|Year : 2012 | Volume
| Issue : 3 | Page : 78-80
Improving compliance in hypothyroidism: What can we do?
Sanjay Kalra, Bharti Kalra
Department of Endocrinology, Bharti Hospital and BRIDE, Karnal, Haryana, India
|Date of Web Publication||11-Aug-2012|
Department of Endocrinology, Bharti Hospital and BRIDE, Karnal, Haryana
Source of Support: None, Conflict of Interest: None
Hypothyroidism is a chronic disease which needs active patient participation for optimal management. Compliance with suggested therapy is necessary in order to achieve euthyroid health. It is surprising, however, that this aspect of thyroid management has not been highlighted in detail in thyroidology literature. This brief communication discusses concerns of physicians as well as patients with hypothyroidism. It lists drug-related, patient-related, and physician-related factors which may impact compliance and suggests simple methods of improving concordance with therapy. The paper calls for acceptance of a patient-centered approach to the management of hypothyroidism.
Keywords: Adherence, concordance, endocrinology, patient-centered approach, persistence
|How to cite this article:|
Kalra S, Kalra B. Improving compliance in hypothyroidism: What can we do?. Thyroid Res Pract 2012;9:78-80
| Introduction|| |
Available for nearly a century, in multiple brands, thyroxine has improved the lives of countless people across the globe. It seems surprising, therefore, that in spite of ample experience and robust evidence regarding the benefits of thyroxine, a simple dosage schedule and very economical therapy, patients still do not comply and persist fully with treatment.
In the management of any disease, especially chronic disease, such as hypothyroidism, patient concerns cannot be swept aside.  If we have to improve therapeutic outcomes in hypothyroidism, we need to target patient compliance and persistence. This can be done by focusing on patient convenience and patient concerns. Both accuracy and appropriateness should be targeted, so as to achieve optimal acceptance of treatment regimes. At the same time, physicians also have certain concerns while treating chronic patients. These concerns, too, should be studied in detail.
| Physicians' Concerns|| |
From a health care provider's viewpoint, prescribing chronic therapy is a time consuming process. It takes time to motivate a patient to accept life-long therapy and to explain the possible risks of stopping therapy. Physicians express concern about patients doctor-hopping and doctor-shopping, especially to alternative medical practitioners, in search of an elusive cure. They feel burdened with having to prescribe polypharmacy and worry about errors of omission. An average prescription of a hypothyroid person may contain, apart from thyroxine, vitamin D, calcium, statin, antihypertensive and antidiabetic drugs, antiobesity drugs, and painkillers.
| Patients' Concerns|| |
The patient centered approach to diabetes care is well ingrained in management philosophy, but a similar approach is, sadly, not accepted in hypothyroidism. 
Many hypothyroid patients are unsatisfied with their treatment.  Patients fear regimes with lack of flexibility and independence [you must take the tablet exactly thirty minutes before breakfast!], and frequent visits to the health care service provider. They also fear a regime which intrudes into their lifestyle and requires frequent investigations. The patient also worries about the impact on his or her life: the index of intrusion. A complex prescription, including statins, calcium, vitamin D, and thyroxine, may achieve biochemical health, but if this comes at a high financial or social or emotional cost, it will not be accepted.
| Patient Compliance|| |
Patient compliance is essential for any therapeutic intervention to succeed. The term "compliance" has been replaced by "adherence" or "concordance". Concordance is a much more appropriate term, as it implies both patient and physician, working together as equals, to achieve a pre-defined target. Another term used is "persistence," which quantifies whether a person is continuing with the prescribed regime or not. Much work has been done on the determinants of patient compliance or concordance with diabetes therapy, but not with thyroxine replacement. Patients do tend to prefer convenient regimes, flexible timing of administration, convenience of administration, and easy titration of dose.
| What Can We Do?|| |
Physicians can utilize various strategies to improve concordance with their hypothyroid patients. These include:
- Shared decision making;
- Minimizing the discomfort of change; 
- Motivational interviewing;
- Behavior change counseling;
- Patient empowerment;
- Patient support;
- Coping skills training. 
