Desiccated thyroid in the management of hypothyroidism:  Part I

Desiccated thyroid in the management of hypothyroidism: Part I

Posted by Thomas Repas, DO, FACP, FACE, CDE  January 2, 2009 04:32 PM

Before I go any further, I must disclose: I do not use desiccated thyroid (Armour Thyroid, Forest Laboratories Inc.) in the management of hypothyroidism. Like most of my endocrinologist peers, I believe that desiccated thyroid is antiquated therapy and should no longer be used. Guidelines published by the American Association of Clinical Endocrinologists and other major endocrinology professional organizations support this position.

However, I am frequently asked by my patients about desiccated thyroid. Some of them tell me that a family member, friend, alternative care practitioner or other acquaintance has told them they do not “believe” in levothyroxine and advised them to be switched. This, along with several negative comments by patients on this blog about levothyroxine, is why I chose to write about this issue in detail now.

Desiccated thyroid is made from dried and powdered animal thyroid gland, a by-product of domesticated animals raised for the meat industry. For many years in the past, it had been successfully used in the management of hypothyroidism. However, once levothyroxine became available, desiccated thyroid fell out of favor. Recently, there has been resurgence in the use of desiccated thyroid as alternative medicine practitioners have proclaimed the benefits of natural over synthetic thyroid hormone preparations.

So why do I and most other endocrinologists refuse to use desiccated thyroid?

There are a number of reasons. First and foremost, desiccated thyroid preparations have an unacceptable level of variability batch to batch, often resulting in unacceptable variation in thyroid-stimulating hormone. The current USP standards specify that the amounts of levothyroxine and liothyronine in each 65 mg of desiccated thyroid should be 38 mcg and 9 mcg; however, the actual amounts vary considerably. According to the American Society of Health-System Pharmacists “Big Red Book,” the mean concentrations of levothyroxine and liothyronine in each 60 mg of desiccated thyroid ranged from 8.8 mcg to 59 mcg and 7.9 mcg to 18 mcg, respectively.

Part of the problem is that many manufacturers have used iodine content rather than actual thyroid hormone to standardize their preparations. Some manufacturers (ie, Armour Thyroid) perform bioassays to maximize batch-to-batch reproducibility. However, as noted above, the range of levothyroxine and liothyronine can vary considerably, even in products standardized by bioassay instead of iodine content.

I and many endocrinologists are concerned when the brand of levothyroxine is switched without our knowledge to other brands or from brand to generic. Whenever a patient must be switched from one levothyroxine product to another, we always recheck the TSH in several weeks to confirm the dose remains optimal. Even as little as a 10% difference between similarly labeled levothyroxine products can result in large variation in clinical response as measured by TSH. When managing my patients on levothyroxine, sometimes I change the dose by as little as an extra half pill more or less per week

If we consider slight variation between various levothyroxine products to be clinically important, then the much larger variation within desiccated thyroid preparations is unacceptable.

-To be continued-

AACE Thyroid Guidelines. Endocr Pract. 2002;8.

AHFS Drug Information. 68:36.04.

Comment by Darlene Garis -- March 2, 2009 10:29 AM

I finally feel some hope! I've been on Synthroid for 12 years but have steadily felt worse and worse and gained 20 lbs. despite ''normal'' blood tests. My doctor refused to consider or allow me to try Armour so I researched and found a new doctor who would. At my first appointment she actually LISTENED to me! She ordered a battery of blood tests including vitamin D. When they came back normal but she HEARD that I did not feel well, she LISTENED and allowed me to try Armour. I just switched meds several days ago but I'm hoping that, after finding the correct dosage, I feel and look like ''me'' again. Doctors need to LISTEN!! Please just listen!! You need to be willing to try things other than what has been indoctrinated into your minds!

Comment by Sammy R -- February 19, 2009 03:04 PM

My endocrinologist and ENT surgeon prescribed levothyroxine/Synthroid to shrink growths on my thyroid prior to removing my thyroid. I had an allergic reaction when I took the synthetic thyroid hormone, i.e., my hands, feet, face swell, my lips grow numb, I have fluid retention resulting in a 6 to 10 lbs gain of weight. The surgery was postponed indefinitely.

Both doctors told me NO OTHER thyroid hormone existed. I cannot understand (other than pressure and financial influence from pharmaceutical companies)why my doctors pointedly ignored this treatment.

