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Can You Take Thyroid Hormone With Food? New Research on Levothyroxine Timing (2026)

June 30, 2026TfriedmanPosts
Can You Take Thyroid Hormone With Food? New Research on Levothyroxine Timing (2026)

Background

Thyroid hormone replacement therapy is the cornerstone in the treatment of hypothyroidism, yet the practical aspects of how and when to take these medications have long been debated. Traditional clinical guidance, without much evidence-based studies has emphasized strict timing—particularly taking levothyroxine (LT4) on an empty stomach and avoiding food and other medications to ensure optimal absorption. However, recent research and Dr. Friedman’s clinical insights challenge this rigid approach, suggesting that flexibility and patient adherence may be equally, if not more, important. 

The thyroid gland produces key hormones, primarily thyroxine (T4) and triiodothyronine (T3), which regulate metabolism and energy balance. In hypothyroidism, patients may be treated with several types of hormone replacement, including LT4 alone, LT3, combination therapies, or desiccated thyroid extract (DTE). Importantly, no single therapy works best for all patients, and individualized treatment remains essential. 

Historically, patients were instructed to take thyroid medications on an empty stomach, typically 30 to 60 minutes before breakfast, and to separate dosing from substances such as calcium, iron, and certain medications that could impair absorption. However, adherence to these instructions proved challenging. Studies have shown that up to half of patients find fasting requirements burdensome, leading to inconsistent dosing or missed medication. 

Recent clinical trial

A recent randomized clinical trial from Willems and colleagues in the Netherlands and published in Journal of Clinical Endocrinology and Metabolism in April 2026 explored whether levothyroxine could be taken with breakfast if the dose were adjusted. In this study, patients were divided into two groups: one taking LT4 in the traditional fasting state, and another taking it with breakfast with a 15% dose increase. The findings were notable—TSH levels remained stable in both groups, suggesting that the adjusted breakfast regimen was equally effective in maintaining thyroid hormone balance. 

Additionally, patients reported improved well-being and preferred the convenience of taking medication with food. Nearly 78% of participants who experienced both approaches favored taking LT4 with breakfast. Benefits included better adherence, a more consistent daily routine, reduced gastrointestinal discomfort, and overall improved quality of life. 

AI-modeling

Dr. Friedman used some AI programs and modelled thyroid hormone levels with and without food for LT4, LT3 and DTE. Modelling showed less of a peak in thyroid hormone levels after LT4 or LT3/DTE, less suppression of TSH, and more even levels of thyroid hormone levels throughout the day. While this is interested, it needs to be replicated with actual pharmacokinetic studies. 

Lessons learned

From a physiological standpoint, taking thyroid medication with food may produce more stable hormone levels. When taken on an empty stomach, hormone levels can peak significantly within a few hours, potentially suppressing TSH levels more than expected. With food, absorption is slower, resulting in more even hormone levels and possibly a more accurate reflection of thyroid function over time. 

Laboratory testing

Another important consideration is laboratory testing. Thyroid hormone levels fluctuate after medication intake, with free T4 levels rising by approximately 12–14% (and sometimes more) in the hours following a dose. For patients taking T3-containing medications, these fluctuations can be even more pronounced. As a result, it is generally recommended that blood tests be performed before taking the daily thyroid dose to capture baseline (trough) levels and avoid misleading results. 

For combination therapies or T3-containing regimens, timing becomes even more critical. T3 has a shorter half-life and leads to peaks in hormone levels approximately 2–4 hours after ingestion. This can transiently suppress TSH and complicate interpretation of lab results. Therefore, Dr. Friedman advises patients to delay their morning dose until after blood testing. When on DTE or T3-containing regimens, Dr. Friedman also encourages patients to divide doses throughout the day to maintain more consistent hormone levels. 

Clinical perspectives

Clinical perspectives emphasize that consistency is more important than rigid adherence to fasting rules. If a patient takes thyroid medication the same way every day—whether with food or without—dosages can be adjusted based on lab results to achieve optimal outcomes. This individualized approach prioritizes adherence and patient comfort over theoretical absorption concerns. Since this article came out, Dr. Friedman has been recommending taking thyroid medicines with foods and gives a higher dose; patients have been quite pleased. 

