Comparative Effectiveness of Generic vs Brand-Name Levothyroxine in Achieving Normal Thyrotropin Levels

Factors influencing drug switching and changes in low-density lipoprotein-cholesterol levels with atorvastatin: a real-world observational study

BACKGROUND

Although generic drugs have been approved with the assurance of interchangeable applications with original drugs, some physicians, and patients still view their efficacy and interchangeability negatively. Using real-world data, we aimed to determine factors that impact switching between drugs that contain the same active ingredient, i.e., atorvastatin, and, in turn, whether this 'switch' could alter clinical outcomes.

METHODS

Using the National Health Insurance Service senior cohort, a retrospective cohort study was conducted to assess patients who had newly started atorvastatin 10 mg and had at least two records of national health examinations from 2010 to 2014. Drug switching, which was defined as a change in the atorvastatin product administered 90 days before the first and second examinations, was assessed. Greedy propensity score matching (1:2) was performed between switchers and non-switchers to control for potential confounders. Factors influencing switching were analyzed using multivariate logistic regression to estimate odds ratios and 95% confidence intervals (CIs). Changes in low-density lipoprotein-cholesterol (LDL-C) levels attributable to drug switching were evaluated using difference-in-differences regression.

RESULTS

A total of 1,588 patients were included, of whom 25.3% switched drugs (1,187 non-switchers and 401 switchers). Compared to patients taking generics before the first examination, those taking the original drugs had a lower odds ratio (0.31; 95% CI [0.21, 0.46]) for subsequent drug switching. A change in medical institution was associated with a significantly higher odds ratio (6.83; 95% CI [4.66, 10.02]). There were no significant differences in LDL-C alterations between switchers and non-switchers (0.42 mg/dL; 95% CI [-2.29, 3.13]).

CONCLUSION

The type of first-time drug administered and changes in medical institution can influence drug switching. No significant changes in LDL-C values were observed in the various switching scenarios between the original and generic drugs, suggesting their interchangeable application in real-world clinical practice.

Getting the levothyroxine (LT4) dose right for adults with hypothyroidism: opportunities and challenges in the use of modern LT4 preparations

Lifelong treatment with levothyroxine (LT4) is the mainstay of management for individuals with hypothyroidism. Many hypothyroid patients start LT4 treatment at a low dose (e.g. 25-50 µg), especially the elderly, those with residual thyroid function, those with low body weight, and those with significant (especially cardiac) comorbidities. Almost half of patients on LT4 replacement therapy demonstrate either under- or over-treatment. Many LT4 preparations have relatively large intervals between tablet strengths at the lower end of their dose ranges (providing 25 µg, 50 µg, and 75 µg tablets), which may represent a barrier to achieving the optimum maintenance treatment for some patients. The availability of intermediate tablet strengths of LT4 in the 25-75 µg range may facilitate precise and effective dose titration of LT4 and may also enable convenient maintenance regimens based on a single LT4 tablet daily, to support adherence to therapy.

Towards De-Implementation of low-value thyroid care in older adults

PURPOSE OF REVIEW

This review discusses the current literature regarding low-value thyroid care in older adults, summarizing recent findings pertaining to screening for thyroid dysfunction and management of hypothyroidism, thyroid nodules and low-risk differentiated thyroid cancer.

RECENT FINDINGS

Despite a shift to a "less is more" paradigm for clinical thyroid care in older adults in recent years, current studies demonstrate that low-value care practices are still prevalent. Ineffective and potentially harmful services, such as routine treatment of subclinical hypothyroidism which can lead to overtreatment with thyroid hormone, inappropriate use of thyroid ultrasound, blanket fine needle aspiration biopsies of thyroid nodules, and more aggressive approaches to low-risk differentiated thyroid cancers, have been shown to contribute to adverse effects, particularly in comorbid older adults.

SUMMARY

Low-value thyroid care is common in older adults and can trigger a cascade of overdiagnosis and overtreatment leading to patient harm and increased healthcare costs, highlighting the urgent need for de-implementation efforts.