Comment by Henry Lindner, MD -- February 15, 2009 05:22 PM

Dr. Mallette,

Thank you for your honest and detailed response. Thank you for emphasizing the importance of listening to the patient, of practicing clinical medicine as we were once taught to do. Yet you say that proper treatment means a TSH of 1-1.4 mIU/L. So which is it? Do you treat patients or TSH levels? What evidence do you have that every patient's TSH response to circulating thyroid hormones is always perfect? Surely there many factors beside gross H-P disease that can perturb TSH response and make it dysfunctional from emotional state, to toxins, to other hormones, to genetics. How do you exclude partial secondary hypothyroidism when the TSH is within the broad population ref. range and yet the FT4 and/or FT3 are near the bottom of their reference ranges AND the patient is clearly hypothyroid by signs and symptoms? (I see this frequently and I'll bet you do too.) The TSH cannot be perfect, no hormonal system is perfect. Low LH production is why men become hypogonadal as they age. Too much worry or exercise reduces FSH/LH secretion. We know that the TSH response to low T4 levels declines with age (Carle, 2007). The number of persons with "normal" but suboptimal free thyroid hormone levels due to inadequate TSH response could be huge.

Your target of a relatively low TSH shows that you already realize that the TSH is overly suppressed by oral thyroid hormone replacement compared to thyroidal production for given level of overall thyroid hormone effect. Otherwise your target would be just anywhere within the 95% population reference range, right? Maybe the TSH overreacts because the HP axis was not designed to deal with oral replacement with the peak caused by getting the day's full thyroid hormone dose within a few hours after swallowing a tablet. I agree, the TSH seems to be more easily suppressed by oral T4, and this can often leave FT3 levels rather low and the patient symptomatic.

So the question is "How much is the TSH oversuppressed by oral T4 and/or T4/T3 therapy? In the only study I know of where experienced thyroidologists adjusted doses of T4 by signs and symptoms, resultant TSH levels were all over the place (95% TSH treatment range was undetect. to 20mIU/L), and the FT3 ended up being the best predictor of clinical state (Fraser 1986). And what if the TSH response was weak before starting therapy in a symptomatic patient – they had low TSH and relatively low FT4 to start with? Surely the TSH will be suppressed below the ref. range in such cases with almost any dose of oral thyroid replacement.

And what about thyroid hormone resistance? What evidence can one point to that proves that no one can have partial peripheral resistance to thyroid hormones, so that they need FT4 and FT3 levels above the ref. ranges to feel and function well?

Then the question remains of the clinical endpoint. Is it good enough to make the patient "not so hypothyroid" as before? What is it like to have optimal thyroid levels? How do we know when that is except by clinical criteria — by slowly increasing the dose until there are any signs or symptoms of hyperthyroidism and then backing off?

Why don't endocrinologists accept and deal with all these complicated issues? Why do they follow the TSH/FT4 "within range" algorithm when they know that the picture is not that simple?