Summary

In summary, emerging evidence supports a more flexible approach to thyroid hormone timing. Many patients can take thyroid medicines with food, provided dosing is adjusted and consistency is maintained. With more experience on giving thyroid medicine with food, Dr. Friedman anticipates being able to say patients should take thyroid medicines with food. Blood tests should generally be performed before medication intake, especially for those on T3-containing therapies. Ultimately, successful thyroid management depends on individualized care, careful monitoring, and a focus on patient-centered outcomes rather than rigid protocols. 

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Update on Desiccated Thyroid

April 22, 2026TfriedmanPosts
Update on Desiccated Thyroid

Dr. Friedman frequently prescribes Natural Desiccated Thyroid (NDT), also called desiccated thyroid extract (DTE) to patients with hypothyroidism, especially to the 20% of hypothyroid patients on synthetic thyroid hormone replacement who still have hypothyroid symptoms, despite normal TSH values. Of the NDT products, Dr. Friedman prescribes either NP Thyroid or Armour Thyroid to his patients. NDT has other substances not found in synthetic thyroid preparations, and contrary to misinformation, are well-formulated products with excellent quality control. No NDT product is currently U.S. Food and Drug Administration (FDA)-approved, although Acella Pharmaceuticals, the manufacturer of NP Thyroid is completing a study that will be the basis for their FDA application. Synthroid and other L-T4 products were on the market for over 50 years before FDA-approval.


FDA Announcement

While on August 6, 2025, the FDA announced that it plans to remove all DTE, on March 11, 2026, the FDA issued a follow-up statement to DTE manufacturers. In this follow-up announcement, the FDA stated that it would “continue applying its risk-based enforcement approach to ‘unapproved’ animal-derived medications …,” while reiterating that it may “take action against a manufacturer that is not meeting quality standards and putting patients at risk.” This follow-up memo stated that the FDA will continue to allow DTE products to remain on the market beyond August 2026, while manufacturers pursue full approval of their DTE products as biologics.


We thank Dr. Makary and the FDA for their leadership in protecting access to DTEs for the 1.5 million Americans who depend on this vital medication to treat hypothyroidism. Acella Pharmaceuticals has been collaborating with the FDA since 2018 to pursue formal approval of a new DTE product. They remain committed to delivering a quality treatment that meets all current good manufacturing practices and FDA requirements.

CVS Caremark Announcement

However, starting April 1, 2026, CVS Caremark, a pharmacy benefit manager (PBM) that manages the prescription benefits for many health plans (including some Aetna plans), notified its members that they are removing DTE medications from its standard list of covered drugs. They did not give a reason for this decision, but Dr. Friedman suspects that CVS Caremark is pushing patients toward synthetic thyroid medicines instead of DTE products. This is not the first instance of CVS Caremark putting profits over patient care, as in 2019, they claimed that all doses of NP thyroid were on backorder, even though they were not.

Dr. Friedman encourages his patients to make their voices heard. If you are upset or concerned about losing coverage for NDT, you can tell CVS Caremark directly:

o Phone: 1-888-217-4161
o Email: customerservice@caremark.com

Alternatives for DTE

Fortunately, there are alternatives for DTE that may even be lower cost than insurance coverage. Dr. Friedman recommends you explore these options before suggesting Dr. Friedman change your thyroid medication, especially if you are doing well. Dr. Friedman recommends patients taking DTE and other T3-containing preparations twice a day.

Acella Pharmaceuticals offers a program called Vytal, with reasonable cash pricing. The following doses of NP thyroid are available at $69 for a 90-day supply including free shipping: 15 mg, 30 mg, 60 mg, 90 mg, 120 mg, 45 mg (15 mg + 30 mg), 75 mg (15 mg + 60 mg). Dr. Friedman frequently prescribes the 45 mg dose, so this is an excellent option.

