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Patients’ persistent symptoms, clinician demographics and geo-economic factors are associated with choice of therapy for hypothyroidism by European thyroid specialists: The “THESIS”* collaboration (*T reatment of H ypothyroidism in Europe by S pecialists, an I nternational S urvey)

Open access
Attanasio, Roberto, Žarković, Miloš, Papini, Enrico, Nagy, Endre V., Negro, Roberto, Perros, Petros, Akarsu, Ersin, Alevizaki, Maria +48 more·2024·Thyroid®
DOI 10.1089/thy.2023.0580
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Abstract

Background:Hypothyroidism is common, however, aspects of its treatment remain controversial. Our survey aimed at documenting treatment choices of European thyroid specialists and exploring how patients' persistent symptoms, clinician demographics, and geo-economic factors relate to treatment choices. Methods:Seventeen thousand two hundred forty-seven thyroid specialists from 28 countries were invited to participate in an online questionnaire survey. The survey included respondent demographic data and treatment choices for hypothyroid patients with persistent symptoms. Geo-economic data for each country were included in the analyses. Results:The response rate was 32.9% (6058 respondents out of 17,247 invitees). Levothyroxine (LT4) was the initial treatment preferred by the majority (98.3%). Persistent symptoms despite normal serum thyrotropin (TSH) while receiving LT4 treatment were reported to affect up to 10.0% of patients by 75.4% of respondents, while 28.4% reported an increasing such trend in the past 5 years. The principal explanations offered for patients' persistent symptoms were psychosocial factors (77.1%), comorbidities (69.2%), and unrealistic patient expectations (61.0%). Combination treatment with LT4+liothyronine (LT3) was chosen by 40.0% of respondents for patients who complained of persistent symptoms despite a normal TSH. This option was selected more frequently by female thyroid specialists, with high-volume practice, working in countries with high gross national income per capita. Conclusions:The perception of patients' dissatisfaction reported by physicians seems lower than that described by hypothyroid patients in previous surveys. LT4+LT3 treatment is used frequently by thyroid specialists in Europe for persistent hypothyroid-like symptoms even if they generally attribute such symptoms to nonendocrine causes and despite the evidence of nonsuperiority of the combined over the LT4 therapy. Pressure by dissatisfied patients on their physicians for LT3-containing treatments is a likely explanation. The association of the therapeutic choices with the clinician demographic characteristics and geo-economic factors in Europe is a novel information and requires further investigation.

AI snapshot

Written from the paper’s full text.

TL;DR

In a 28-country online survey of European thyroid specialists, nearly all preferred levothyroxine (LT4) as initial therapy, but 40.0% chose LT4+liothyronine (LT3) for patients with persistent symptoms despite normal TSH, even though they mostly attributed those symptoms to nonendocrine causes. Combination therapy choice was more frequent among female specialists, those with high-volume practice, and those in high gross-national-income-per-capita countries.

Key findings

  • Response rate was 32.9% (6058 of 17,247 invitees); LT4 was the preferred initial treatment for 98.3% of respondents.
  • Persistent symptoms despite normal TSH on LT4 were reported to affect up to 10.0% of patients by 75.4% of respondents, and 28.4% reported an increasing trend over the past 5 years.
  • The main explanations offered for persistent symptoms were psychosocial factors (77.1%), comorbidities (69.2%), and unrealistic patient expectations (61.0%).
  • LT4+LT3 combination treatment was chosen by 40.0% of respondents for patients with persistent symptoms despite normal TSH; this choice was more frequent among female specialists, high-volume practices, and countries with high gross national income per capita.

Methods

  • Online questionnaire survey of 17,247 thyroid specialists across 28 countries, collecting respondent demographics and treatment choices for hypothyroid patients with persistent symptoms.
  • Country-level geo-economic data were incorporated into the analyses.
  • Analysis examined associations between treatment choice and patient symptoms, clinician demographics, and geo-economic factors (specific statistical methods not stated in the abstract).

Limitations

  • The paper states the association of therapeutic choices with clinician demographics and geo-economic factors is novel information that "requires further investigation."
  • The paper notes physicians' perception of patient dissatisfaction appears lower than that described by hypothyroid patients in previous surveys, suggesting a possible mismatch in perspective.
  • Not stated in the paper beyond the abstract (e.g., response bias, self-report limitations) — the provided text is the abstract and bibliographic record only.

Model-written summary. Check it against the paper before relying on it.

Integrity signals

Registry

Crossref · 10.1089/thy.2023.0580

Cites

46 of 46 references verified0 citation errors · 0 not checkable

Statistics

Nothing to recompute.

Claims the paper makes

  • Findingown data
    § Abstract

    The LT4+LT3 option was selected more frequently by female thyroid specialists.

    “This option was selected more frequently by female thyroid specialists”
    Quote in the paperNot a substantial claim
  • Findingown data
    § Abstract

    28.4% of respondents reported an increasing trend of persistent symptoms despite normal TSH in the past 5 years.