Comment by Lawrence E. Mallette, MD, PhD -- February 12, 2009 06:47 PM

I would like to provide a "counterpoint" to Dr. Repas' article. The following comments are based on 35 years experience LISTENING to and working WITH my thyroid patients and trying to use as physiologic a replacement program as possible: Many patients feel fine while being replaced with levothyroxine (T-4) alone. Wonderful. Don't fix what isn't broken. (They probably won't be coming to see me, the specialist, anyway). Many patients, however, have residual hypothyroid symptoms despite a good TSH level (ideal TSH is 1.0 to 1.4). Symptoms range from vague fatigue to a total non-functional state, with severe "brain fog." How do we explain residual symptoms in the face of a normal TSH? T-3 is the ACTIVE hormone, the form that binds to the thyroid hormone receptor T-4 can be viewed as a pre-hormone - it becomes active when it is converted to T-3 by removing one iodine atom. The pituitary is set up to read blood T-4 levels preferentially over T-3, so it may not sense a deficiency of circulating T-3. TSH may not give the whole picture, then. The normal thyroid, when it is working, makes about 6 to 8 mcg of T-3 daily along with its 100 mcg (roughly) of T-4. The second source of T-3, about 40 mcg a day, is from deiodination of T-4 after secretion. Many patients don't deiodinate T-4 well enough to get by without this critical 7 mcg. [We now know that people who inherit two low-affinity alleles of the main deiodinase enzyme - one from each parent - show lower free T-3 levels while taking T-4 replacement. They don't convert T-4 to T-3 well. I suspect that these subjects with two weak alleles are more likely to be unhappy on T-4 replacement, although this hypothesis has not been formally tested yet.] Furthermore, the deiodination step is downregulated by caloric restriction and inflammatory conditions, explaining why it is hard to lose weight and why other illness produces more fatigue during levothyroxine replacement. In my experience, providing the tiny amount of T-3 (6-8 mcg) that used to come from the thyroid will correct the symptoms at least 80% of the time. The source can be either Cytomel, 5 mcg tablets, one or two a day (synthetic T-3) or Armour Thyroid 30 or 45 mg daily (to provide 4.5 or 6.75 mcg of T-3). The latter has the advantage of low cost. I do not use generic thyroid extract because of a prior bad experience with a totally inactive lot of the generic (some 30 years ago now), but I have found the brand name to be quite reliable and to provide quite steady blood test result (free T-4, free T-3 and TSH) over several years. The "formula" for the substitution (to keep TSH at the same value) is to reduce T-4 dosage by approximately 25 mcg to accomodate the addition of 5 mcg of T-3. Exchanging 25 for 5 will lower free T-4 by about 0.2 and raise free T-3 by about 20-40. T-3 levels do not go above the reference range. I believe that one should almost never prescribe more than 60 mg of thyroid extract (9 mcg T-3), but simply add or include synthetic levothyroxine when the dosage of the extract must exceed 30 or 60 mg. There are, unfortunately, a small number of misguided physicians who prescribe as much as 240 mg daily, saying the TSH test is meaningless (it's not). Their patients soon become thyrotoxic and are placed in jeopardy. These malpracticing physicians give us all a bad name. The dose of T-3 IS important, and TSH SHOULD be kept around 1.2. We should mimic nature by providing the correct amount of T-3, not use the product indiscriminatly because it is "Natural" - it works for patients because it contains the missing T-3, not because it is "Natural." I would urge all Endocrinologists, Internists and Family Medicine physicians to listen to their patients, and give a trial of T-3 when levothyroxine has not restored normal well-being, using these guidelines. If it doesn't improve things, its easy to go back to levothyroxine alone and seek other causes for the residual symptoms. To do less for our patients, is to abandon our dut

Comment by Becca -- February 2, 2009 11:25 AM

And, you state that you retest TSH no wonder patients stay sick TSH does tell what FT4 and FT3 levels are. This irresponsibly keeps us sick!!

Comment by Christina (continued) -- February 2, 2009 10:21 AM

that is very commendable. Unfortunately, thousands of your colleagues are not... and that is why you read in mail after mail how disillusioned, angry and disappointed patients are. Don't you think they would rather trust and believe what their doctors are telling them? ... but how can they when doctors are "treating the blood results" and not the patient? When sick patients are sent away and told "all is normal" or worse, told it is 'all in their heads' and get palmed off with antidepressants! If Armour "really" did not work, do you think patients would flog to it the way they do? Do give us credit, most of us have got a brain we can use ... at least when we are well again... and the word is spreading.

Comment by Christina (continued) -- February 2, 2009 10:14 AM

unlike levothyroxine, contains calcitonine, which strengthens the bones.

"Some have had anxiety, insomnia, tremulousness, heat intolerance and other symptoms clearly due to iatrogenic hyperthyroidism. The long-term consequences of hyperthyroidism are not benign. Nevertheless, many have absolutely refused to allow me to decrease their dose, despite my concerns."

I do, however, take your point about your above statement. There are — and always will be — patients who misuse Armour and overdose themselves — sometimes for stupid reasons (like wanting to lose weight easily), but most of the time it results out of confusion and desperation. And granted, the long term consequences of hyperthyroidism are not benign. But shouldn't you (as a profession) ask yourselves - Why are patients doing that? I'll give you the answer.... Because most people who take Armour do so without the support of their endos or GPs. Although most patients are more than willing to learn as much about thyroid illness as they can, their doctors are unwilling to listen, to explain and - yes - frightened to follow common sense and question the dictates of the professional endocrinology Associations.

Nobody disputes that doctors are highly qualified individuals, who have spent many years studying medicine. But all that knowledge is only of use, when you are taught ALL the facts... and sadly there is too much anecdotal evidence to ignore that you (as a profession) — and for reasons best known to themselves — are not taught all the facts .... at least not as far as thyroid disease and its treatment is concerned.
I assure you, your patients are desperate to find doctors who will listen to their side of the story and are willing to work with them to restore good health.

"Some alternative care practitioners claim that standardized laboratory testing is unreliable. They use other methods to justify their approach such as basal body temperature measurement, testing of tendon reflexes and how the patient generally feels subjectively."