The following are other options for obtaining NP thyroid:

Glendale Pharmacy
There are also coupons at GoodRx, WellRx or Optum PerksFor more information In case you missed it, Dr. Friedman’s webinar with Dr. Henderson entitled Dueling Academic-Based Endocrinologists discussing state of the art hypothyroidism diagnosis and treatment, September 14, 2025 is available at https://www.youtube.com/watch?v=hNx3ekkc0-Q or https://www.goodhormonehealth.com/webinars/ or https://www.facebook.com/goodhormonehealth
This webinar discussed the advantages of DTE and Drs. Friedman and Henderson’s view on why the FDA should not ban these products
Please contact our office at mail@goodhormonehealth.com or go to our website, www.goodhormonehealth.com for more information or to schedule an appointment.

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The Vegetable Revolution Diet

February 10, 2026TfriedmanPosts
The Vegetable Revolution Diet

Dr. Friedman has been running the Obesity Clinic at MLK Ambulatory Care Clinic in Los Angeles and has come up with a simplified strategy for weight loss for everyone who is serious about losing weight.  This approach is to have a simplified food guide that everyone can follow that stresses eating healthy foods, especially vegetables, to fill you up and avoiding foods that have high caloric load.  The hallmark of this diet is the three servings of vegetables (a serving is 8 ounces, or a handful) with each meal- breakfast, lunch, and dinner.  Yes, breakfast! The philosophy is the vegetables are low in calories and provide you excellent sources of minerals and vitamins, give you fiber and fill you up and you will not need to each much higher calorie foods.   

In the past, people have shied away from vegetables due to the fact they required a lot of preparation or went bad readily. Now vegetables are often pre-cut and washed and come in a large variety of preparations and readily available in stores like Whole Foods and Trader Joe’s. Frozen vegetables are excellent and convenient and even canned vegetables are good.  Vegetables can be stir-fried with vegetable spray (“PAM”), canola spray or olive spray or soy sauce (as long as you are not on a low salt diet). Vegetables can also be flavored with spices, soy sauces, or tomato or marinara sauce. Vegetables can be made into soups, as well. 

The vegetables Dr. Friedman recommends include:

#Alfalfa/ Bean Sprouts*Okra
*Asparagus+Onions (especially Vidalia onions)
ArtichokesParsnips
*Artichoke hearts#*+Peppers
+Beets#Pickles
+Bok choy#*+Peas
*#BroccoliPumpkin
*Brussels sproutsSalads (careful about the dressings and additions)
#CabbageSauerkraut
#+Carrots+Snap peas
*Cauliflower#+Snow peas
#+CelerySquash-butternut/winter/spaghetti
Collard or mustard greens#Spinach
#Cucumbers+Stir-fry vegetables
Eggplant+#Tomatoes
*Green beansTurnips
JicamaV8-or other vegetable juices
LeeksWater chestnuts
#Lettuce*Zucchini
+#Mushrooms

*Frozen-perfect for micro-waving
#Fresh-can be eaten raw
+Cut-up (at stores like Trader Joes) and perfect for stir-frying or microwaving

The only vegetables not recommend are potatoes and corn. Sweet potatoes and yams can be eaten in moderation.

For strict weight loss, Dr. Friedman advises against eating anything with sugar and also to be on a no-starch diet. Sugar includes honey, sucrose, fructose, molasses or high fructose corn syrup. Ingredients with sugar include sodas (except diet soda), cookies, candy, ice cream and cakes. He also recommends looking at the ingredients of sauces and dressings. If it has sugar or fructose in the first four ingredients, avoid it.

Additionally, Dr. Friedman recommends avoiding starches. For most patients, this needs to be strict to ensure proper weight loss. Starches include all bread, tortillas, pasta, rice, potatoes, and corn. Dr. Friedman does not feel there is much difference between whole grains such as brown rice and regular starches such as white rice, nor is there any difference between whole grain bread and white bread. After initial weight loss for about two months, patients could go on to a moderate amount of whole grains such as whole wheat bread or brown rice.