    “while 28.4% reported an increasing such trend in the past 5 years.”
    Quote in the paperNot a substantial claim
  • Findingown data
    § Abstract

    The LT4+LT3 option was selected more frequently by thyroid specialists with high-volume practice.

    “with high-volume practice”
    Quote in the paperSubstantial claim
  • Findingown data
    § Abstract

    69.2% of respondents offered comorbidities as an explanation for patients' persistent symptoms.

    “comorbidities (69.2%)”
    Quote in the paperNot a substantial claim
  • Findingown data
    § Abstract

    Combination treatment with LT4+liothyronine (LT3) was chosen by 40.0% of respondents for patients who complained of persistent symptoms despite a normal TSH.

    “Combination treatment with LT4+liothyronine (LT3) was chosen by 40.0% of respondents for patients who complained of persistent symptoms despite a normal TSH.”
    Quote in the paperSubstantial claim
  • The quote only partly states this claim. 1
  • Classified as probably not a substantial claim. 2

  • The quote only partly states this claim.

    Findingown data
    § Abstract

    The LT4+LT3 option was selected more frequently by thyroid specialists working in countries with high gross national income per capita.

    “working in countries with high gross national income per capita.”
    Quote in the paperSubstantial claim

  • Probably not a substantial claim: may not pass S4 (based).

    Interpretationreasoning
    § Abstract

    Pressure by dissatisfied patients on their physicians for LT3-containing treatments is a likely explanation for the frequent use of LT4+LT3 treatment.

    “Pressure by dissatisfied patients on their physicians for LT3-containing treatments is a likely explanation.”
    Quote in the paperNot a substantial claim

  • Probably not a substantial claim: may not pass S3 (load-bearing).

    Study design and conductown data
    § Abstract

    The response rate was 32.9% (6058 respondents out of 17,247 invitees).

    “The response rate was 32.9% (6058 respondents out of 17,247 invitees).”
    Quote in the paperNot a substantial claim
3 of 3

  • The paper relies on this without support.

    There is evidence of nonsuperiority of combined LT4+LT3 over LT4 therapy.

    “despite the evidence of nonsuperiority of the combined over the LT4 therapy.”

  • The paper relies on this without support.

    Aspects of hypothyroidism treatment remain controversial.

    “aspects of its treatment remain controversial”
2 of 2

Self-check

Percentages, sums and reported differences re-computed from the paper’s own numbers.

  • Reported response rate does not match respondent and invitee counts

    Major

    The stated 6,058 respondents out of 17,247 invitees give a response rate of approximately 35.1%, not 32.9%.

    Reported 32.9 · recomputed 35.124949

1 of 1

Cites

Flagged first, then by citations

1 of the 47 references couldn’t be matched to a known paper.

Research works printed but not linked: 6

  1. Borissova A-MI, 2020, Endokrinologia (Sofia), 24, 299
  2. Jiskra J, 2022, BMC Endocrinol, 22, 117
  3. Galofré JC, 2022, Endocrinol Diabetes Nutr (Engl Ed), 69, 520
  4. Marques Puga F, 2022, Rev Portug Endocrinol Diabetes Metab, 17, 9
  5. Nedeljkovic Beleslin B, 2022, Serbian Arch Med, 150, 667
  6. Perros P, 2022, Thyroid, 32, 1158