Surgeon specialty effect on early outcomes of elective posterior spinal fusion for adolescent idiopathic scoliosis: a propensity-matched analysis of 965 patients

BACKGROUND AND OBJECTIVE

Comparative effectiveness research plays a vital role in health care delivery. Specialty training is one of these variables; surgeons who are trained in different specialties may have different outcomes performing the same procedure. The objective of this study was to investigate the impact of spine surgeon specialty (neurosurgery vs orthopedic surgery) on early perioperative outcome measures of elective posterior spinal fusion (PSF) for adolescent idiopathic scoliosis (AIS).

METHODS

This is a retrospective, 1:4 propensity score-matched cohort study. 5520 AIS patients were reviewed from ACS-NSQIP pediatric database. Propensity score matching was utilized.

RESULTS

Patients operated on by orthopedic surgeons were more likely to have shorter operation time (263 min vs 285 min), shorter total hospital stay (95 h vs 118 h), lower rate of return to operating room within the same admission (1.2% vs 3.8%), lower discharge rates after postoperative day 4 (23.8% vs 30.9%), and lower unplanned readmission rate (1.6% vs 4.1%), (p < 0.05). On the other hand, patients operated on by neurosurgeons had lower perioperative blood transfusion rate (62.1% vs 69.8%), (p < 0.05). Other outcome measures and mortality rates were not significantly different between the two cohorts.

CONCLUSIONS

This retrospective study found significant differences in early perioperative outcomes of patients undergoing PSF for AIS by neurosurgeons and orthopedic surgeons. Further studies are recommended to corroborate this finding which may trigger changes in the educational curriculum for neurosurgery residents.

Association Between Generic-to-Generic Levothyroxine Switching and Thyrotropin Levels Among US Adults

IMPORTANCE

Switching among generic levothyroxine sodium products made by different manufacturers typically occurs at the pharmacy and may affect serum thyrotropin (TSH) levels.

OBJECTIVE

To compare TSH levels between patients who continued taking the same sourced generic levothyroxine product and those who switched.

DESIGN, SETTING, AND PARTICIPANTS

This comparative effectiveness research study with 1:1 propensity matching used data from OptumLabs Data Warehouse, a national administrative claims database linked to laboratory test results. Adults aged 18 years or older were included if they filled a generic levothyroxine prescription between January 1, 2008, and June 30, 2019, and had a stable drug dose, the same drug manufacturer, and a normal TSH level (0.3-4.4 mIU/L) for at least 3 months before either continuing to take the same product or switching among generic levothyroxine products (index date). Patients were excluded if they were pregnant, had diagnosed hypopituitarism or hyperthyroidism, or had a medical condition or used medications that could affect thyrotropin levels. They were also excluded if they filled a prescription for other forms of thyroid replacement therapy between 6 months before the index date and when the first TSH level was obtained 6 weeks to 12 months after the index date. Data were analyzed from December 1, 2019, to November 24, 2021.

MAIN OUTCOMES AND MEASURES

Proportion of individuals with a normal (0.3-4.4 mIU/L) or markedly abnormal (<0.1 or >10.0 mIU/L) TSH level using the first available laboratory result 6 weeks to 12 months after the index date. A propensity score model was developed to minimize confounding using logistic regression with the binary outcome of continuing the same sourced levothyroxine product vs switching generic levothyroxine. Covariates were demographics, comorbidities, and baseline TSH level. The balance among the treatment groups was evaluated by comparing standardized mean differences of baseline covariates between the groups.

RESULTS

A total of 15 829 patients filled generic levothyroxine (mean [SD] age, 58.9 [14.6] years; 73.4% [11 624] were women; 4.5% [705] were Asian, 10.2% [1617] were Black, 11.4% [1801] were Hispanic, and 71.4% [11 295] were White individuals); of these patients, 56.3% [8905] received a daily levothyroxine dose of 50 μg or less. A total of 13 049 patients (82.4%) continued taking the same sourced preparation, and 2780 (17.6%) switched among generic levothyroxine preparations. Among 2780 propensity-matched patient pairs, the proportion of patients with a normal TSH level after the index date was 82.7% (2298) among nonswitchers and 84.5% (2348) among switchers (risk difference, -0.018; 95% CI, -0.038 to 0.002; P = .07). The proportion of patients with a markedly abnormal TSH level after the index date was 3.1% (87) among nonswitchers and 2.5% (69) among switchers (risk difference, 0.007; 95% CI, -0.002 to 0.015; P = .14). The mean (SD) TSH levels after the index date were 2.7 (2.3) mIU/L among nonswitchers and 2.7 (3.3) mIU/L among switchers (P = .94).