Yes, they do ... and to a large degree they are right. Blood results are not the be-all-and-end-all. Thyroid blood parameters measure the amount of thyroid that is circulating in the blood — not the amount of thyroid that is reaching the cells. I, for instance, had "perfect" thyroid blood parameters on Levothyroxine.... yet I still felt ill — unlike now, that I am on Armour.

Clinical symptoms and a patient feeling "subjectively ill" should not be dismissed. - You state for instance that there are many other factors that affect basal body temperature, other than the thyroid... - you are very right! Apart from hypothyroidism there are pituitary insufficiency, gonadal insufficiency, adrenal insufficiency, hypoglycemia, cirrhosis, acute pancreatitis, drug or alcohol abuse, central nervous system abnormalities and metabolic toxicity — and probably a few others conditions that I can't think of right now. But very few people will measure just their temps and then conclude they must be hypothyroid.... it is usually a number of clinical signs and symptoms that leads them to their conclusions.

You are wrong in saying that there is a 'wide intra-individual variation in body temperature'. There isn't ! Yes, body temperatures depend on time of day, how it is measured and on activity levels. However, we are not talking about just any old measurement, we are talking about the basal body temperature, taken last thing at night and first thing in the morning — and THAT is defined within a very small range. Many hypothyroid patients, including myself, have subnormal basal temperatures of less than 35 C (95 F). And please do give us some credit ... we are using mercury thermometers or/and the equivalent that's available nowadays and we do know how to take temperatures correctly.

Finally, you have mentioned how vitally important it is for patients to be listened to and to be heard. It seems that *you*

Comment by Sheila (continued) -- February 2, 2009 10:09 AM

liver, kidneys and other receptors to the active hormone T3. T3 is required by every cell in the body and brain to make it function. There are numerous reasons why some sufferers cannot convert.

Thyroxine was introduced without any comparison with natural thyroid extract. The Medicines Control Agency (MCA) has continued its use without review. Given that levothyroxine is the cheaper medication (at least here in the UK), one has to question why the manufacturers would not wish to demonstrate equal effectiveness. Natural thyroid extract USP has been making patients better since 1894, long before the introduction of synthetic thyroxine. Thus, the burden of proof lies with the synthetic product to demonstrate it is as safe, effective and as consistent as Armour.

Thyroid Patient Advocacy-UK responded to the British Thyroid Association’s statements on Armour Thyroid and synthetic T4/T3 combination therapy — which you can read on their web site. Many of their statements are downright misleading and some incorrect. Please check out the TPA rebuttals and note the many citations to the science, studies and research that are there to show the BTA to be incorrect. It is of serious concern that the BTA could only find one reference to back up their statement on Armour USP and only three to back up the synthetic T4/T3 combination therapy statement.

It is also of concern that the BTA never acknowledge receipt of these rebuttals, nor have they changed a word on their web site. This is grossly irresponsible.

Comment by Chris L. -- February 2, 2009 05:55 AM

***As I read through the comments on the past few posts, I see that unfortunately many, if not most, are full of misconceptions and commonly held fallacies about the endocrine system.

Dr. Repas - would you care to explain what you mean by the above statement, please? I have just read through all of the comments, and although I am "only" a qualified nurse and not a doctor, I do have a brain and I do pride myself in having learned and understood how (in principle) the endocrine system works. I haven't come across any glaring ''misconceptions'' as you put it, and I feel offended by your patronizing comment above.

There is nothing easier than making sweeping statements without providing prove to the contrary .... if you are going to ''dismiss'' comments in the global way you are doing above, then at least have the courtesy to point out what — in your opinion — those ''misconceptions and commonly held fallacies'' are.

Thank you

Comment by Christina -- February 1, 2009 02:53 PM

Dear Dr. Repas,

First of all - I take my hat off to you for attempting to tackle a highly sensitive subject and to go into the lions den, armed with only your trust and belief in the Guidelines published by the American Association of Clinical Endocrinologists and other major endocrinology professional organizations. It takes guts to stand up and face the wrath of hundreds/thousands/ hundreds of thousands (??) of dissatisfied patients, who have lost their faith in the conventional health systems on both sides of the pond — and more often than not for very good reason. - Still, you are making a stand for what you believe to be true, even though you no doubt are aware that every coin has two sides, and I applaud you for your willingness to talk.... which is more than the majority of your colleagues are prepared to do. - So let's talk.

