Desiccated thyroid in the management of hypothyroidism: Part II

Desiccated thyroid in the management of hypothyroidism: Part II

Posted by Thomas Repas, DO, FACP, FACE, CDE  January 6, 2009 09:49 AM

Most board-certified endocrinologists avoid desiccated thyroid in the management of hypothyroidism for additional reasons.

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.

In my own practice, I have seen numerous individuals referred to me on desiccated thyroid with fully suppressed thyroid-stimulating hormone. This is because the dose was titrated based on symptoms or clinical findings rather than biochemical assays. 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.

With hormone therapy, just as too little is unacceptable, too much is also unacceptable. More is not always better.

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.

Although thyroid hormone certainly has effects on metabolism, in order for there to be a consistently measurable increase in body temperature, many patients must be rendered hyperthyroid. There are many other factors that affect basal body temperature, not only the thyroid. In addition, there is wide intra-individual variation in body temperature. Body temperature varies depending on time of day and how it is measured. “Normal” body temperature should not be defined as 98.6º F ± 0º, just as we do not define “normal” TSH as exactly 1.00 mIU/L. Normal is a range, not a single value. Using basal body temperature to modify the dose of thyroid HT is imprecise and not supported by the scientific evidence. It is the same with measurement of reflexes and other non-specific clinical findings.

Regarding symptoms and the subjective feeling of wellness, that is problematic. My goal is not only to prevent and treat disease, but for all of my patients to feel better on whatever therapy we have chosen. The problem here is that there are innumerable reasons to feel poorly, often with identical symptoms to hypothyroidism, and yet not due to thyroid dysfunction.

Too many times have I seen other medical diagnoses missed, because every symptom a patient had was attributed to their thyroid and no further evaluation was done. It is easier and less time consuming to write a prescription than it is to think, ask questions and most important of all ... to listen.

Sometimes we need to tell patients what they need to hear, even if it is not what they would like to hear. This should be done as kindly and tactfully as possible, but it must be done nonetheless.

-To be continued-

Comment by Micki Jacobs -- March 20, 2009 05:39 AM


Comment by Leah -- February 1, 2009 01:32 PM

I've an idea, I have a friend who is very good mechanically, why don't I get him to make a TSH measuring machine, then patients can just put their arm in, the blood test can be taken, and the levothyroxine script could be automatically be printed out!! Why has nobody thought of this before??

And by the way - why is using TSH less abitrary than using basal temperature measurement combined with symptoms?

Comment by rcp -- January 30, 2009 11:53 PM

(a) Yes, there are some hypothyroid patients with pituitary, adrenal, and other more complex factors, but (b) the vast majority of hypothyroid patients, in my clinical experience, are not that complicated and do better by adding even as little as 5 mcg of triiodothyronine [T3].

To set this up as science/ Synthroid versus non-science/ Dessicated Thyroid argument is to set up a false argument. For the vast majority of patients, in my clinical experience, it is not "rocket science" to measure the Free T3 as well as the Free T4 and TSH and then to (a) keep both FT3 and FT4 in the upper half of the lab's "normal" range while (b) keeping the TSH above the rock-bottom level of the lab's range. It also helps, while starting treatment, to get the patient physically active. As another blog entry noted, it is not that complicated to split the dose if an occasional patient does better in that manner. In my clinical experience it is very unusual for a patient so treated to become hyperthyroid or to feel jittery, etc; that is just a "straw man" argument. Of course it helps if patient and physician actually communicate with each other on a regular basis [I have seen patients coming in with a 1-year supply of Synthroid without any lab tests in recent memory and that approach does not exactly reflect any real communication between two people who are working together, trying to solve a problem.]

Comment by E -- January 28, 2009 06:39 PM

“In my own practice, I have seen numerous individuals referred to me on desiccated thyroid with fully suppressed thyroid-stimulating hormone…..Nevertheless, many have absolutely refused to allow me to decrease their dose, despite my concerns.” I wonder what would happen if you said decreasing their dose would trigger weight loss. I’m serious and think a study of that nature would be beneficial to perhaps bring forth the true motive behind the desire to obtain and maintain such a physical state.