CONCLUSIONS AND RELEVANCE

Results of this comparative effectiveness research study suggest that switching among different generic levothyroxine products was not associated with clinically significant changes in TSH level. These findings conflict with the current guideline recommendation that warns clinicians about potential changes in TSH level associated with switching among levothyroxine products sourced from different manufacturers.

Optimal Thyroid Hormone Replacement

Hypothyroidism is a common endocrinopathy, and levothyroxine is frequently prescribed. Despite the basic tenets of initiating and adjusting levothyroxine being agreed on, there are many nuances and complexities to consistently maintaining euthyroidism. Understanding the impact of patient weight and residual thyroid function on initial levothyroxine dosage and consideration of age, comorbidities, thyrotropin goal, life stage, and quality of life as levothyroxine is adjusted can be challenging and continually evolving. Because levothyroxine is a lifelong medication, it is important to avoid risks from periods of overtreatment or undertreatment. For the subset of patients not restored to baseline health with levothyroxine, causes arising from all aspects of the patient's life (coexistent medical conditions, stressors, lifestyle, psychosocial factors) should be broadly considered. If such factors do not appear to be contributing, and biochemical euthyroidism has been successfully maintained, there may be benefit to a trial of combination therapy with levothyroxine and liothyronine. This is not supported by the majority of randomized clinical trials, but may be supported by other studies providing lower-quality evidence and by animal studies. Given this discrepancy, it is important that any trial of combination therapy be continued only as long as a patient benefit is being enjoyed. Monitoring for adverse effects, particularly in older or frail individuals, is necessary and combination therapy should not be used during pregnancy. A sustained-release liothyronine preparation has completed phase 1 testing and may soon be available for better designed and powered studies assessing whether combination therapy provides superior therapy for hypothyroidism.

Comparative Effectiveness of Persistent Use of a Name-Brand Levothyroxine (Synthroid®) vs. Persistent Use of Generic Levothyroxine on TSH Goal Achievement: A Retrospective Study Among Patients with Hypothyroidism in a Managed Care Setting

Introduction

Levothyroxine monotherapy (Synthroid® or multiple generic levothyroxine [GL] formulations) is standard treatment for hypothyroidism. Our objective was to compare effectiveness (as measured by achievement of thyroid-stimulating hormone [TSH] levels) and economic outcomes of Synthroid vs. any one of multiple GLs in patients with hypothyroidism.

Methods

Data for this retrospective cohort study were obtained from the HealthCore Integrated Research Database®. All study patients had ≥ 2 claims between 1 January 2006 and 31 December 2017 with ICD-9/10-CM diagnosis codes for hypothyroidism; were persistent users of Synthroid vs. any GL; and had ≥ 1 TSH laboratory result during 12-month follow-up. Patients were divided into one of two cohorts based on index medication and were 1:1 matched using propensity scores. The primary outcome was the proportion of patients with last TSH laboratory result during follow-up within the reference range (0.3–4.12 mIU/L). Secondary outcomes included all-cause and hypothyroidism-related healthcare resource utilization (HCRU) and costs.

Results

After propensity score matching, the Synthroid and GL cohorts each contained 18,382 patients. At follow-up, significantly more patients receiving Synthroid were in the TSH reference range vs. GL (78.5% vs. 77.2%, respectively, p =  0.002). HCRU and costs were broadly similar between the cohorts in terms of all-cause inpatient hospitalizations, emergency department visits, outpatient services, and pharmacy fills. Irrespective of index medication, patients with TSH within the reference range had significantly lower hypothyroidism-related medical and total costs compared to those outside the range.

Conclusions

This real-world data study showed Synthroid was associated with better TSH target achievement vs. GL in a US managed care population. Achieving TSH goals may provide substantial economic value by reducing hypothyroidism-related HCRU and costs.

