LAUSR

Abstract Background Approximately 88% of endocrinologists agreed that intravenous levothyroxine (IV T4) is not medically necessary in euthyroid patients if they are nothing by mouth (NPO) for less than 3 days. A prior 2013 retrospective database analysis at our institution revealed that a majority of IV T4 was prescribed inappropriately for NPO status. Therefore, we sought to develop an intervention to reduce inappropriate IV T4 use among hospitalized adults. Methods A training session was provided to clinical pharmacists and medical providers in areas with high IV T4 utilization rates (SICU, MICU, CICU, medical and surgical floors). Compelling reasons to use IV T4 were highlighted, including myxedema coma, cardiogenic shock, suspected malabsorption, or NPO status for >3 days. A retrospective 1-year database analysis was conducted after the intervention to assess IV T4 utilization rates and new onset of arrhythmias and troponin elevations among hospitalized patients. Rates of inappropriate use and adverse effects associated with T4 therapy were compared prior to and after the intervention with the chi-square test. Results Prior to the intervention, 76 patients (mean age 65 years) received IV T4 during the 6-month study period. Of these, 80% of IV T4 was prescribed inappropriately for NPO status at the cost of $38,423. Approximately 11% and 8% of these patients developed new onset arrhythmias and troponin elevations, respectively. After the intervention, 183 patients (mean age 61 years) received IV T4 at our institution during the 1-year study period. Of these, 56% of IV T4 was prescribed inappropriately for NPO status with no other compelling indication at the cost of $75,936. Approximately 20% and 12% of these patients developed new onset arrhythmias and troponin elevations, respectively. Approximately 31% of patients who had unwarranted IV T4 after the intervention had a history of atrial fibrillation, congestive heart failure, or coronary artery disease. The pharmacist led training intervention significantly reduced inappropriate use of IV T4 (p<0.05), however total cost and rates of new onset arrhythmia and troponin elevations did not significantly change (p>0.05). Conclusion A pharmacist led training intervention designed to educate providers and pharmacists about appropriate indications to use IV T4 among hospitalized adults led to a significant reduction in the use of inappropriate IV T4. Cost did not significantly change despite the reduction of inappropriate IV T4 use, likely due to rising drug prices. Despite a modest decrease in inappropriate IV T4 use, our institution aims to further reduce adverse effects, inappropriate use, and cost through a variety of quality control measures, such as implementing EMR order sets and/or restricting use of IV T4 subject to endocrinology approval.