Should the Treatment of Hypothyroidism Be Withdrawn in Hospice Care?

Abstract

Approximately one-quarter of patients enrolled in hospice continue to be on disease-focused therapies at the end of life.1Dwyer L.L. Lau D.T. Shega J.W. Medications that older adults in hospice care in the United States take, 2007.J Am Geriatr Soc. 2015; 63: 2282-2289Crossref Scopus (26) Google Scholar Medications often cited include anticoagulants, antidepressants, and proton pump inhibitors, medications not directly palliating symptoms.1Dwyer L.L. Lau D.T. Shega J.W. Medications that older adults in hospice care in the United States take, 2007.J Am Geriatr Soc. 2015; 63: 2282-2289Crossref Scopus (26) Google Scholar In a recent article published in this journal, “The burden of polypharmacy in patients near the end of life,” McNeil et al.2McNeil M.J. Kamal A.H. Kutner J.S. Ritchie C.S. Abernethy A.P. The burden of polypharmacy in patients near the end of life.J Pain Symptom Manage. 2016; 51: 178-183.e2Abstract Full Text Full Text PDF PubMed Scopus (74) Google Scholar looked at the significant medication load among patients near the end of life. The study showed there was no significant difference with the amount of pill burden patients with a life expectancy of less than one month (47.5% of whom had a primary diagnosis of malignancy) were on during hospice enrollment compared with the time of death and/or study termination (11.5 [standard deviation 5] vs. 10.7 [standard deviation 5], respectively). The study also showed that levothyroxine was a commonly prescribed medication. I recently saw a patient who had terminal dementia and was enrolled in hospice. She was a 92-year-old female with advanced Alzheimer's dementia residing in a nursing home. She had a slow, steady decline medically and functionally for months and was deemed appropriate for hospice enrollment as her life expectancy was predicted to be less than six months. Her medical history was significant for a low-grade papillary thyroid cancer that was treated by thyroidectomy 30 years earlier. She had been on levothyroxine since then. More recently, levothyroxine was dosed at 200 μg daily. On her enrollment in hospice, her medications including levothyroxine were discontinued. Laboratory orders before hospice enrollment to monitor her thyroid function were missed and not discontinued upon hospice enrollment. This was unfortunately carried out two months after hospice enrollment. Her serum thyroid-stimulating hormone was noted to be 78 uIU/mL (N, 0.3–4.2 uIU/mL), which was 0.07 uIU/mL three months earlier. She remained confused and cognitively impaired without acute changes in her previous mental status despite biochemical evidence of overt hypothyroidism. This case illustrates that patients who are nearing the end of life and, thus, appropriately enrolled in hospice services should have a thorough clinical review of their co-morbidities and medications.3Currow D.C. Stevenson J.P. Abernethy A.P. Plummer J. Shelby-James T.M. Prescribing in palliative care as death approaches.J Am Geriatr Soc. 2007; 55: 590-595Crossref PubMed Scopus (162) Google Scholar Aside from this, the unforeseen laboratory evaluation, which other providers may deem inappropriate for a hospice patient, fortuitously confirmed the presence of overt biochemical hypothyroidism in the patient. Although no clinically evident alterations in mentation occurred, such occurrence may have happened or will happen had she remained overtly hypothyroid for a longer period of time. Furthermore, clinical effects of hypothyroidism may be difficult to establish in a patient who has advanced dementia at baseline. Hypothyroidism, particularly in the oldest old, is highly prevalent.4Aoki Y. Belin R.M. Clickner R. et al.Serum TSH and total T4 in the United States population and their association with participant characteristics: National Health and Nutrition Examination Survey (NHANES 1999-2002).Thyroid. 2007; 17: 1211-1223Crossref PubMed Scopus (260) Google Scholar Patients with hypothyroidism have impairment in cognition and mood.5Osterweil D. Syndulko K. Cohen S.N. et al.Cognitive function in non-demented older adults with hypothyroidism.J Am Geriatr Soc. 1992; 40: 325-335Crossref PubMed Scopus (200) Google Scholar, 6Samuels M.H. Psychiatric and cognitive manifestations of hypothyroidism.Curr Opin Endocrinol Diabetes Obes. 2014; 21: 377-383Crossref PubMed Scopus (80) Google Scholar Overt hypothyroidism, although usually not deemed a life-threatening condition, could sometimes be associated with confusion, disorientation, and psychosis, previously described as “myxedematous madness.”5Osterweil D. Syndulko K. Cohen S.N. et al.Cognitive function in non-demented older adults with hypothyroidism.J Am Geriatr Soc. 1992; 40: 325-335Crossref PubMed Scopus (200) Google Scholar Thyroid hormone replacement may ameliorate some of these symptoms.5Osterweil D. Syndulko K. Cohen S.N. et al.Cognitive function in non-demented older adults with hypothyroidism.J Am Geriatr Soc. 1992; 40: 325-335Crossref PubMed Scopus (200) Google Scholar This factor may be of importance in managing hospice-enrolled patients as these symptoms affect quality of life, which is a foremost goal with symptom palliation. Unfortunately, studies addressing this issue are lacking. It may be prudent to pursue treatment of hypothyroidism among hospice patients on a high doses of levothyroxine, those who have hypothyroidism with clear indications for treatment (i.e., history of Hashimoto's thyroiditis, surgically induced hypothyroidism), and most importantly, those who are projected to have a longer survival on hospice enrollment (i.e., months). This may result in palliation of hypothyroid symptoms. Normalization of thyroid-stimulating hormone occurs much later (at least four weeks, possibly much longer,7Roos A. Linn-Rasker S.P. van Domburg R.T. Tijssen J.P. Berghout A. The starting dose of levothyroxine in primary hypothyroidism treatment: a prospective, randomized, double-blind trial.Arch Intern Med. 2005; 165: 1714-1720Crossref PubMed Scopus (107) Google Scholar usually in six to eight weeks). Although it is true that the weight of polypharmacy in patients near the end of life is high and that “deprescribing” needs to happen as the life-limiting condition advances, clinicians need to be judicious, always putting this in the context of the patient's terminal disease. A portion of patients enrolled in hospice may still benefit from treating their comorbidities, such as hypothyroidism; addressing this may still affect quality of life, even in a dying patient. The pill burden of an extra levothyroxine tablet may potentially negate risks of clinical hypothyroidism in a hospice-enrolled patient. Future studies are needed to address this issue. The Burden of Polypharmacy in Patients Near the End of LifeJournal of Pain and Symptom ManagementVol. 51Issue 2PreviewPatients with advanced illness are prescribed multiple medications in the last year of life, intensifying the risk of negative consequences related to polypharmacy. Full-Text PDF Open Access