**** First and foremost, desiccated thyroid preparations have an unacceptable level of variability batch to batch, often resulting in unacceptable variation in thyroid-stimulating hormone. The current USP standards specify that the amounts of levothyroxine and liothyronine in each 65 mg of desiccated thyroid should be 38 mcg and 9 mcg however, the actual amounts vary considerably. According to the American Society of Health-System Pharmacists “Big Red Book,” the mean concentrations of levothyroxine and liothyronine in each 60 mg of desiccated thyroid ranged from 8.8 mcg to 59 mcg and 7.9 mcg to 18 mcg, respectively.....

Desiccated thyroid preparations contain an approximately 4:1 ratio of thyroxine (T4) to triiodothyronine (T3), whereas the normal human thyroid has of a ratio of 11:1. These preparations result in supraphysiologic levels of T3 in the two to four hours after ingestion. This is due to the rapid release of T3 from thyroglobulin and the immediate almost complete absorption of T3. ****

Well, I am not a scientist, and therefore not in a position to discuss this from a scientific point of view. But I trust that if you were to look closely into the matter, you will find that your accusations re Armour-Thyroid are quite unfounded. The variation of thyroid hormone in Armour is minimal and well controlled (max 5-10%) as specified by the US FDA.

.Whether the quoted ratio of ~ 4:1 in Armour satisfies your (or the Association's) professional standards is not for me to decide, but Armour has one undeniable advantage over synthetic thyroxine... thousands of hypothyroid sufferers report that it works ! ... and in your own words ...''you can't argue with success''. I have just changed from Levothyroxine to Armour, and I assure you — I am not aware of any supraphysiological activity. I have no palpitations (unlike on T4 only), no sweating, no urge to run a marathon or otherwise engage in any kind of hyperactivity.... I just feel ''normal."

You talk about seeing individuals on Armour with fully suppressed TSH.... - well, yes, I would expect the TSH to be fully suppressed whilst on Armour ... wouldn't you? Why should there be any more demand from the pituitary gland to produce more thyroid hormone when the body gets all it needs from Armour?

Let's face it ... The TSH - hailed as "scientific" and holding all the answers to diagnosing and monitoring thyroid disease only arrived in the late 60s — yet it is far from being the perfect tool for measuring how much thyroid hormone the body really needs. The TSH has been made so sensitive to orally given thyroid hormone that literally everyone ended up with a significantly lower dose of thyroid hormone than was previously effective for about 80 years prior to the TSH.

The argument that a below than "normal" TSH leads to atrial fibrillation and osteoporosis doesn't hold water either. As far as I am aware, there are no clinical tests proving that a below the range TSH would lead to such things. More importantly - if anything, patients on Armour have stronger bone density because Armour, unlike levothyr

Comment by Karen Rufolo, Palos, IL -- February 1, 2009 10:28 AM

I've been suffering with fatigue mostly in the afternoon and low energy for years. I am looking for a solution to my hypothyroidism. I exercise, eat well and do all I can but need help.

Comment by Sheila -- February 1, 2009 07:33 AM

The problem with those who believe they know everything is that they simply listen to what others say about Armour Thyroid USP and do not do the research to find out the true facts.

First, you try to mislead your readers by writing “desiccated thyroid is made from dried and powdered animal thyroid gland, a by-product of domesticated animals raised for the meat industry”. Armour thyroid USP is made from the desiccated thyroid glands of grain fed pigs only.

The FDA would NEVER allow natural thyroid extract USP to be prescribed in the USA or anywhere else in the world if the T4 and T3 content were not standardised to the USP specifications. This would be highly dangerous, and your comment regarding this is, again, incorrect. The response by Richheimer and Jensen should serve to correct any misrepresentations (implied or otherwise) regarding the T4 and T3 content in Armour USP and the nature of the collaborative study for the U.S. Pharmacopeia. As determined by Armour Pharmaceutical Company and other participating laboratories, the T4 and T3 content in Armour is well within the specifications set by the U.S. Pharmacopoeia.

Thyroid extracts continued their popularity since 1894 and were not affected by the introduction of synthetic thyroxine in the 1930s until a hoax batch of thyroid extract, containing only iodine with no thyroid hormone, was shipped to Europe and the US in 1963, with the goal of discouraging the use of thyroid extracts. This hoax made T4 the ONLY eligible thyroid preparation for hypothyroidism because the iodophobic domino effect of the 1948 Wolff-Chaikoff publication prevented physicians from supplementing their patients with iodine. Many doctors were reluctant to switch to thyroxine only, preferring to prescribe the desiccated gland. They were, however, eventually persuaded to change their allegiance.