The factors which influence compliance can be listed as drug-related factors, physician-related factors, and patient-related factors.
| Drug-Related Factors|| |
Thyroxine from reliable manufacturers, designed to provide accurate dose delivery, should be preferred. The preparation should be effective, with low inter-patient and intra-patient variability; safe, and well tolerated. Tolerability, safety, and dependability are important issues for every patient. An appropriate regime should be chosen for each patient, depending on her or his needs. In case a patient complains of uneasiness or a lack of satisfaction with a "biochemically correct dose," one may divide the dose into two halves or shift the time of administration to late night or after meals. Once the patient has accepted this form of therapy, one can try to reinstate early morning administration of thyroxine.
| Patient-Related Factors|| |
Patient convenience and acceptance cannot be ignored while choosing a particular regime. To achieve optimal concordance, patients need to be educated, counseled, empowered, and supported.  An empowered patient will be able to participate in shared decision-making process more effectively, to internalize his or her locus of control, and to accept chronic thyroxine therapy, without feeling despondent. Structured education and support programs should be encouraged to improve the understanding and awareness of people with hypothyroidism, regarding all aspects of thyroid care. It is surprising that while we accept the need for such programs in diabetes care, we do not extend the same courtesy to our patients with thyroid disorders. 
| Physician-Related Factors|| |
Physicians should develop an empathic understanding of the needs and concerns of patients in their care.  This will occur once soft skills of counseling are inculcated in our medical students. Knowledge about local social, cultural, and religious beliefs and taboos, economic limitations, lifestyle including dietary patterns is helpful in prescribing a comprehensive therapeutic regime for hypothyroidism. For example, emphasis on dietary restriction of goitrogens helps the patient perceive the physician as a concerned person, who does not think of the patient only in terms of drugs and disease. Assessment of patient concerns, such as weight gain, asthenia, or sexual dysfunction, is essential if one has to plan an acceptable and effective treatment.
Physicians also need to be trained in the principles and practice of various motivational strategies, as listed earlier. Physicians dealing with hypothyroidism should also guard against compassion fatigue and burnout, which is known to occur in chronic care providers. 
| Conclusion|| |
Optimal outcome from a prescription for hypothyroidism can be obtained by focusing on all four players: the patient (her or his concerns), the prescription (dose and time of administration), the palate (dietary advice), and the physician (the four Ps). This four pronged strategy is somewhat similar to that advised by Atreya: ensuring that physician, patient, attendant, and drug work together to ensure an appropriate therapeutic outcome. 
Patient convenience occupies center stage. If the patient feels comfortable with his or her physician, as well as the treatment prescribed, the prescription will yield required results. On the other hand, a patient who feels that her or his concerns have not been addressed will not respond in the expected manner to therapy. Physicians need to be sensitized to the importance of patient-centered therapy convenience while managing hypothyroidism. They should improve their communication and motivational skills and use regimes which are accurate, appropriate, acceptable, and easily available for both physician and patient. This will ensure compliance, persistence, and ensure successful therapeutic outcomes.
| References|| |
|1.||Saravaven P, Cahu WF, Roberts N, Vedhara K, Greenwood R, Dayon CM. Psychological well-being in patients on 'adequate' doses of l-thyroxine: Results of a large, controlled community-based questionnaire study. Clin Endocrinol (Oxf) 2002;57:577-85. |
|2.||Kalra S, Baruah M, Ganapathy M, Game A, Sahay R, Unnikrishnan A. Patient centered approach to diabetes management. The dawn philosophy. Internet J Fam Pract 2010;8. |
|3.||Kalra S, Khandelwal SK. Why are our hypothyroid patients unhappy? Is tissue hypothyroidism the answer? Indian J Endocrinol Metab 2011;15(Suppl 2):S95-8. |
|4.||Kalra S, Kumar S, Kalra B, Unnikrishnan A, Agrawal N, Sahay R. Patient-provider interaction in diabetes: Minimizing the discomfort of change. Internet J Fam Pract 2010;8. |
|5.||Kalra S, Kalra B, Agrawal N, Sahay R, Unnikrishnan A, Chawla R. Coping strategies in diabetes. Internet J Geriatr Gerontol 2010;5. |
|6.||Kalra S, Kalra B. A good diabetes counsellor 'Cares': Soft skills in diabetes counseling. Internet J Health 2010;11. |
|7.||Kalra S, Unnikrishnan AG, Skovlund SE. Patient empowerment in endocrinology. Indian J Endocrinol Metab 2012;16:1-3. |
|8.||Kalra S, Chawla K, Kalra B. Compassion fatigue in diabetes care professionals: Effect of cognitive behaviour therapy. Indian J Endocrinol Metab 2008;12:7-10. |
|9.||Kalra S, Kalra B, Agrawal N. Therapeutic patient education: Lessons from ayurveda - the quadruple of Atreya. Internet J Geriatr Gerontol 2010;5. |
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