“Some alternative care practitioners claim that standardized laboratory testing is unreliable.” That’s because they usually don’t qualify to get the license required to be able to order such laboratory testing in the first place. Same goes for scans, etc. Amazing what a lack of making the grade will do to a mind. ...Kidding aside, this is one particular area where things cross over from the trivial to the serious. What if a thyroid diagnosis gets missed? I have seen it happen (I met a woman who describes herself as ‘lucky to be alive’ after getting caught up in a stint with one of these yahoos that turned out to be thyroid cancer).

As a real patient with real thyroid disease, who interacts with others of the same, I think I can safely speak for many of us in that group by saying: We are not paying insurance premiums, co-pays and cash toward our thyroid disease to have a doctor treat us primarily on how we''re ''feeling.'' We're paying all that to have them treat us primarily on how we're ''doing!''

Comment by Lily -- January 28, 2009 02:58 PM

Thank God I have always had doctors who were smart enough to prescribe Armour Thyroid. I feel so sorry for your suffering patients.

Low TSH alone does not equal hyperthyroid in people being treated with supplemental hormones.

None of my friends on Armour are being kept in a hyperthyroid state. Instead their doctor monitors their symptoms. Imagine that!

You remind me of the doctors who promoted lobotomies as a great medical breakthrough for patients with mental illness. So sure of your medical wisdom, oblivious to the suffering you cause.

As a Public Health professional, with degrees in patient education, I can say that the current under treatment and mistreatment of thyroid patients has reached epidemic proportions.

Comment by Upset -- January 9, 2009 07:42 PM

Can you explain to me why someone with a normal TSH and taking Synthroid still feels horrible? Do you just dismiss them as mental cases? When someone who has a TSH of say .01 feels great on dessicated thyroid?

Comment by So sad -- January 9, 2009 09:51 AM

Its pretty sad that patients know more than their doctors about thyroid disease.

Why do our thyroids make so many hormones if we only need t4?

Comment by D.B. -- January 9, 2009 01:30 AM

Dr. Repas,
Don't you think this illustrates how little the medical community understands in regards to treating the thyroid? Obviously dosing by the TSH isn't working because patients are suffering and not being diagnosed properly. I recently had a doctor claim that I was hyperthyroid because all she looked at was the TSH, which was 0.01. (No I am not taking any thyroid medications). She immediately diagnosed me as on the verge of becoming hyper without any further testing! However going with my gut (and my other pituitary problem-diabetes insipidus), I opted for more testing. I am now finding that it is likely secondary HYPOthyroid. She had put so much emphasis on the TSH that she had misdiagnosed me big time! Even with my history, she did not see my concern with the TSH being a pituitary problem whatsoever. Rather than talking to the patient and getting the free T3 and free T4 checked, she went by what the TSH told her. You claim that doctors are listening, but they are not. I had to go to a naturopathic doctor to get the other testing done. Something is seriously wrong with that.

You said that a lot of patients have undiagnosed conditions. I agree with you there. There is likely more than just a thyroid problem. However, let's not forget that conventional medicine doesn't even acknowledge conditions like adrenal fatigue, heavy metal poisoning (from dental amalgams) and estrogen dominance (from plastics and commercially raised meats) to name a few. It is hard to get people better when you don't believe conditions exist. That is why more and more people are opting for alternative doctors and treatments. Conventional medicine has repeatedly burned the very patients they were supposed to help. It should be no surprise we've given up trying to listen to doctors, when the doctors (and big organizations in charge) themselves won't listen. It goes both ways, sir.

Dare I say, you are in need of a paradigm shift, Dr. Repas. Bear with me for a second with this analogy. Let's say for a moment, we are all looking at the hourglass/faces optical illusion and we (the patients) can see both pictures. Meanwhile you (majority of doctors) can only see the hourglass. You (majority of doctors) continue to tell us there aren't any faces in the picture. The problem here is that you have all the big endo/thyroid organizations agreeing with you proclaiming there isn't a face in this picture (when there clearly is one). Thankfully there is a small minority of doctors who can see the faces AND the hourglass. The doctors prescribing armour and dosing by symptoms are the ones who can see both in the picture. Who is right and who is wrong? Obviously neither is right or wrong, but the doctors who can see both pictures are looking at this much differently than you. Maybe you should take another look at the picture...

Comment by Darla -- January 8, 2009 04:22 PM

You and various other doctors are overlooking the obvious. Like low ferritin and adrenal fatigue.

