choosing wisely -- endocrine

endocrine society and am assn of clinical endocrinologists added their suggestions to the choosing wisely website (see http://www.choosingwisely.org/doctor-patient-lists/the-endocrine-society-and-american-association-of-clinical-endocrinologists/ , or choosing wisely endocrine 2013 in dropbox). this website in general has suggestions about unnecessary tests from many of the major specialty and primary care organizations and is really well-organized.

 

the endocrine society points:

 

1. avoid routine daily self-glucose monitoring in adults with stable DM2 or agents not causing hypoglycemia (eg metformin).  The issue here is that it does not make sense to have patients check their fingersticks more than once a day if they are well-controlled.  There was a study in BMJ a couple of years ago suggesting that glucose self-monitoring in the aggregate did not change diabetes management, largely because physicians did not act on that information.  However, I do find there is an additional role for checking fingersticks, which is for patients to get direct feedback themselves about the effect of what they're eating, or the effects of exercise in lowering blood sugar.  So, I do encourage patients to check their fingerstick after they have high carbohydrate meals, for example, to learn the effect of that meal on their blood sugar -- as a means to educate themselves about what they should or should not eat and what quantities are okay.
2. Do not routinely measure 1, 25-dihydroxy vitamin D unless the patient has hypercalcemia or decreased kidney function.  The issue here is that 25-hydroxy vitamin D assesses vitamin D stores more accurately than the 1,25-dihydroxy vit d.  Patients who have low vitamin D may well have preserved 1, 25 dihydroxy vitamin D levels as the body struggles to maintain appropriate levels of the active hormone (1,25-dihydroxy).
3. Do not routinely order a thyroid ultrasound in patients with abnormal thyroid function tests in the absence of a palpable thyroid gland abnormality.  The point here is that there is not often a relationship between having thyroid nodules and thyroid dysfunction, and additionally the ultrasound are too sensitive and frequently picks up inconsequential small nodules.  As in many radiologic studies, ultrasounds beget ultrasounds beget ultrasounds ( or CT scans beget CTs or MRIs or...) for insignificant problems, leading to patient anxiety, loss of work/interference with daily life, and  cost.
4. Do not order a total or free T3 when assessing levothyroxine dose in hypothyroid patients.  Although T3 is the more active hormone, TSH is the physiologic measure indicating appropriate thyroxine repletion.  In fact, patients on oral levothyroxine may well have high T4 and low T3 levels appropriately.  Ordering TSH to monitor thyroid replacement of course applies only to patients who have hypothyroidism from a primary thyroid dysfunction.
5. Do not prescribe testosterone unless there is biochemical evidence of deficiency.  The issue here is that the symptoms associated with   testosterone deficiency are common and very often related to other medical or psychosocial issues.  There has been an apparent massive TV advertising campaign by the drug companies to promote  testosterone replacement, which (not surprisingly) creates a significant financial advantage to them.  However, testosterone replacement therapy is not indicated unless there is true testosterone deficiency, documented by a low total testosterone level from a morning blood sample.  This probably should be repeated on a second day if low.  In labs with high-quality assessment of free or bioavailable testosterone, that also might be helpful in documenting testosterone deficiency