In addition, after the patient eats their three servings of vegetables with each meal, they can consume a moderate amount of protein, fruit, or dairy products, including milk. The dairy product should be as low in fat as possible. Skim milk would be recommended over whole milk, nonfat yogurt over regular yogurt, etc. Dr. Friedman also advises against fried foods and consumption of alcohol beverage except in small amounts.

With this lifestyle modification (its not really a diet as it should be continued for a lifetime), weight loss of one pound a week is expected. Most people report more energy and less brain fog on this diet. Give it a try!

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Study Challenges Standard Testing for Hypothyroid Patients 

February 4, 2026TfriedmanPosts
Study Challenges Standard Testing for Hypothyroid Patients 

A new study published in PLOS One co-authored by Theodore C. Friedman, MD, Chair of the Department of Internal Medicine at Charles R. Drew University of Medicine and Science (CDU), is bringing fresh attention to a long-overlooked lab test that may help explain why some patients with hypothyroidism continue to feel tired—despite being on standard thyroid medication.

The peer-reviewed study looked at nearly 1,000 patients treated from his private practice at GoodHormoneHeath.com for low thyroid function over an 11-year period. Dr. Friedman focused on a hormone called reverse T₃ (rT₃), which isn’t typically checked in routine care but may play an important role in lingering symptoms in hypothyroid patients like fatigue.

Dr. Friedman and his team found that patients taking the standard medication, levothyroxine (known as L-T₄), were more likely to have high levels of reverse T₃. By contrast, patients on other therapies that included T₃—such as desiccated thyroid extract (DTE) or L T₄ plus liothyronine (L-T₃)—had much lower levels. The findings suggest that standard treatment may not work equally well for everyone.

“I was inspired to figure out why my patients with underactive thyroids aren’t doing well, even though they’re on what’s considered optimal thyroid hormone replacement,” said Dr. Friedman. “I wanted to look at this older test and see if it can explain why these patients have fatigue.”

Reverse T₃ is often viewed as outdated and rarely tested in conventional medicine, but Dr. Friedman believes it’s worth reconsidering. “There are articles that came out saying we shouldn’t be measuring this,” he said. “But the test is important, especially in patients who aren’t doing well on optimal replacement.”

One of the study’s more surprising discoveries was just how common elevated rT₃ levels were in patients on L-T₄-only therapy. “Most of the high reverse T₃ was seen in those patients,” Dr. Friedman said. “People not on any thyroid medicine usually had pretty good levels.”

The study doesn’t claim that high reverse T₃ is the direct cause of fatigue, but it opens the door to more personalized treatment strategies. Dr. Friedman plans to follow up with a study that tracks patient symptoms alongside rT₃ levels to better understand whether changing medications guided by rT₃ levels can improve quality of life.

Dr. Friedman combines research and patient care so his patients with hormone problems can feel better. For more information or to schedule an appointment, please go to goodhormonehealth.com.

The full study, “Reverse T3 in patients with hypothyroidism on different thyroid hormone replacement,” is available now in PLOS One or on goodhormonehealth.com

PLOS One is a peer-reviewed journal published by the Public Library of Science.

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Osteoporosis: A New approach 

January 23, 2026TfriedmanPosts
Osteoporosis: A New approach 

What is Osteoporosis?

Osteoporosis, or thinning of the bones, is a big industry in the United States, with millions of dollars spent on testing and treatments that are usually expensive and have side effects. Of course, nobody wants to have a bone fracture. Is it needed, or is there a simple solution to help preserve bone health?

First, an explanation of what osteoporosis is. Osteoporosis is defined by a DXA test that looks at the bone density in a bone density machine, in the lumbosacral area (back), the hip area (femoral), and sometimes in the forearm (radius). They give 2 scores. One is the T-score, which is the bone density compared to a young person of the same gender. Osteoporosis is defined as a T-score that is greater than -2.5 standard deviations from that of a young person. No other test in medicine compares people to a young person, so, from Dr. Friedman’s view, this does not make that much sense. The osteoporosis experts say you do not want to decrease bone density, but, in general, bone density does decrease with age.