In 1969, Dr. Wolff from the National Institute of Health published his paper titled, “Iodide goiter and the pharmacologic effects of excess iodide”. In 1970, Goodman and Gilman stated, ‘This episode gave thyroid a bad name because several publications about the unreliability of thyroid appeared before the hoax was uncovered’. There was widespread concern that the effects of this “drug” were not consistent with previous clinical experience and so all thyroid extract was labelled “unreliable”. Although the hoax was uncovered seven years later and ‘The Medical Letter’ in 1973 maintained that desiccated thyroid extract had never been unreliable, mud sticks, and doctors started using synthetic l-thyroxine.

ArmourThyroid USP does have a higher amount of T3 compared to T4 than the relative amounts of T3 to T4 secreted by the human thyroid gland, however it is well documented that Armour is often more effective and is better tolerated than synthetic preparations of T4, T3 and T4/T3 combination. This is because the T3 in natural thyroid extract is absorbed more slowly than synthetic T3. The normal thyroid gland contains approximately 200 mcg of T4 per gram of gland, and 15 mcgs of T3 per gram. The ratio of these two hormones in the circulation does not represent the ratio of the thyroid gland, since about 80% of peripheral T3 comes from monodeiodination of T4. Peripheral monodeiodination of T4 also results in the formation of reverse T3, which is iatrogenically inactive. A similar ratio can be obtained by prescribing both Armour and synthetic thyroxine, although clinical response and symptom control should take precedence over a theoretical ideal. Perhaps the ultimate form of thyroxine for difficult patients is whole thyroid extracted from animals, such as Armour thyroid tablets.

By treating ALL hypothyroid patients with thyroxin only, doctors are leaving tens of thousands (probably millions) of sufferers to lives of sheer hell and misery where many have to leave paid employment and try to thrive on State Benefits? T4 is a mainly inactive hormone which must convert through the li

Comment by Geri -- January 31, 2009 10:34 PM

I was diagnosed with hypothyroidism approximately 14 years ago. My symptoms at the time were weight gain (I was vegetarian and walking 5 miles EVERY day), considerable hair loss, fatigue, muscle pain, severe menstruating, dry skin, heart palpitations, mood changes, etc., etc. I was placed on synthroid/levothyroxine. My symptoms decreased for a short period of time, but were not all together alleviated. I worked at my weight, barely eating and lost some weight, but never enough to return to my original low weight. Then, the weight started to climb, and I was always feeling fatigued. My doctor appeared not to believe that I was eating very little and increased my dosage of synthroid. I lost a considerable amount of weight by drinking three cups of coffe a day and eating a small salad in the evening. That's all! After introducing other foods into my diet (I do not eat junk food) my weight began to climb and climb. I am embarrassed by my appearance and am quite depressed. I eat all natural foods, fruits, vegetables, and overall, I have very healthy habits, but am unable to budge my weight. I came across a book by Mary Shomon. I found this website and wanted to share my struggle with others. I am trying to educate myself on this disease so I can be better informed to approach my doctor. I have never felt worse in my life. It is quite worrisome to not have clear cognitive ability, forgetfulness, extreme fatigue, and joint and muscle pain. I don't know what it feels like to feel good.

Comment by Christene -- January 31, 2009 04:12 PM

I am a individual who has been hypothyroid for 5 years. I felt positively ill using synthroid for 3 years. I begged my endo to try armour. She gave me a prescription for antidepressants instead. I finally found a doc who prescribes armour and I feel better than I have felt in years. I have a question for all you docs out there Why do you dismiss a patient who does not feel well just because your lab results are "normal"? Do you believe your patient is lying? I was told I needed therapy when I knew deep down my body was not working correctly. Guess what? Two weeks after I started taking armour my energy levels increased, the depression went away, my hair and skin improved and I actually lost some weight! Shame on all you docs who dismiss your patients as raving lunatics. Just because you have the title MD does not mean you have all the answers or are more intelligent than everyone else. BE OPEN MINDED

