Endocrinologists Issue First 'Choosing Wisely' List

Miriam E. Tucker

October 18, 2013

The first "Choosing Wisely" list for endocrinologists has been published. Following similar initiatives in other medical specialties, it has pinpointed "5 Things Physicians and Patients Should Question" in the field of endocrinology.

These touch on advice regarding self–glucose monitoring in type 2 diabetes, how best to monitor hypothyroid patients, and what not to test to determine vitamin-D deficiency. Also documented is when it is appropriate to order a thyroid ultrasound or prescribe testosterone.

The idea of the "Choosing Wisely" initiative, launched by the American Board of Internal Medicine (ABIM) Foundation in 2011, is to guide physicians away from common practices deemed not necessary or not supported by evidence toward more thoughtful consideration of certain tests, procedures, and treatments.

American College of Endocrinology (ACE) President Daniel Einhorn, MD, medical director of the Scripps-Whittier Diabetes Institute, La Jolla, California, told Medscape Medical News: "There's lots of nuance in this. The whole Choosing Wisely campaign is to alert physicians to be thoughtful and for patients to also question when something is ordered or suggested."

Not a Prescriptive List of Don'ts, Rather a Guide

The Endocrine Society (TES) and American Association of Clinical Endocrinologists (AACE) are the latest organizations to partner to issue a list of common practices to avoid (ACE is the educational arm of AACE). They are joining more than 80 other medical societies and partnering organizations, and by March 2014, there will be a total list of approximately 250 tests and procedures that have been deemed overused or inappropriate.

Dr. Einhorn explained how the endocrine societies came up with their recommendations. "The list reflects the observation of a group of experts who've seen people order certain tests that are just not necessary. Other items could have been chosen, but these were felt to be perhaps the most common mistakes made." However, the recommendations "are likely to evolve over time as more is learned," he added.

The 5 advisories are:

  • Avoid routine multiple daily self–glucose monitoring in adults with stable type 2 diabetes on agents that do not cause hypoglycemia.

  • Do not routinely measure 1,25-dihydroxyvitamin D unless the patient has hypercalcemia or decreased kidney function.

  • Do not routinely order a thyroid ultrasound in patients with abnormal thyroid-function tests if there is no palpable abnormality of the thyroid gland.

  • Do not order a total- or free-T3 level when assessing levothyroxine (T4) dose in hypothyroid patients.

  • Do not prescribe testosterone therapy unless there is biochemical evidence of testosterone deficiency.

Testosterone Expensive, Demand Fueled by TV Ads

The testosterone issue is probably the most commonly encountered clinical scenario on the list, Dr. Einhorn said, and is also notable in that it's actually an expensive treatment, rather than a test, and has likely been influenced by demand from patients who see television commercials about treating "low T."

Some physicians will prescribe testosterone to men with low-normal levels who have symptoms of fatigue or stress and, anecdotally, report feeling better. "So, is it a placebo effect? It's very difficult to tell. Testosterone is one of those messy areas. In endocrinology, we like to have proof that we're doing some good," he remarked.

Multiple daily self–glucose monitoring in adults with stable type 2 diabetes who are using medications that do not cause hypoglycemia has also been financially damaging, as until recently there had been widespread overbilling of Medicare for unnecessary glucose test strips for beneficiaries.

The vitamin-D advisory has an educational purpose, said Dr. Einhorn, because many physicians are genuinely unaware that 1,25-dihydroxyvitamin D is not the correct test to screen for vitamin-D deficiency. The correct test is 25-hydroxyvitamin D, he explains.

"The 1,25 is a more expensive, more difficult test and doesn't add anything," he noted, but added that, as with most Choosing Wisely list items, there are exceptions. In this case, measuring 1,25-dihydroxyvitamin D can be useful in patients with hypercalcemia or end-stage kidney disease.

The advice not to measure free T3 when assessing the dose of levothyroxine (T4) in hypothyroid patients is given because the T3 level can be misleading. "In most patients, a normal [thyroid-stimulating hormone] TSH [level] indicates a correct dose of levothyroxine," the guidance states.

And ordering thyroid ultrasounds without palpable abnormalities of the gland will more often than not lead to unnecessary worry for patients, says Dr Einhorn.

"Overzealous use of ultrasound will frequently identify nodules, which are unrelated to the abnormal thyroid function, and may divert the clinical evaluation to assess the nodules, rather than the thyroid dysfunction," the advice states.

"Of course, there are circumstances where any or all of these things are appropriate to do in a given individual," Dr. Einhorn stressed. "Choosing Wisely is not a guideline, it's not a standard of care. It's an observation that sometimes people do inappropriate tests or give inappropriate medication, and that could be prevented with a little education and reflection."

Dr. Einhorn is a shareholder in MannKind and Halozyme and consults and/or does clinical research for Eli Lilly, Novo-Nordisk, Medtronic, Bristol-Myers Squibb/AstraZeneca, and Janssen.

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