Probably the more accurate test, which is not used, would be the Z-score, which is the bone density compared to people of the same age and gender. Most elderly patients, especially women, will have at least osteopenia, which is defined as a T-score between -1.0 and -2.5. Many of them will also have osteoporosis, defined as a T-score greater than -2.5, even though the chances of fracture are pretty low.

Bone density is influenced by multiple hormonal factors, including estrogen decline after menopause and thyroid hormone levels, which are often overlooked when osteoporosis is treated in isolation.

The reason why bone density is done is to prevent fractures. Most fractures occur with falls, so it makes more sense to prevent people from falling, in addition to trying to keep their bones strong. Little emphasis is done on working on muscle strength and balance to help prevent people from falling.

Bone density markers

In addition to, or sometimes instead of, a bone density test, Dr. Friedman recommends a urine test called a urinary N-telopeptide (N-Tx) that is done on the second urination of the day. Dr. Friedman has an article on this on his website at
https://www.goodhormonehealth.com/best-tests-to-predict-likelihood-of-a-fracture/.

This test tells what is happening with bone breakdown currently, while the DXA scan looks at bone density over one’s whole life. Therefore, they can be done together, with the urinary N-telopeptide telling what is happening now and the bone density telling what is happening over one’s life.

If high, urinary N-telopeptide shows active breakdown and is bad, while a urinary N-telopeptide at a normal level shows normal bone turnover and is favorable. Dr. Friedman uses this test to determine who should get treatment and who should not get treatment for osteoporosis.

The test is also helpful in patients with hypothyroidism on treatment and having a suppressed TSH. A high N-telopeptide might lead Dr. Friedman to lower the thyroid dose, while a normal N-telopeptide might lead Dr. Friedman to keep the same dose.
More information on thyroid conditions can be found here.

Osteoporosis medicines

The current osteoporosis medicines are either older drugs, of which the main one is alendronate, that work modestly well but is hard to take because you have to take it standing for a half hour. Otherwise, you can get esophageal and stomach problems. It is usually given once a week. It is inexpensive, but it can lead to depression, and it also leads to what is called atypical fractures.

Atypical fractures, as opposed to regular fractures, occur without trauma and are usually in the large bone in the thigh called the femur bone. The last thing someone wants is an atypical fracture, where your bone just snaps in half without any fall. The risk of these atypical fractures is relatively high, although less than the amount of the typical fractures prevented by the medicine but is still a serious side effect. Alendronate may need to be held for dental procedures. This should be discussed with your oral surgeon.

The new medicines are extremely expensive and may or may not be covered by insurance and also have side effects. One is called Prolia, which is a shot given in a doctor’s office twice a year. This drug is also associated with atypical fractures and is quite expensive. Another drug is called Forteo, which is a daily shot and does build up bone, but it also has a fair amount of side effects.

Another drug that Dr. Friedman sometimes uses, with very little side effects but only modest effects on the bone, is called raloxifene. It is a selective estrogen-receptor modulator (SERM) and has the beneficial effects of estrogen on the bone, but not the detrimental effects. This medicine is well tolerated and not too expensive.
Estrogen decline during menopause plays a significant role in bone loss.

Calcium and Vitamin D

Recent studies have suggested that calcium pills, which used to be given to strengthen bones, are actually detrimental overall and lead to a higher rate of heart disease. The detrimental effects of calcium supplementation on the heart outweigh the beneficial effects on the bones, and Dr. Friedman does not recommend calcium supplementation.

Vitamin D supplementation does seem to help prevent fractures to a small degree and is probably beneficial. Dr. Friedman recommends taking vitamin D so that the 25-hydroxyvitamin D level is between 30 and 50.

Low Sodium and Falls

Chronic hyponatremia (low sodium) with a serum NA < 135 mmol/L is associated with increased falling leading to fractures and should be corrected. All patients with known or suspected osteoporosis should have electrolytes measured at least annually.