I took Synthroid for 20 years. I developed carpal tunel and plantar fasciitis. It got to where I couldn't climb stairs from muscle weakness. I had developed a stutter and brain fog so bad that I was to be tested for Alzheimer's at 45.

My TSH was anywhere between 3.5 and 14. My Free T4 was above range and my Free T3 way below.

But after just one month of desiccated thyroid and a low dose cortisol replacement these symptoms quickly started to go away. Since I have reached an optimal dose of desiccated thyroid symptoms are completely gone.

TSH is completely suppressed. My Free T3 is now towards the top of the range and Free T4 is a little below that. My blood pressure, pulse, cholesterol and other labs are perfect.

I wish more doctors would treat hypothyroidism with desiccated thyroid and pay closer attention to cortisol and ferrtin. Maybe some one else wouldn't have to waste 20 years looking for an answer. Then you wouldn't have to tell patients what they "need" to hear. It really isn't that hard.

Comment by Julie Sue -- January 8, 2009 03:11 PM

As with most doctors and especially endocrinologist you are missing the point.

Get off the TSH train and you may be able to actually practice medicine. What happened to “do no harm”. Using TSH and Synthroid is killing us and is certainly doing us harm. Wasn’t the intent of practicing medicine to help people, to stop suffering because you sure aren’t doing that? By continuing with the “company line” you are doing harm. Might I remind you that TSH is a pituitary hormone not a thyroid hormone. That’s like testing your ankles to see how you knee is doing. Give me a break. This practice and that’s what you’re doing is practicing on us, is destroying lives. People have lost everything, marriages, jobs, homes etc because of their inability to work because of this way of practicing medicine.

You are TSH obsessed like 99% of the doctors in this country. What happened to signs and symptoms and how a person felt? The way they used to doctor before the might TSH test was invented. Try treating someone by symptoms, it’s not that difficult. Perhaps you need some further education in this matter. Might I suggest Dr. Broda Barnes, the father of thyroid treatment. You could certainly learn something from him.

I agree with the other posters with regard to adrenal support. Open your eyes!!! Did you not learn that one needs excellent working adrenals to be able to tolerate thyroid medications. I direct you to an article from John Hopkins University (Adrenal Insufficiency – Grand Rounds) that clears states NO thyroid treatment should be started unless adrenal stability is established. Even in the literature that comes with ones Synthroid prescription, it states it is not to be used with adrenal insufficiency. Before you jump on this by saying, “they are referring to Addisons Disease” please be aware that it does NOT state Addisons Disease. Adrenal Insufficiency comes in all kind of forms, from fatigued and exhausted adrenals due to years of stress, especially stress from lousy thyroid treatement all the way to Secondary Adrenal Insufficiency. If the general public can figure this out why can’t you “professionals”.

There are thousands of thyroid patients who will not sit idly by any longer. We will not give you our business until you learn how to treat us properly. Use the proper testing (Free T3, Free T4, Thyroid Antibodies, Reverse T3, Cortisol, Aldosterone, DHEA etc) and then we’ll continue to LET you help us. Since it seems that many doctors are driven by the might dollar please remember YOU WORK FOR US, not the other way around. We have fired many a doctor and will continue to do so until you learn how to work for us in the proper manner.

Stop torturing us with your subpar treatment and then blaming us because we must “be depressed” or because we have “high anxiety”. Yes, we have high anxiety because you people are not listening. This is for you to solve not for us but luckily for some of us we have. We have gotten our lives back in spite of you. Yes, it’s true…proper testing and proper treatment of adrenals and thyroid with desiccated thyroid actually allows people to have jobs, marriage that aren’t strained by illness and fully functioning lives.

As I’m sure this and other posts will be deleted, heaven forbid someone contradict you, perhaps the folks doing the deleting would at least have the decency to print out our suggestion, comments and complaints. It never hurts to learn something new. Your patients seem to be able to do it everyday.

