The Micawber approach to thyroid hormone doses

Charles Dickens, Micawber and thyroid dosing

Mr Micawber's famous, and oft-quoted, recipe for happiness:

"Annual income twenty pounds, annual expenditure nineteen [pounds] nineteen [shillings] and six [pence], result happiness. Annual income twenty pounds, annual expenditure twenty pounds ought and six, result misery."

If you take 100 micrograms of levothyroxine a day and your body expends 99 micrograms, result happiness. Take 100 micrograms of levothyroxine a day, body expends 101 micrograms, result misery.

Every extra day leaves you further behind, until eventually you reach a new but definitely suboptimal steady state. A tiny, tiny amount more than you need is of little or no consequence.

For example, if you were on 125 micrograms and needed a small dose reduction, say to 112, but you were actually reduced to 100, you would be falling behind by 12 micrograms a day. In one week, you are down by 84 micrograms. Only when your body reduces its "consumption" of levothyroxine to 100 can the new steady state occur - and you will be well down by then.

(Be careful not to interpret this as an invitation to take more and more levothyroxine, that is taking the analogy too far.)

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Private Prescription Charges

If you ever get issued with a private prescription, Stop! Consider how much it will cost to get the item dispensed

First, is the item actually prescription-only? If it is available over-the-counter, that will almost certainly be the cheapest option.

What is the actual price of the medicine?

The pharmacy will likely have a range of possible suppliers with a range of prices. Then discounts depending on all sorts of factors. That makes it very difficult to get the exact price. But you can often get an idea from the British National Formulary.

https://bnf.nice.org.uk/

NHS pay the pharmacy through an agreed reimbursement mechanism based on the NHS Drug Tariff.

NHS also pays a dispensing fee (something like 245.0 through 286.8 per item depending on prescription).

NHS Drug Tariff prices for amitriptyline range from 75 through 98 pence per 28 (depending on dosage). Actually very similar prices to most levothyroxine tablets.

A pharmacy might charge £9.65 might is simply a base price equal to NHS prescription charge.

For example:

For private prescriptions you've obtained from another GP, we have a minimum dispensing charge of £9.65 per item.
https://www.pharmacy2u.co.uk/prescriptions/

I've never seen anything that stops pharmacies charging whatever they want for private prescriptions. But maybe there is some sort of price control mechanism?

Find the cheapest private prescriptions 

While NHS prescription prices are fixed, pharmacies can set their own for private prescriptions. These are given when you want a drug not covered by the NHS in your region, such as Malarone to prevent malaria if you're travelling and some cancer drugs. 

It could be a drug for a lifestyle-enhancing purpose, such as sexual aid Viagra (although this can be on the NHS if your erectile dysfunction's caused by a medical problem, such as diabetes, prostate cancer or a kidney transplant) or anti-baldness drug Propecia. 

Non-NHS doctors can't give NHS prescriptions. So go to one for emergency weekend diagnosis, or because you're a member of a scheme, and you'll get a private prescription.

Always compare prices 

Unlike the world of NHS prescriptions, with private prescriptions it's an open marketplace and pharmacies can set their own prices, meaning costs vary hugely. 

The table below shows how prices can vary for just one item, but it can be an even bigger difference if you ask for the generic version.
https://www.moneysavingexpert.com/family/cheap-prescriptions/

Note: NHS prescription charges only apply in England and even then only if you do not qualify for exemption.

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helvella - Thyroid USP

The Standard

Thyroid USP is, first, a standard. The U.S. Pharmacopeia defines medicine standards for the USA. And some countries follow USP standards, especially when there are few, if any, other standards for something.

The Products

Secondly, Thyroid USP is the substance produced that conforms to the USP standard.

And on the Thyroid UK forum, we do try to use the terms Natural Desiccated Thyroid (NDT) and Desiccated Thyroid Extract (DTE) solely for products which conform to USP. Sometimes this results in admin action to ensure consistency of information.

Products which do not claim to be Thyroid USP tend to be called "thyroid glandulars" as we don't really have any other suitable term.

The current Thyroid USP standard is not readily accessible. Which makes it difficult to say anything definitive. Some of what follows is historic and might no longer be true.

Discussion

Nothing in USP demands that the animal source is porcine. It could be bovine (cattle) or ovine (sheep). But I am not aware of ANY Thyroid USP product which isn't porcine. Though there are at least a few bovine glandular products.

The USP standard was originally devised to try to ensure consistency of the product but the chemical assay techniques were nothing like as refined and capable as those now available. The standard checked the amount of iodine which was bound - and assumed that represented thyroid hormone.

More recently it has been revised to use techniques which specifically check levothyroxine and liothyronine content much more directly.

 Further, in general we rely on the manufacturer's claims. For USA products, we know the FDA is involved. Similarly the relevant agencies for Canada and any EU countries.

The current official Thyroid USP monograph is not readily accessible. The link below claims to be the version from 2007 but this cannot be verified.

http://pharmacopeia.cn/v29240/usp29nf24s0_m83400.html

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