Cited by

Sorted by citations

Related

Authors
Attanasio, R., Žarković, M., Papini, E., Nagy, E. V., Negro, R., Perros, P., Akarsu, E., Alevizaki, M., Ayvaz, G., Bednarczuk, T., Beleslin, B., Berta, E., Bodor, M., Borissova, A. M., Boyanov, M., Buffet, C., Burlacu, M.-C., Ciric, J., Díez, J. J., Dobnig, H., Fadeyev, V. V., Field, B. C., Fliers, E., Führer, D., Galofré, J. C., Hakala, T., Jiskra, J., Kopp, P. A., Krebs, M., Kršek, M., Kuzma, M., Lantz, M., Lazúrová, I., Leenhardt, L., Luchytskiy, V., Marques Puga, F., McGowan, A., Metso, S., Moran, C., Morgunova, T., Niculescu, D. A., Perić, B., Planck, T., Poiana, C., Robenshtok, E., Rosselet, P. O., Ruchala, M., Ryom Riis, K., Shepelkevich, A., Tronko, M. D., Unuane, D., Vardarli, I., Visser, W. E., Vryonidou, A., Younes, Y. R., & Hegedus, L.
Affiliations
  • Associazione Medici Endocrinologi, Scientific Committee, via Compagnoni 1, Milan, Italy, 20129, ;
  • University of Belgrade (RS)
  • Ospedale Regina Apostolorum (IT)
  • University of Debrecen (HU)
  • Ospedale Vito Fazzi (IT)
  • Newcastle University (GB)
  • Gaziantep University (TR)
  • National and Kapodistrian University of Athens (GR)
  • Koru Ankara Hospital, Department of Endocrinology and Metabolism, Çankaya/Ankara, Turkey, ;
  • Medical University of Warsaw (PL)
  • University of Debrecen, 37599, Division of Endocrinology, Department of Internal Medicine, Faculty of Medicine, Debrecen, Hajdú-Bihar, Hungary, ;
  • Medical University of Sofia (BG)
  • Alexandrovska Hospital (BG)
  • Sorbonne Université (FR)
  • Cliniques Universitaires Saint-Luc (BE)
  • Institute for endocrinology, diabetes and metabolic disorders , Belgrade, Serbia,
  • Hospital Universitario Puerta de Hierro Majadahonda (ES)
  • Thyroid and Osteoporosis Praxis, Kumberg, Austria,
  • Sechenov University (RU)
  • University of Surrey (GB)
  • Amsterdam University Medical Centers (NL)
  • Essen University Hospital (DE)
  • Clinica Universidad de Navarra (ES)
  • Tampere University Hospital (FI)
  • Charles University (CZ)
  • University of Lausanne (CH)
  • Medical University of Vienna (AT)
  • 5th Department of Internal Medicine, Faculty of Medicine, Comenius University in Bratislava, Bratislava, Slovakia, ;
  • Skåne University Hospital (SE)
  • University of Pavol Jozef Šafárik (SK)
  • Assistance Publique – Hôpitaux de Paris (FR)
  • V.P. Komisarenko Institute of Endocrinology and Metabolism (UA)
  • Centro Hospitalar Universitário de Santo António, 112085, Endocrinology, Diabetes and Metabolism Service, Porto, Portugal, ;
  • Tallaght University Hospital (IE)
  • University College Dublin (IE)
  • Carol Davila University of Medicine and Pharmacy (RO)
  • University Hospital Center “Sisters of Mercy”, Department of Endocrinology, Diabetes and Metabolic Diseases “Mladen Sekso”, Zagreb, Croatia, ;
  • Carol Davila University of Medicine and Pharmacy, Department of Endocrinology, Bucharest, Romania, ;
  • Tel Aviv University (IL)
  • Cabinet Médical 2, Lausanne, Switzerland, ;
  • University of Medical Sciences, The Department of Endocrinology, Metabolism and Internal Medicine, ul.Przybyszewskiego 49, Poznañ, Poland, 60-355, ,
  • Odense University Hospital, Department of Endocrinology and Metabolism, Odense, Denmark, ;
  • Belarusian State Medical University (BY)
  • Universitair Ziekenhuis Brussel (BE)
  • Klinikum Vest (DE)
  • Erasmus MC (NL)
  • Hellenic Red Cross (GR)
  • East Surrey Hospital (GB)
  • Odense University Hospital, Department of Endocrinology and Metabolism, Kloevervaenget 6, 6th floor, Odense, Denmark, 5000, ;
Corresponding author
Attanasio, Roberto
ORCID
Venue
Thyroid®
Publisher
SAGE Publications
Published
2024-02-18
Volume
34
Issue
4
Pages
429-441
ISSN
  • 1050-7256 (ISSN-L)
  • 1557-9077
DOI
10.1089/thy.2023.0580
OpenAlex
W4391915767
Semantic Scholar
82fd531f6053231fc0c28fa7ca3fde6eb70b1ac6
Cited by
11
References
47
Citations by year
2025: 7 · 2024: 4
FWCI
2.99
Type
journal article
Language
en
Open access
Licence
Locations
  • Thyroid (publishedVersion)
  • PubMed (publishedVersion)
  • EUR Research Repository (Erasmus University Rotterdam) (publishedVersion, other-oa)
  • University of Southern Denmark Research Portal (University of Southern Denmark) (publishedVersion)
  • Universitätsbibliographie, Universität Duisburg-Essen (submittedVersion)
  • Digital Access to Libraries (submittedVersion, other-oa)
  • IRIS (submittedVersion)
  • Pure Amsterdam UMC (submittedVersion, other-oa)
  • SERVAL (Université de Lausanne) (submittedVersion)
  • VUBIR (Vrije Universiteit Brussel) (submittedVersion)
Funders
  • Andrew W. Mellon Foundation
  • Eli Lilly and Company
  • Sanofi
  • Merck KGaA
  • Recordati Rare Diseases
  • Society for Endocrinology
  • Trinity College Dublin
  • Deutsche Forschungsgemeinschaft
  • Novo Nordisk
  • Ipsen
Topics
  • Health Sciences › Medicine › Endocrinology, Diabetes and Metabolism › Thyroid Disorders and Treatments
  • Health Sciences › Medicine › Surgery › Thyroid and Parathyroid Surgery
  • Health Sciences › Medicine › Endocrinology, Diabetes and Metabolism › Thyroid Cancer Diagnosis and Treatment
Keywords
hypothyroidism, levothyroxine, liothyronine, combination thyroid hormone therapy, patient dissatisfaction, gross national income, psychosocial factors, patient expectations
MeSH terms
Demography, Female, Humans, Hypothyroidism, Thyrotropin, Thyroxine, Triiodothyronine

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Classified by jev-1.13-20260917 (gold-guideline-v0.2) on 2026-10-14.

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