Comment by Maria -- January 8, 2009 02:53 PM

I must say that your letter is very upsetting to me. But I am glad that I ran across it. As a hypothyroid patient myself I understand this disorder better than anyone, I live it every single day. I was told by a dozen doctors that I need antidepressants and that I was a hypochondriac (by many Endocrinologists) because my TSH level was normal and all blood tests were normal. Once I did find a good doctor, not an endocrinologist, but a regular MD who believed that my symptoms were real and not just in my head, then I was put on Armour thyroid. I got very sick on the Armour thyroid at first, so I had to quit it and the doctor told me about a great book called "Safe uses of Cortisol" by Dr. Jefferies and asked me if I would be willing to try cortisol, and I said YES, he then put me on a low, safe dose of cortisol, turns out I had very low cortisol levels (within range) but still very low. Once I got my adrenals working properly on cortisol (after a few weeks) then I was able to handle the Armour thyroid and thank GOD I did! Armour thyroid and cortisol saved me from a life of misery. 15 years I lived a life of misery and nobody could help me. Now others that I know have made the switch from Synthroid to Armour with AMAZING results. My friends and family now have their lives back, life is worth living once again. Armour is amazing, and if it doesn't work then don't give up, try cortisol first, and try lowering the dose of Armour. I started out on very small doses of Armour. Like 1/4 grain for many weeks, and then raised by 1/4 grain every few weeks, very slowly, once I felt better I stopped raising and it took 3 grains to feel better. Now life is great and completely worth living again, I got my energy back and I can focus and I have no complaints now, my husband is in heaven having his old wife back again and I am a better mother for it! So many people are not completely symptom free on Synthroid, but millions are symptom free on Armour, like me you just have to know how to use it properly. Armour saved my life!!
God Bless!
Virginia, USA

Comment by Valerie Taylor -- January 7, 2009 06:38 PM

You say there are many things that affect the body temperature, what are they? I am sorry but I was in Synthroid for 25 long miserable uears with an "in range" TSH and I was dying of Myxedemaa from LOW T3. Many hypothyroid patients do not convert well and NEED the higher T3 in Armour Thyriod. Why did it work so well for 100 years without problems until the MIGHTY TSH lab and Synthroid were produced? That hyperthyroid symptoms you are talking about is due to adrenals being too weak and the HPA being downregulated due to hypothyroidism not being diagnosed in a timely manner due to poor testing such as the TSH lab is. Please come into the 21st century with thyroid treatment!

Comment by Janie -- January 7, 2009 06:25 PM

You have continued to miss some important information about the dosing and treatment of desiccated thyroid in reference to the 4:1 ratio of T4 to T3. Namely, wise doctors have their patients multi-dose desiccated thyroid, which means that 2 hour peak is not as severe as you describe it.

Second, the symptoms of "anxiety, insomnia, tremulousness, heat intolerance" are due to adrenal fatigue, not "iatrogenic hyperthyroidism" from a suppressed TSH. Adrenal fatigue is the result of too many years of undiagnosis from the lousy TSH lab test (which can be normal for years before it rises high enough to reveal the patient's hypothyroidism) or from undertreatment on the lousy T4-only thyroxine medications (which leaves the vast majority of patients with their own degree of lingering hypothyroid symptoms). As a result of either of the above, the patient's adrenals have been kicking in, and kicking in again to support the patient. And over time, the adrenals become fatigued with its low cortisol. And since cortisol is needed to transport thyroid hormones from the blood to the cells, these patients are wrongly dismissed as having "iatrogenic hyperthyroidism because of a suppressed TSH". Instead, they are having pooled thyroid hormones in the blood not making it to the cells, and thus the above symptoms.

And to call it problematic to regard "symptoms and the subjective feeling of wellness" is exactly why patients all over the world are running from doctors who say that. What has been truly "problematic" are the years and years of hundreds of millions of patients who came into their doctors offices with problems of depression, poor stamina, easy fatigue, rising cholesterol, rising blood pressure, thinning hair, feeling cold..and a myriad of other clear hypothyroid symptoms while undiagnosed because of the TSH, or on thyroxine, and the doctor pronounced them "normal" simply because the dubious TSH range said so. THAT is problematic.

You betcha there are innumerable reasons to feel poorly. But doctors have routinely failed patients for five decades in their belief that Thyroxine was adequately treating patients (it hasn't been) or that the TSH was diagnosing them soon enough (it hasn't been) or that staying in the TSH range was resulting in euthyroidism (it hasn't).

Sometimes patients need to tell doctors what they need to hear, even if it isn't what they want to hear. Are you going to listen?


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