Will Brink, October 19, 2022, Articles, General Health, Mens Health, Women's Health, 4
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Considering how many people are on thyroid meds and or SSRI’s, it’s surprising – especially in the case of thyroid medications – how much confusion exists in the medical community on how best to treat people with hypothyroid.

I find many people feel they are often in some sort of battle between themselves and their doctor as to what doses, types, etc of thyroid meds they need. Frankly, I find most medical professionals do a sub par job of managing hypothyroid patients, and there’s simply no justifiable reasons for it any more.

A book called “Thyroid Disorders” written by a Dr Gilbert Daniels, listed as Co- Director of the Thyroid Clinic at Mass General Hospital makes for a good reference guide. The book was published in 2006, so I am assuming he’s still there. The book is written for physicians, specifically for GPs/family physicians vs. specialists. Most of the information would be basic rehash for the people here that have already done a lot of research on the topic, and most of what he recommends is in line with the standard recommendations. Some of Dr. Daniels comments below on T4/T3 combination therapy was supported by recent studies that found people on a combo therapy much prefer it over a T4 mono therapy. Since his book, there’s been study after study that supports T4/T3 combination therapy vs T4 mono therapy for those who either subjectively fail to thrive on T4 mono therapy, and or, those who do not adequately convert T4 to the active T3, yet very few doctors (at least in the United States) are aware of it, and once made aware, often refuse to even try it with their patients who continue to feel poorly on T4 alone. If you are one of those people, you need to have a conversation with who ever manages your thyroid condition, and if they refuse to work with you, find one who will. That’s how strongly I feel about the issue as someone who has personally had to deal with medical doctors over the years refusing to acknowledge the above.

Why the resistance is unclear, but one of them is they’re often under the impression that the inclusion of T3 will lead to risks of atrial fibrillation, increased blood pressure, thyrotoxicosis, cardiovascular complications, and arrhythmias. Yet, studies and clinical experience of those rare doctors willing to use T4/T3 combination therapy, simply don’t see it. As always, the dose makes the poison and proper dosing and management is the key success. For some, simply increasing the dose of T4 mono therapy was beneficial to patients. The real problem is, many medical doctors treat their thyroid patients via labs alone, vs labs plus subjective symptoms, and that’s a mistake, a mistake far too many suffer with years or decades without relief. It’s time that stopped!

Dr Daniels makes a few salient points regarding optimizing therapy, which seems to be the major issue for most people and clearly differs between individuals. A one size fits all approach to thyroid management does not work and is all too common among doctors sadly, and their patients suffer for it. Unlike many ‘traditional’ docs out there, Dr Daniels seems fairly open minded. For those looking for a decent reference guide to tests, diagnoses, etc, it’s a good little book.

It could also be helpful for when making your case that you are not happy with your current meds/dose, etc and the doc you are working with is resistant. For example, he states:

“Although thyroid function can be precisely, monitored, not all ‘optimally treated’ patients feel well. For example in one study in which patients were treated with increments of thyroid hormone, those whose T4 dose was increased by 25-50 mcg/d, resulting in a suppressed serum TSH, felt consistently better than those receiving the highest dose at which TSH could be maintained within the normal range. In another community population-based study, patients taking T4 felt psychologically less well than a matched control population.”

Possible explanations for the above findings he lists as:

o Some of these patients may have been subtly under treated. When hypothyroid patients remain symptomatic, the T4 dose should be increased until TSH reaches the lower normal range.

(Note, however, he’s clear to point out that an intact hyopthalamo-pituitary axis is necessary for TSH to reflect thyroid status appropriately and other measures such as free hormones and symptoms should be used in that situation in addition to TSH)

o The patients may have remained symptomatic because their symptoms were related to other disorders possibly associated with Hashimoto’s thyroiditis, such as depression.

o True physiological replacement of thyroid hormone may require both T4 and T3.

o Clinical deterioration after starting T4 therapy should raise the question of concomitant adrenal insufficiency, known as Schmidt’s syndrome.
For a ‘traditional’ endocrinologist I thought his comments above showed an open minded approach I wish more docs followed.

Finally, an excellent review paper recently published – Optimal Hormone Replacement Therapy in Hypothyroidism – A Model Predictive Control Approach – covers the topic in depth and also makes the case T4/T3 combination therapy often yielding the best results.

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