Abstract/Project Summary
Older adults have a disproportionately higher prevalence of hypothyroidism compared to their younger
counterparts, with levothyroxine (the most widely used synthetic thyroid hormone) consistently one of the top
most frequently prescribed medications in the United States. Alarmingly, up to 48% of older adults aged ¿65
years receive a thyroid hormone dose that is too high, resulting in overtreatment. In addition, thyroid hormone
therapy is often initiated for inappropriate indications (misuse) which can also lead to overtreatment. This is
especially concerning for older adults, who comprise the fastest growing demographic group and the most
vulnerable to polypharmacy. Studies conducted by our team and others have demonstrated that thyroid hormone
overtreatment can lead to significant cardiovascular and skeletal risks, and increased mortality. Despite potential
patient harm, ~90% of patients continue lifelong thyroid hormone treatment. Thus, in the context of thyroid
hormone overtreatment, there is a critical need to deprescribe, which can be achieved either via thyroid hormone
dose de-escalation (in patients overtreated) or thyroid hormone discontinuation (in patients without an
appropriate indication). The proposed study is the first multi-site trial to evaluate a novel evidence-based adapted
multilevel intervention, D-THIO (Deprescribing Thyroid Hormone In Older Adults), consisting of evidence-based
pharmaceutical opinion letters to providers, education brochures to patients and facilitated by clinical champions,
to support thyroid hormone deprescribing in older adults. We will conduct a type 1 hybrid effectiveness-
implementation trial of D-THIO vs. enhanced usual care (American Thyroid Association [ATA] provider
abbreviated guidelines, ATA patient brochure) at 3 sites (University of Michigan, Henry Ford, University of
California San Francisco) in 150 providers (primary care, endocrinologists, geriatricians, advance practice
providers) and 750 of their patients ¿65 years overtreated with thyroid hormone. We will randomize 1:1 at the
provider level within each site. We propose three specific aims: 1) to assess the effectiveness of D-THIO on
thyroid hormone deprescribing by providers and on reducing overtreatment and misuse with thyroid hormone
via EMR, 2) to assess the effectiveness of D-THIO on provider and patient knowledge and attitudes regarding
thyroid hormone deprescribing via surveys, and 3) to identify factors related to the implementation of D-THIO
across diverse general care settings via post-trial interviews with key stakeholders. Ultimately, our findings will
serve as a model for deprescribing inappropriate medications for other endocrine conditions and conditions with
biochemical monitoring, and advance our understanding of de-implementation of low-value care in older adults
across the nation.