Supplementary Information

The online version contains supplementary material available at 10.1007/s12325-021-01969-3.

Year in Thyroidology-Recent Developments and Future Challenges: Clinical Science Review

Background: The 2021 Year in Thyroidology-Recent Developments and Future Challenges: Clinical Science Review featured key clinical research within five categories: Thyroid Nodules and Cancer, Thyroid Function and Thyroid Eye Disease, Thyroid and Pregnancy, Thyroid and Pediatrics, and Disparities in Thyroid. Methods: A literature search of PubMed from November 2019 to August 2021 was performed to identify relevant peer-reviewed articles published in English and with a focus on human subjects. Results: There were three nominees for each of the five categories and one featured article per category. The featured articles had the most potential to change clinical practice, focused on a novel topic, and/or included of strong methodology. Conclusions: There were many strong publications on thyroid between November 2019 and August 2021; the 15 nominees and 5 featured articles span a breadth of topics and methodological approaches. The featured articles all have potential to change practice patterns or to stimulate further research that will ultimately change practice patterns.

Nursing Management and Adverse Events in Thyroid Cancer Treatments with Tyrosine Kinase Inhibitors. A Narrative Review

Simple Summary

Tyrosine kinase inhibitors are an effective and promising therapy in the treatment of advanced differentiated medullary thyroid cancers. The prevention and management of new adverse events of these drugs are important to keep patients on their treatment course, avoiding drug discontinuation or interruption, and are associated with a faster recovery of the disease. The contribution of a multidisciplinary team of healthcare professionals optimizes the management of adverse events, maximizing the benefits and reducing the risks of treatment, consequently improving the quality of life of patients.

Abstract

Background: The advent of multikinase inhibitors has changed the treatment of advanced, metastatic, unresectable thyroid cancers, refractory to available treatments. These drugs cause new adverse events that should be prevented and treated for long periods, and sometimes beyond their discontinuation. The purpose of this narrative review was the description, prevention, and nursing management of the most frequent adverse events of locally advanced or metastatic differentiated thyroid cancer with sorafenib and lenvatinib, and medullary Thyroid cancer with vandetanib and cabozantinib treatment. Methods: A narrative literature review. Results: Studies included in this narrative review suggest that over 90% of patients treated with tyrosine kinase inhibitors experience at least 1 adverse event of any grade affecting their quality of life. Patients treated with tyrosine kinase inhibitors experienced at least one adverse event at any grade in ≥90% of cases, with a higher incidence in the first 6–8 weeks of treatment. The most frequent adverse events that can affect a patients’ quality of life are dermatological, gastrointestinal, cardiovascular, and metabolic. Conclusions: Early assessment of risk factors and identification of adverse events can help nurses support these patients throughout their clinical-therapeutic pathway, increasing the benefits of treatment and reducing reduction/discontinuation.

Real world evidence in effectiveness, safety, and cost savings of generic levothyroxine: a systematic review

PURPOSE

Generic levothyroxine, approved through Abbreviated New Drug Application (ANDA), is available for generic substitution. But ANDA does not require nonclinical or clinical data to establish safety and efficacy. Post-marketing evidence in generic equivalence for marketed levothyroxine products is limited. We conducted a systematic review to synthesize evidence in effectiveness, safety, and cost savings between patients using generic and branded levothyroxine.

METHODS

We systematically searched published literature from Medline, International Pharmaceutical Abstracts, APA PsycInfo, and CINAHL from inception through 04/18/2021. Included studies were limited to post-marketing empirical studies including patients who used levothyroxine products, with direct comparison between generic and brand levothyroxine, and published in English. Risk of bias was assessed using the National Institute of Health Study Quality Assessment Tools. Two reviewers independently extracted data and conducted quality assessment for included studies. Given that the nine studies are so diverse, a meta-analysis was not possible. Therefore we provided a narrative review of the included studies.

RESULTS

Of 349 studies identified, nine met the inclusion criteria. Six studies compared thyrotropin levels and adverse events between generic and brand users and provided mixed findings. In addition, generic users may generate prescription cost savings for payers but had suboptimal medication adherence than brand users.