Comment by Dawn marie -- January 30, 2009 06:21 PM

I was diagnosed with Hypothyroidism in 2002 and was put on Levoxyl .88mcg. I was tested several times in the first year and my physician kept upping the dosage based upon the TSH. She did not test for Free T3/Free T4-just the TSH. Needless to say, I am now up to 150 mcg of Levothyroxine and feel terrible. I had a lab test done a month ago and for the first time, they ran a free T3 and free T4 and my free T3 was at .3, my free T4 was 1.21, and my TSH was 1.13 — my doctor said I needed to lower my Levothyroxin! Even though my free T3 was so low. I am not an expert in Hypothyroidism but it is pretty clear that I need an increase in T3 and it's possible that the synthetic T4 (Levothyroxin) is not converting to T3 like it's supposed to. My point is, my doctor did not give me any explanation but just told me my Synthroid level is too high. She will not prescribe Armour or Cytodel so I ordered it online. Unfortunately, there are doctors out there that are not familiar with other options for us. All they know is Synthroid for Hypothyroidism. It makes us seek out other avenues to get desiccated thyroid — in my case, I ordered it online as a last resort.

Comment by Dr. C. Salmeron -- January 30, 2009 02:45 PM

I was taking Synthroid medication for years before I found a physician willing to prescribe Armour. The improvement in my symptoms was startling, even when my TSH was around 1.0 while on Synthroid. I will never go back to the synthetic version.

My doctorate is in physics, not medicine, so I’m not fully credentialed to discuss the biochemistry of the treatment, but what I am qualified to discuss is your (and your colleagues) so-called application of the scientific method. It is erroneous. Your approach to the treatment is reductionist: you are equating hypothyroidism with a TSH level that is yet to be unequivocally established and is therefore somewhat arbitrary, ignoring the complexity of the endocrine system. If you consider the patient as your "closed system", and not merely the results of some laboratory numbers, you will realize that many other factors come into play, many of which (I am certain) are yet to be understood.

I'm sorry for those who feel that they don't have the intellectual capacity to question the medical establishment even when their symptoms hold the answers to their questions. I hope my own experience is of help to them.

Comment by Ginger -- January 30, 2009 12:38 PM

I was on Synthroid for 5 years and still felt lousy. I had dry skin, joint and muscle aches, painful menstrations, and mood swings. I had no energy whatsoever. I think after 5 years of taking this medicine, a person should know whether or not it's going to work for them, don't you think? I argued and argued with my endo, who would not budge from prescribing Synthroid. I am a medical transcriptionist and, believe me, I know how to research drugs and medical conditions. It's a "no brainer" to figure it out, when you see drug salesman go in and out of the office while you're sitting there in the waiting room. Synthroid costs more than Armour. Shame on doctors who are more concerned about the "benefits" they receive from the drug reps, than the "benefits" their patients will receive from a medicine!
Needless to say, I "fired" that endo and found one who would prescribe Armour thyroid. Within 2 weeks, I felt the difference in my body. It has been over a year now, and I have felt better than I've felt in a long, long time! Everyone's bodies are different. What works for one, may not necessarily work for another. Synthetic isn't for everyone!

Comment by Tami -- January 30, 2009 11:59 AM

I was diagnosed hypothyroid in 2001. I was prescribed a synthetic T4 drug and took it faithfully. However, other than short burst of energy after starting or a doseage increase, I continued to feel symptomatic. Desperation for a better quality of life lead me to seek out more information than I was receiving from my Dr. I read about Armour and asked my Dr. and pharmacist about it. The Pharmacist said most people have a better sense of well being on Armour. My Dr. was hesitant but agreed to let me try it. All I can say is, Armour works, I have my life back and I feel great.

It's a terrible shame that some docs won't even consider it as an alternative. The attitude portrayed in this article will do nothing but give docs TSH numbers they're comfortable with while the patient still feels sick.

Comment by Logan Fay -- January 30, 2009 11:01 AM

I've been a hypothyroid patient for 4 years. I've been on Synthroid and Levothyroxen and Armour at different times. I find with Armour for what ever reason, I am more clear headed, more physically active, less achy. Although I do experience palpitations much more. Whatever it is in the Armour that makes the difference is enough to make those of us that are living with hypothyroid and who know how are bodies best to want it. I had gone undiagnosed for years and am able to really compare how I used to feel prehypothyroid with now being hypothyroid it's a no brainer when it comes to the differences between each medication and how I am feeling. My HDL is up and my total cholesterol is down 40 points.

