid pharmaceutical, an autoimmune diagnosis, or central hypothyroidism (poor TSH secretion),
- Gather as much of your own laboratory history as you can to keep records at home in case technologies and staffing make this information difficult to obtain later. Sometimes doctors’ offices charge fees for copies of records and it may take time and staff to fulfill a request.
- Collect, write down or print out information about all your medications including the dose and the very specific name brand and manufacturer, even the DIN number (Canada’s drug information number). Record the time of day it’s taken, and number of hours away from food or supplements (this can significantly interfere with T4 hormone absorption). Tell a family member where this information is so they can can bring or send it to you if you are in hospital.
- Gather the scientific and clinical evidence to defend your current therapy if it’s not standard but it’s working well. On the other hand, if your thyroid therapy is not going well, prepare to self-advocate for changes that could improve your overall health.
- Investigate diverse options for thyroid health care that may be available in your province, such as Nurse Practitioners and Pharmacists that have the licensing and ability to prescribe medications and order laboratory tests. Often, naturopathic doctors and functional medicine doctors can also order tests and prescribe for thyroid.
Laboratories
Currently, some of us are afraid of going to blood test laboratories because we may spread or contract the virus in doing so, so we’re putting it off. This stance can only help if the crisis is short term.
In addition, laboratories are suspending some tests. As of March 24, Global News reported “Manitoba is temporarily suspending non-essential, routine diagnostic tests to protect health-care workers and patients from the spread of COVID-19. “Specifically, this includes laboratory blood tests, diagnostic imaging and cardiac services,” Lanette Siragusa, the province’s chief nursing officer, said Tuesday. Affected patients will be contacted, she added.”
What is a non-urgent test? A similar policy has been implemented in the U.S. at the University of Vermont Health Network, and they say
- “Non-urgent elective encounters are defined as any surgery, procedure, diagnostic test or clinic visit that can be safely delayed or deferred, without threat to the immediate health and safety of the patient.”
Even laboratories that continue to offer “non-urgent” tests are experiencing restructuring. LifeLabs in Canada is reporting as of March 22 on their coronavirus page that “Some locations have already adjusted their hours, and more will temporarily close or reduce hours in the next few days.” Articles in the news are discussing the use of local laboratories to process COVID-19 tests.
What can you do?
- “Call ahead before you get medical care,” says the College of Pharmacists of British Columbia. By calling ahead, you help the clinic, hospital, lab, urgent care or doctor’s office prepare for your visit and stop the spread of germs.”
- Investigate alternative laboratories. Depending on your province’s laws, there may be private laboratories in your region that offer thyroid tests for a fee. Google this phrase (without the quotation marks): “online lab tests thyroid Canada.”
- If you are symptomatic in ways that you suspect are related to thyroid hormone excess or deficiency, track your own vital signs (heart rate, body temperature, blood pressure) in a table or spreadsheet. Systematic data that is based on numbers is always better than subjective report about your “feelings.”
- If you take medicines containing T3 hormone, measure before you take T3 and then 2.5-3 hours after the dose when Free T3 is at its peak. Five to seven full days’ of data at different times of a month and different days of the week can help you see patterns and rule out temporary anomalies.
- In addition to vital signs, consider using clinically-tested thyroid symptom scores which do offer relevant information, although it is always best to view them in the context of very recent thyroid blood test information (Kalra et al, 2011).
Pharmacies
News articles are discussing changes regarding pharmacies and pharmacists’ roles. They may expand their authority to new infectious disease testing. This is good and necessary. But this can also shift their workload and attention, especially if they have to enact precautions and social distancing and adapt to a new global pharmaceutical economy.
We also see limitations on prescription renewals being considered in public. A March 19, 2020 Global News report quoted the Government of Alberta: “To ensure Albertans can access the medications they need, the Alberta College of Pharmacy supports measures that will reduce the likelihood of drug shortages by limiting prescription quantities to 30 days. This will assist in stabilizing our drug supply.” The report concludes by saying “Other provinces, including Ontario, British Columbia and Quebec, have either taken action or are in the process of implementing measures to protect drug supply chain stability.”
What can you do?
- Check on the status of your own pharmaceutical supplies. Do an inventory of what’s in your medicine cabinet, what’s expired, and how much you have left — record the date when prescriptions will run out.
- As soon as you obtain a new prescription, make a calendar entry to remind yourself when to order a renewal — this is very important in case renewals become restricted to 1 month’s supply of medication.
- Don’t trust pharmacies to tell you if a medication is out of stock. Thyroid medications, especially Cytomel and ERFA Thyroid, often come up with distributor-specific or local information. Go to the Canadian Drug Shortages website and click “search” to look for your pharmaceutical’s brand name. Go to the pharmaceutical company’s own website, Twitter feed, or Facebook page for updates. Even call them.
- If your medication is out of stock at one pharmacy, sometimes you can find it at another pharmacy. You may be able to find an online or brick-and-mortar pharmacy that delivers across Canada (Google Canada-wide pharmacy shipping). Consider asking at “compounding pharmacies,” which are special pharmacies that may have a powdered format of your medication available to put into capsules.
- Obtain the Canadian “product monograph” of the thyroid medication you are on, whether it’s Aspen’s Eltroxin, Mylan’s Synthroid, ERFA’s desiccated Thyroid, or Pfizer’s Cytomel. Scan the lists of substances, health conditions, and medications that can interfere. This may be a service your pharmacist may be too busy to offer you. Your diet or supplements may change in ways that shift your absorption.
- Ask if your pharmacy offers services such as delivery to your home. Policies are changing to allow patients to arrange to have someone to pick up their medications for them.
- If you ever need to change thyroid pharmaceutical brand or type due to distribution and pricing changes, understand the difficulty of establishing bioequivalence even between two different brands of Levothyroxine (LT4) (Synthroid, Eltroxin) at the same dose. Pharmaceutical equivalence is even more difficult to determine between desiccated thyroid, LT3, and LT4. Be prepared for months of readjustment based on symptoms, signs and any laboratory tests you can get.
Let’s support each other with information and practical advice as the situation develops.
– Tania S. Smith