CONCLUSION

Findings from this systematic review highlighted the limited and mixed evidence in real-world clinical and economic outcomes for generic levothyroxine. Continuous post-marketing monitoring and assessment of generic drugs are warranted to ensure treatment effectiveness, patient safety, and achieve financial savings in prescription costs.

Effect of patient's sex on early perioperative outcomes following anterior cervical discectomy and fusion

OBJECTIVE

Differences in morbidity and mortality measures between males and females have been demonstrated for a variety of spinal surgeries, however, studies of anterior cervical discectomy and fusion (ACDF) are limited. To investigate the impact ofsexon 30-day perioperative outcomes of ACDF.

METHODS

Retrospective 1:1 propensity score-matched cohort study. Patients who underwent ACDF between 2016 and 2018 were reviewed from the ACS-NSQIP database.Propensity score matchingand subgroup analysis were used.

RESULTS

21,180 patients met inclusion criteria. 11,194 patients underwent single-level ACDF and 9986 patients underwent multi-level ACDF. In the single-level group, there were 6168 (55.1%) males and 5026 (44.9%) females. In the multi-level group, there were 5033 (50.4%) males and 4953 (49.6%) females. In both single/multi-level groups, females were more likely to be of older age, be functionally dependent, and have higher BMI and lower preoperative hematocrit level. Males were more likely to be Caucasian, smokers, have myelopathy, diabetes mellitus, hypertension and bleeding disorders. In both single/multi-level groups, except for the higher incidence of urinary tract infection (UTI) in females and myocardial infarction (MI) in males, there were no significant differences in morbidity and mortality between males and females.

CONCLUSIONS

Several differences in demographics and baseline health status exist between males and females undergoing ACDF. When attempting to control for comorbid conditions, we found that sex by itself is not an independent risk factor for higher perioperative morbidity or mortality in patients undergoing ACDF, except for the higher incidence of UTI in females and MI in males. These results are important findings for clinicians and spine surgeons while counseling patients undergoing this type of procedure.

Spending and Utilization on Drugs Prescribed by Otolaryngologists to Medicare Beneficiaries, 2013 to 2017

OBJECTIVES

The significant and rising cost of prescription drugs is a pressing concern for patients and payers. However, little is known about spending on and utilization of drugs prescribed by otolaryngologists.

METHODS

Utilizing publicly available Medicare Part D Prescriber Public Use data, we conducted a retrospective cross-sectional analysis of 34 small-molecule drugs commonly prescribed by otolaryngologists (defined as 2017 Medicare Part D spending ≥$500 000) to Medicare beneficiaries. Prescription data was characterized by drug type (brand name vs generic). Primary outcomes for each prescription drug included the total annual cost and the total annual number of days supplied.

RESULTS

From 2013 to 2017, spending on drugs prescribed by otolaryngologists to Medicare beneficiaries decreased by $32.1 million ($131.7-$99.5 million; relative decrease 24.4%; compound annual growth rate [CAGR] -5.4%), while total utilization increased by 24.9 million days supplied (74.6-99.5 million; relative increase 33.3%; CAGR 5.9%). For brand name drugs, there was a decrease in spending ($71.1-$26.7 million; relative decrease -62.4%; CAGR -17.8%) and utilization (11.2-3.1 million days supplied; relative decrease -72.5%; CAGR -22.8%). In contrast, generic drugs demonstrated increased spending ($60.6-$72.8 million; relative increase 20.2%; CAGR 3.7%) and utilization (63.5-96.4 million days supplied; relative increase 51.9%; CAGR 8.7%).

CONCLUSIONS

Spending on drugs prescribed by otolaryngologists to Medicare Part D beneficiaries declined between 2013 and 2017 in part due to a transition from brand name drugs to lower-cost generic equivalents.

Does the Specialty of the Surgeon Performing Elective Anterior/Lateral Lumbar Interbody Fusion for Degenerative Spine Disease Correlate with Early Perioperative Outcomes?

BACKGROUND

Comparative effectiveness research has a vital role in health reform and policies. Specialty training is one of these provider-side variables, and surgeons performing the same procedure who were trained in different specialties may have different outcomes. The objective of this study was to investigate the impact of spine surgeon specialty (neurosurgery vs. orthopedic surgery) on early perioperative outcome measures of elective anterior/lateral lumbar interbody fusion (ALIF/LLIF) for degenerative disc diseases.

