BMJ 2013;347:f6388 doi: 10.1136/bmj.

f6388 (Published 22 October 2013)

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NEWS
US endocrinologists release choose wisely list
Michael McCarthy
Seattle

The Endocrine Society and the American Association of Clinical Endocrinologists have released a list of five common endocrinology practices whose use should be questioned.1 The list is part of the American Board of Internal Medicine Foundations Choose Wisely program, an initiative that calls on specialty organizations to identify common practices that may not be necessary and could actually be harmful. To date, more than 50 specialty societies have joined the campaign.2

by parathyroid hormone levels, which in turn are regulated by calcium and/or vitamin D. In vitamin D deficiency, 1,25-dihydroxyvitamin D levels go up, not down.

The third recommendation is to stop routinely ordering thyroid ultrasonography for patients with abnormal thyroid function tests if there is no palpable abnormality of the thyroid gland.

The lists are not meant to be prescriptive guidelines on practice but rather seek to identify common practices whose necessity healthcare providers should question and whose risks and benefits they should discuss with patients before using them. The new list was drawn up by a panel composed of representatives of both organizations that was commissioned to identify tests and procedures that should be used only in specific circumstances. The panel came up with recommendations concerning five common but questionable practices.

Overzealous use of ultrasound will frequently identify nodules, which are unrelated to the abnormal thyroid function, and may divert the clinical evaluation to assess the nodules, rather than the thyroid dysfunction, the panel said. The fourth recommendation is to avoid ordering a total or free triiodothyronine (T3) level when assessing levothyroxine (T4) dose in hypothyroid patients. In most patients a normal TSH [thyroid stimulating hormone] indicates a correct dose of T4, the panel said.

The final recommendation is not to prescribe testosterone unless there is biochemical evidence of testosterone deficiency. Many of the symptoms attributed to male hypogonadism are commonly seen in normal male aging or in the presence of comorbid conditions. Testosterone therapy has the potential for serious side effects and represents a significant expense, the panel said.
bmj.com US Editors Choice: When good care means less pay (BMJ 2013;347:f5997, doi:10.1136/bmj.f5997); Feature: The challenge of doing less (BMJ 2013;347:f5904, doi:10.1136/bmj.f5904) The BMJs Too Much Medicine campaign is at www.bmj.com/too-muchmedicine.
1 2 Endocrine Society, American Association of Clinical Endocrinologists. Five things physicians and patients should question. www.choosingwisely.org/doctor-patient-lists/theendocrine-society-and-american-association-of-clinical-endocrinologists. Tucker ME. Physician groups each identify five of their own inappropriate practices. BMJ 2013;346:f1266.

One recommendation is for adults with stable type 2 diabetes who are taking agents that do not cause hypoglycemia to avoid routine multiple daily self monitoring of glucose concentrations. Once target control is achieved and the results of self monitoring become quite predictable, there is little gained in most individuals from repeatedly confirming, the panel said. Another recommendation is to stop routinely measuring calcitriol (1,25-dihydroxyvitamin D). This test should be reserved for patients with hypercalcemia or decreased kidney function.

Because 1,25-dihydroxyvitamin D is the active form of vitamin D, many practitioners think that measuring 1,25-dihydroxyvitamin D is an accurate means to estimate vitamin D stores and test for vitamin D deficiency, which is incorrect, the panel said. Serum levels of 1,25-dihyroxyvitamin D have little or no relationship to vitamin D stores but rather are regulated primarily

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