Is it appropriate to discontinue Synthroid (levothyroxine) and pantoprazole in a long-term care patient approaching palliative care?

From the Guidelines

Discontinuing Synthroid and pantoprazole in a long-term care patient approaching palliative care should be considered on a case-by-case basis, prioritizing the patient's quality of life, symptoms, and goals of care, as recommended by the American Heart Association in 2024 1. When considering the discontinuation of these medications, it's essential to weigh the potential benefits and harms. For Synthroid, the decision to discontinue should be based on the patient's life expectancy and the potential impact of hypothyroidism symptoms on their quality of life.

• If the patient has a very limited life expectancy (days to weeks), continuing Synthroid may provide minimal benefit.
• However, if the patient has a longer life expectancy, discontinuing Synthroid could lead to hypothyroidism symptoms, reducing their quality of life. For pantoprazole, the decision to discontinue should be based on the presence of symptoms requiring acid suppression.
• If the patient no longer has symptoms, discontinuing pantoprazole may be appropriate, as the medication primarily treats symptoms rather than extending life. The decision to discontinue these medications should involve discussion with the patient (if possible), family members, and the healthcare team to align with the patient's wishes and comfort goals, as emphasized in the standards of medical care in diabetes-2022 1. Regular reassessment of all medications is essential in palliative care to ensure the focus remains on symptom management and quality of life rather than disease modification or prevention.
• This approach is supported by the American Heart Association's scientific statement on palliative pharmacotherapy for cardiovascular disease, which highlights the importance of deprescribing and de-escalating medications in palliative care 1.
• Additionally, the standards of medical care in diabetes-2022 provide guidance on simplifying regimens and relaxing the intensity of lipid management in older adults with diabetes, which can be applied to palliative care 1.

From the Research

Discontinuing Medications in Palliative Care

• The decision to discontinue medications in palliative care should be based on the individual patient's needs and goals, as well as the potential benefits and burdens of continuing treatment 2, 3.
• There is no direct evidence to suggest that discontinuing Synthroid (levothyroxine) and pantoprazole is appropriate or inappropriate in palliative care, as the decision to continue or discontinue these medications depends on the patient's specific medical condition and treatment goals.

Considerations for Discontinuing Synthroid

• The study on treating hypothyroidism suggests that treatment is not necessary unless the TSH exceeds 7.0-10 mIU/L, and that TSH goals are age-dependent 4.
• In patients with subclinical hypothyroidism, treatment may not improve symptoms or cognitive function if the TSH is less than 10 mIU/L, and may even be harmful in elderly patients 4.

Considerations for Discontinuing Pantoprazole

• The study on the effect of morning versus night-time administration of pantoprazole on thyroid function test in levothyroxine-treated primary hypothyroidism found that concomitant use of pantoprazole leads to significant elevation in serum TSH, irrespective of timing of pantoprazole intake 5.
• However, this study does not provide direct evidence on the appropriateness of discontinuing pantoprazole in palliative care.

Palliative Care Principles

• Palliative care focuses on improving symptom management, addressing the needs of patients and families, and maximizing quality of life 2, 3.
• The decision to discontinue medications should be guided by these principles, taking into account the patient's individual needs, goals, and values.