-A three-part article portraying the typical idiotic thought process of the classically trained endocrinologist.
all parts by Thomas Repas, DO, FACP, FACE, CDE January 2009
Desiccated thyroid in the management of hypothyroidism: Part I
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.
Desiccated thyroid in the management of hypothyroidism: Part II
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.
Desiccated thyroid in the management of hypothyroidism: Part III
Most people would not dream of directing a cardiologist how to perform cardiopulmonary resuscitation during a cardiac arrest. They also would not come in to see the surgeon with a specific outline on how to do the procedure. Most would decline to have their surgery done in the same way and with the same techniques as in the 1970s. Despite this, many intelligent, otherwise reasonable people have no hesitation trying to “teach” me about the thyroid. Many of these same people also request to have their thyroid disorder managed similar to how we did decades ago.
Why is this?
There are several reasons. For one, despite the advances made in technology, scientific knowledge and outcomes over recent decades, modern medicine has failed many patients from a humanistic perspective. It is not too much to expect for questions to be answered and treatment options explained. Everyone desires to be listened to and heard. There is nothing more discouraging than when one’s symptoms are ignored. I have witnessed this myself when I and family members have been patients. It is extremely frustrating. Not surprisingly, some pursue alternative options.
Some believe in a more natural approach towards health. Their goal is to minimize the synthetic, processed and man-made. I actually understand this philosophy very well. My family and I grow a large portion of our vegetables organically. We enjoy the sense of connection with the land and the seasons. We take pride in knowing that we participated in the sustainable production of our food. If someone presented to us a well-crafted, scientifically valid argument as to why there is no benefit to organic vs. conventional gardening, we would smile, nod and keep doing what we are doing. We garden organically as much on philosophical grounds as any other reason.
For me to argue for patients to change someone’s belief system based on science is equivalent to attempting to convince them to change their religion or political party on the same grounds. It would be futile as well as absolutely inappropriate.
Health care is different, however, because there is the potential for harm as well as benefit. I am obliged to inform my patients about the positive as well as negative potential consequences of one option over another. This is true no matter if we are discussing alternative vs. more mainstream therapies. However, I realize that I am only one advisor among many. My duty is to provide the most accurate information possible. Patients are free to choose for themselves how they would like to proceed.
Finally, last week I saw a woman who had been on desiccated thyroid for decades. I explained that we now prefer levothyroxine instead of desiccated thyroid. I also quickly pointed out that her thyroid-stimulating hormone has been perfect, between 0.7 mIU/L and 1.0 mIU/L over the last several years. She had no symptoms; it was difficult for me to argue with success. After discussing and asking her what she wanted to do, she left my office still on desiccated thyroid.
Comment by Tom Repas DO FACP FACE CDE — June 12, 2009 12:24 PM
Hello all – I continue to read the comments posted on this and related threads.
I appreciate everyone sharing their insights and experiences. I haven’t responded to every single posted comment because the sheer volume makes it impossible.
I also get the impression that no matter what else I might add, it would be futile and encourage only further attacks.
I confess to purposely choosing a subject which many are passionate about — and which many of my peers avoid discussing at all.
However, if we take our respective positions, dig our heels in and never talk to those with differing opinions, how will medical care ever progress and improve?
Rather than avoiding talking about such topics, I usually prefer to meet them head on and encourage — not discourage — conversation. I’ll do that even if I know that everyone does not agree with me. I could have written about something or taken a position that everyone agrees with — but that would have been too easy.
Several endocrinologist colleagues have told me I’m crazy for writing about such a sensitive issue and in a way that I know would be sure to make me a target.
They are probably correct — but then I’ve never been known to be one who takes the easiest route, simply because is it easy. Don’t forget, I run ultramarathons in my spare time because marathons are “too easy.”
We might not agree on many things but I appreciate everyone sharing their thoughts, opinions and experiences. It actually has helped me in discussing this issue with patients in my own practice.
You have been heard — loud and clear.
Thank you all again for commenting.
(Please DO NOT accuse me of being patronizing — I sincerely do appreciate your comments, even if they differ from my own).
http://www.endocrinetoday.com/comments.aspx?rid=35717
—————————–
Reader comments regarding this article. A tragic thing is happen to patients nowadays.
| Comment by Micki Jacobs — March 20, 2009 05:39 AM
see: http://www.thyroidscience.com/Criticism/lowe.3.16.09/lowe.bta.rebuttal.3.16.09.pdf
|
| 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, 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!!
|
| 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? Janie |