METHODS

In a retrospective, 1:1 propensity score-matched cohort study, 9070 patients were reviewed from the American College of Surgeons National Surgical Quality Improvement Program database. Propensity score matching and subgroup analysis were used.

RESULTS

In both groups (single-level and multilevel ALIF/LLIF), patients operated on by neurosurgeons had longer operative time (188 minutes vs. 172 minutes/239 minutes vs. 221 minutes); shorter total hospital stay (71 hours vs. 90 hours/89 hours vs. 96 hours); and lower rates of return to the operating room (2.1% vs. 4.1%/2.4% vs. 4.2%), nonhome discharge (8.7% vs. 11.1%/10.1% vs. 14.9%), discharge after postoperative day 3 (22.0% vs. 30.0%/38.0% vs. 43.9%), and perioperative blood transfusion (2.1% vs. 5.1%/5.0% vs. 9.9%) (P < 0.05). In multilevel ALIF/LLIF, patients operated on by neurosurgeons had lower readmission rates (3.9% vs. 6.9%) (P < 0.05). Other outcome measures and mortality rates were similar between the single-level and multilevel ALIF/LLIF cohorts regardless of surgeon specialty.

CONCLUSIONS

Our analysis found significant differences in early perioperative outcomes of patients undergoing ALIF/LLIF by neurosurgeons and orthopedic surgeons. These differences have significant clinical and cost implications for patients, physicians, program directors, payers, and health systems.

Effect of once weekly oral levothyroxine therapy

SUMMARY

Primary hypothyroidism is one of the most common endocrine disorders with widely available treatment. A minority of patients remain with uncontrolled hypothyroidism despite therapy. The objective of this case series was to demonstrate that medication non-adherence, rather than malabsorption, should be sought as the most common cause of unsuppressed TSH levels in patients receiving treatment for this condition. Non-adherence is often considered as a diagnosis of exclusion. Nonetheless, a diagnosis of malabsorption requires a more extensive workup, including imaging and invasive procedures, which increase healthcare costs and burden to the patient. The findings of this study allow for a cost-effective approach to uncontrolled hypothyroidism.

LEARNING POINTS

Medication non-adherence is a common cause of insuppressible TSH levels. Once weekly levothyroxine is an alternative approach to non-compliant patients. Assessing compliance is more cost-effective and less burdensome than testing for malabsorption.

Influence of Sex on Early Outcomes of Elective Lumbar Fusions: An Updated Propensity-Matched and Subgroup Analysis

OBJECTIVE

Existing data have demonstrated significant differences in morbidity and mortality measures between men and women undergoing various spinal surgeries. However, studies of lumbar fusion surgery have been limited. Thus, we investigated the effects of patient sex on 30-day perioperative outcomes after elective lumbar fusion spine surgery.

METHODS

Patients who had undergone lumbar fusion from 2015 to 2018 were reviewed from the American College of Surgeons National Surgical Quality Improvement Program database. Propensity score matching was used to determine whether the patient's sex had influenced the 30-day perioperative complications.

RESULTS

A total of 44,526 cases had met the inclusion criteria and were reviewed. Of the 44,526 patients, 13,715 had undergone posterior lumbar fusion, 21,993 had undergone posterior/transforaminal lumbar interbody fusion, and 8818 had undergone anterior/lateral lumbar interbody fusion. The women were more likely to be older, functionally dependent, and taking steroids for chronic conditions and to have a higher body mass index and lower preoperative hematocrit level. The men were more likely to be white, to smoke, and to have diabetes mellitus, hypertension, and bleeding disorders. In all cohorts, except for a higher incidence of urinary tract infection in the female patients and myocardial infarction in the male patients, no significant differences were found in morbidity and mortality between the sexes.

CONCLUSIONS

Several differences in demographics and baseline health status were found between men and women undergoing lumbar fusion. When attempting to control for comorbid conditions using propensity score matching, we found that sex was an independent predictor of urinary tract infection in women and myocardial infarction in men across major morbidity and mortality categories in patients undergoing lumbar fusion surgery.