Monthly Archives: August 2009

Thyroid Hormone Dosing Dilemnas. Part 1


Several members of metabolism.com have posted their opinions on methods to determine the best dose of thyroid medication for treating hypothyroidism (sluggish thyroid). Many physicians work on the assumption when giving thyroid hormone replacement, that the achievement of thyroid function tests in the normal range, particularly TSH , is the sole indication of an appropriate replacement dose. This is a fair assumption but not every treatment is successful using such rough guidelines. (for more on using TSH levels in the treatment of hypothyroidism see my article here at metabolism.com, “Major Revisions Possible in Guidelines for Diagnosing and Treating Hypothyroidism” ).

To answer the question of when the ideal thyroid hormone replacement dose has been reached, I look at nature’s own experiments. I have treated countless people with diseases of the thyroid resulting in both hyperthyroidism (over-active thyroid) and hypothyroidism (under-active thyroid). Standing out prominently for me is how differently people respond to the presence of either too much or too little thyroid hormone.

Many people visiting metabolism.com express dissatisfaction with their replacement dose for hypothyroidism because they continue to experience symptoms typical of thyroid hormone deficiency (hypothyroidism) on thyroid medication. Their physician is reluctant to increase their dose because the TSH levels are in a normal range. It therefore may come as a surprise to know that in a few office consultations I have encountered people actually preferring to operate with deficient thyroid hormone levels as judged by TSH being elevated in the range 4 to 15. In these instances, increasing thyroid levels by giving thyroid hormone results in symptoms we typically associate with hyperthyroidism such as being excessively hot, shaky, nervous, fatigued and increase in palpitations.

Much more commonly, are those on the other end of the spectrum experiencing symptoms compatible with deficient thyroid levels when thyroid functions tests are in the low end of normal with TSH between 2 and 4. Symptoms in this group may include fatigue, puffiness, lack of concentration, weight gain, cold, muscle cramps and achiness, and constipation.

The diversity in symptomatic response to hyperthyroidism (thyroid hormone excess) can be equally broad. I can think of numerous individuals who are not the least bit troubled by extremely elevated thyroid level never experiencing typical symptoms such as feeling hot, shaky,sweaty etc. One might suspect that these people are just a tough breed of non-complainers. But checking for typical signs of hyperthyroidism which are independent of personality such as tremor, or rapid heart rate yields totally negative results. Others however, with just the slightest excess of thyroid hormone are plagued by feeling worn out, anxious, sweaty, hot with markedly elevated heart rates and tremors.

What could explain the wide variation between individuals, in response to thyroid hormone levels? In Part 2 of this article I will explore some of my thoughts and theories, while, as always, I invite members to join in with their own experiences.

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Dr. L. Mallette’s Advice on Handling the Armour Shortage


Lawrence Mallette, M.D., PhD, reports to us on how the Armour shortage has effected his practice, and shares with metabolism.com his advice on how to handle replacement therapy. We appreciate Dr. Mallette’s comments.

Dr. Mallette Writes:

The shortage of Armour Thyroid and other brands of thryoid extract has devastated my office. We have received over 300 requests for changes due to the shortage. We can’t get the other work done!

Synthetic T3 (Cytomel) at a dose of 5 to 10 mcg a day, together with a balancing amount of Synthroid or Levoxyl does the trick for most patients. Only a few find a distinct improvement on Armour versus Cytomel as a source of the T3 supplement. The symptoms experience by 50% of Synthroid- or Levoxyl- treated patients usually do not derive from the Synthroid itself, but from the lack of T3 in those preparations. This is possibly going to be the only work-around, as I’ll not go back to Armour until we have an explanation from Forest Pharma.

I the Federal Government (FDA) responsible for this shortage. Likely. They are criminally neglegent in that case.

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Armour Thyroid Shortage a Nation Wide Problem


Samantha, Nurse Practitioner in New York reports on the effect the national shortage of dessicated thyroid products is having on health care in her area. My own experience is that the situation is getting worse here in Florida, as well. Nature Thyroid and Westhroid which we had hoped would replace Armour in this practice has also become unavailable. At this very minute our office administrator is calling every pharmacy and pharmaceutical mail order companies we have used, trying to locate a source of these products for this practice (8 endocrinologists who serve a large portion of South Florida). Switching people back to T4 because the desired dessicated thyroid medication is unavailable, seems unacceptable in the “best health care system in the world”.

I thought Samantha’s comments were vital to see:

Samantha writes:

I’m a nurse practitioner in NY, and find that our patients generally do better or Armour Thyroid than on the usual T4 products. As for Cale, it sounds as if he’s in love with BigPharma, but many conservative practitioners and dispensors abound, so take what he says with a grain of salt. I, several MDs and NPs and a DO of my acquaintance all use Armour Thy. ourselves, but have noticed a slight decrease in effectiveness since the reformulation. The real frustration is having to convert our patients back to Levothyroxine and Cytomel which many do not find nearly as helpful. Other brands such as wes-throid and nature-throid are now out of stock, (in our area) and so there is no real alternative. Some of our patients have even tried getting stocks from Canada, to no avail. When I last checked with Forest they had stocks of 120 and 360 dosages available, but most of our patients require much less. While I will still use Armour and prescribe it, when we can get it again – as will my colleagues mentioned above – we are thoroughly annoyed at Forest for the reformulation. Most people tolerated the product very well. Patients should not have to have their effective medication routines switched out from under them. No one wants to change horses mid-stream.