Comment by Melissa -- January 30, 2009 08:56 AM

I was on sythroid for 7 years. Guess what...I was still experiencing the symptoms after so many years of regulating. No one ever offered an alternative. Now I found out about Natural thyroid. Guess what...I feel so much better! Not depressed anymore, I'm losing the extra fat, I have ENERGY, my skin finally has moisture, etc. So maybe you should go by what patients experience and not by your little numbers. Out with the old and in with the new doesn't really work here. Don't let the synthroid reps buy you off with expensive lunches and dinners. Nature thyroid worked in treating hypothyroidism for over 100 years why would it not work now? It's too old fashioned for you? you afraid to experiment with something new? oh wait, its not new but its new to you! Learn more then prescribe. Thank you.

Comment by Gloria C. -- January 29, 2009 09:13 PM

I have been on synthetic thyroxine for 26 years now and am concerned about the long term effects. My body's response to thyroxine Synthroid then Levothroid) is not optimal-I've just learned to sublimate my concerns so that I am not having to have a struggle with my doctor over what is best or needed. I am really frustrated with the care I receive and with my doctor's over-reliance on my TSH levels. He never asks about specific body state nor does he compare his notes from one visit to the next. Is it laziness? I am ready to just give it up (Levothroid) and see how that goes.

Comment by E -- January 28, 2009 06:32 PM

I need to ask, regarding: "However, I am frequently asked by my patients about desiccated thyroid." What is the demographic of that particular group of patients? I'll bet it's the same demographic as someone with an untreated eating and/or emotional disorder.

Same question goes to the first commenter, in regards to: "However it seems from the many testimonial of patients I received and a recent survey from the UK thyroid group that there may be a subgroup of patients responding and feeling better with natural desiccated thyroid." Could it be that that particular ''subgroup'' and those with eating and/or emotional disorders are perhaps one-in-the-same?

In my observation, I believe these two groups are indeed one-in-the-same and think it's that unhealthy association between psychology and endocrinology that needs a closer, more honest look.


A word to all doctors: Please know there are those of us with real thyroid disease that don’t listen to all the nonsense averred by the likes of those commenting here, but do listen to you are carrying out your best advise and are not experiencing issues like that of the ''subgroup.''

We thank you for your continued dedication to responsible care.

Comment by Lorie -- January 12, 2009 01:55 AM

Dr. Repas... I believe you took the the Hippocratic Oath "To do no harm". But you and your fellow endocrinologists who refuse to offer your thyroid patients options besides synthroid are doing exactly that. Patients on synthroid suffer continuing hypothyroid symptoms, including high cholesterol, fatigue, low body temperature and general malaise. I should know. I was under the care of an endocrinologist for a 1 1/2 years who would not prescribe anything by synthroid. When I asked about armour, he refused. I still had fatigue, I was still cold and I still had high cholesterol. At first do no harm...Are you listening???

Comment by Tom Repas DO FACP FACE CDE -- January 11, 2009 02:12 PM

Dr. Knafo: Thanks for sharing your insights. I appreciate and agree with the points you make.

For the record, my greatest concern with desiccated thyroid (or levothyroxine or T3) is when they prescribed in a manner that results in long-term exogenous hyperthyroidism.

If a patient is not hyperthyroid and they are doing better on one product vs. another, it is very hard to argue against that.

Comment by Renee Honeycutt -- January 9, 2009 01:14 PM

after being diagnosed of hypothyroid i was placed on synthroid and was on this for several years with out improvement. after doing the research i found out about an antiquated therapy called Armour, so i thought i would give it a try as nothing else was working. It DOES work and much better than the T4 alone, i believe some of us do not do well on T4 drugs alone. My question to you would be why not treat the patient with what works better for that individual? Are you as a Doctor supposed to do your best for each patient, we are not the same? Also Armour is regulated and and does contain the correct amount of T3 and T4 needed.

Comment by Dr H. Knafo -- January 8, 2009 12:49 PM

Dear Colleague. Let me first thank you for writing on this somehow controversial but essential subject. There are a few points that I would like to clarify: 1. USP standards is the standards used by pharma companies and the FDA and the variabilities of T3 and T4 in dessicated thyroid you are mentionning are inaccurate since the API HAS TO BE tested and should be in the range requested by the FDA. Values in the ``Big Red Book`` have been chalenged and are outdated (studies from the 80`s).
Second point is that Synthetic levothyroxine holds an undisputed literature pertaining to its beneficial usage in hypothyroidism and most patients treated with levothyroxine do well. However it seems from the many testimonial of patients I received and a recent survey from the UK thyroid group that there may be a subgroup of patients responding and feeling better with natural desiccated thyroid.
I do think that further evidence based studies are needed to be able to reject desiccated thyroid as an alternative treatment to hypothyrodism.

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