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Leslie Gives Advice to Beth Regarding Armour Dosing


Beth wondered about her lack of response to thyroid hormone treatment. Leslie offers these comments:

Beth – perhaps you are under-medicated. The numbers don’t really mean much – you must convince your doctor to pay attention to how you feel, rather than your labs! Remind him/her: prior to 1973 there was not measure for TSH. Doctors would give their Hypo patients Armour, and increase the dose until the patient felt “right” again – and considered that to be successful treatment! I consider that to be successful treatment too! We’ll see what my doc says next week – I’m feeling great after an increase in meds (in spite of a TSH of 1.9), and I’m sure my TSH has gone WAY low – but it i hard to argue with success! I have absolutely NO Hyper symptoms. I think it is time to throw out TSH testing altogether, and treat patients instead!

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Gastric Banding Can Beat Diabetes. Cancer Too?


On-going research continues to confirm that weight loss surgery can reverse Type 2 (adult onset, obesity related) diabetes. A recent study conducted at NYU medical center of approximately 100 Type 2 diabetics who underwent gastric banding showed almost half had a return of normal glucose levels without needing anti-diabetic medication and the other half were able to significantly reduce the amount of medication they needed to control diabetes. The dramatic reduction in medication requirement in these post-operative diabetics was mirrored by substantial reductions in their weight.

In a separate study conducted in Sweden, researchers compared the occurrence of cancer in obese men and women who underwent gastric surgery for weight loss versus a similar group treated with diet alone. As expected the surgery group lost considerably more weight than the group treated with diet only. After 4 years it was found that women who underwent weight loss surgery had significantly lower incidence of cancer than the diet only group. There was no similar benefit in the men.

Obese women are known to have an increased risk of certain cancers compared to normal weight women. In particular, uterine and breast cancer are more commen in overweight women. Adipose tissue (fat cells) increases estrogen levels in the blood by converting other naturally occuring hormones to estrogen. It is thought that the excess estrogen is responsible for the increased cancer risk in obese women. In the Swedish study of women after gastric weight loss surgery, the reduction in cancer was most obvious for skin and blood cell cancers. This is not what would be expected if the cancer prevention was due to weight loss effects on lowering estrogen. The reason for the cancer reduction after gastric surgery in obese women is still under investigation.

Gary Pepper, M.D. , Editor-in-Chief, metabolism.com

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Researcher Comments on the Lack of Studies Comparing Synthetic Thyroid and Armour.


I noticed this very interesting post from Sarah who is a non-medical researcher. She has discovered what other contributors to metabolism.com have, that a serious lack of research exists comparing Armour thyroid to synthetic thryoid hormone in treatment of hypothyroidism. How is it then that the community of endocrinologists who pride themselves on their scientific approach to the practice of medicine, or who claim they follow “evidence based” medical decision making, are so uniformly opposed to the use of Armour thyroid or similar dessicated thryoid products?

Sarah, I believe the vast majority of contributors to metabolism.com including myself, are as astonished and troubled as you are by this apparent lack of insight by the policy makers in the field of endocrinology, in regards to this issue.

Sarah posts the following comments to metabolism.com:

It was very interesting to read these posts. I have never posted to a site such as this but I wanted to contribute my perspectives on this topic. I am a researcher by trade (in a very different line of research). I have been reading general “google” information for years on the controversy between synthroid and Armour. I have had trouble with mild symptoms at 88 mcg (synthroid) but 100 mcg brought my TSH to .4. My doctor was not comfortable with a TSH that low. For a number of years I have requested to try Armour and been denied. My main argument for trying Armour has been that if there are not risks with Armour (beyond the typical risks seen with any thyroid meds) why should I not try it. He has responded that the literature does not support Armour or the use of T3. I sat down for a few hours yesterday and looked at primary research articles and was very surprised. First of all there is a serious lack of research with autoimmune related thyroid disease. Second the few clinical trials that looked at Armour vs synthroid products were very poorly designed. Very small sample sizes with high variability in sample populations. The samples involve wide age ranges, multiple ethnicities represented and both genders. These variables would be important to consider but statistically inappropriate with small sample sizes. Of a greater concern was that in many of the studies most of the patients were being treated for hypothyroidism post surgical removal of the thyroid and then had only two patients with autoimmune related hypothyroidism mixed into the sample. They even noted that with the two patients with autoimmune hypothyroidism there were trends toward more positive outcomes related to the Armour. You will not find statistical significant with these kinds of research design (if being responsive is specific for the autoimmune variety) even if differences exist. If anyone could please provide the references for well designed research studies (either pro or con for Armour) I would really appreciate it.

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