Correcting the low sodium is likely to prevent falls and fractures to a greater extent than expensive osteoporosis medicines. Low dose furosemide (Lasix) is a good option to raise sodium if it is between 130 and 135 mmol/L. Other options are available for a sodium < 130 mmol/L.

So what does Dr. Friedman recommend to prevent and treat osteoporosis?

Two common sense things. One is exercise, and one is eating a healthy, plant-based diet. Exercise has been shown to increase bone density and helps with muscle strength, which helps prevent falls, which, as Dr. Friedman says, is the major reason why people break bones.

Dr. Friedman recommends a combination of aerobic and weightbearing exercises to increase bones. The exercises can include just walking or more strenuous exercises, depending on the health of the individual. The more exercise, the better.

Exercise is especially important in patients experiencing muscle loss from aging or from weight loss medications such as GLP-1 receptor agonists.

The second treatment Dr. Friedman recommends is getting your calcium from plant sources. Studies have shown that dairy products actually increase fracture rates and are not recommended. However, plant-based calcium is better absorbed than dairy-based calcium.

Broccoli, kale, and spinach do contain a lot of calcium and are better sources for calcium intake. Other high-calcium plant-based foods include tofu, fortified nut milks, beans, tahini, sweet potatoes, watercress, okra, chia seeds, and almonds. This approach aligns with a broader lifestyle medicine focus.

There are some supplements Dr. Friedman recommends for bone health. The most important one is vitamin K2 at a dose of 150 mcg twice a day. This can be purchases on Amazon. It has very little side effects. This is different from vitamin K1, which affects clotting and should not be taken by someone who is on a blood thinner. Vitamin K2 can be taken by people on blood thinners, and it does help improve bone density with very little detrimental effects. Boron is another supplement that can also help prevent osteoporosis and decrease osteoarthritis. Avocados and nuts contain boron. A reasonable dose of boron supplementation is 10 mg twice a day. Strontium citrate at a dose of 750 mg a day is also helpful for bone health.

Overall, Dr. Friedman rarely uses osteoporosis medicines but rather recommends preventing falls by increased exercise and eating a plant-based diet.

Please look at these webinars from Lifestyle Medicine expert, Michael Greger, MD
https://nutritionfacts.org/webinar/preventing-and-treating-osteoporosis/
https://nutritionfacts.org/video/fall-prevention-is-the-most-important-thing-for-preventing-osteoporosis-bone-fractures/

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Patient Guide: 24-Hour Urine Cortisol Collection for Cushing’s Syndrome Diagnosis

March 19, 2025TfriedmanPosts
Patient Guide: 24-Hour Urine Cortisol Collection for Cushing’s Syndrome Diagnosis

A 24-hour urine collection (also known as a urinary free cortisol test or UFC) is an essential diagnostic tool used to measure cortisol levels—especially when evaluating for Cushing’s syndrome or episodic Cushing’s disease. This guide will walk you through why this test matters, how to complete it correctly, and how to understand your results.

What Is Cortisol and Why Test It?

Cortisol is a hormone produced by your adrenal glands, often released in response to stress (also known as the “fight or flight” hormone). In patients with Cushing’s syndrome, the body produces too much cortisol, which can lead to a wide variety of symptoms—from weight gain and insomnia to fatigue and high blood pressure.

Episodic Cushing’s Disease: Why Multiple Tests Matter

Unlike classic cases where cortisol is consistently elevated, episodic (or periodic) Cushing’s disease means cortisol levels spike on some days and appear normal on others. Dr. Theodore Friedman, a leading Cushing’s specialist, emphasizes the importance of multiple UFC tests and salivary cortisol tests to catch these intermittent spikes.

In a 2010 study published in Hormone and Metabolic Research, Dr. Friedman found that 65 out of 66 patients with Cushing’s had at least one normal cortisol test result. This is why multiple collections are often needed, especially during suspected “high cortisol” periods.

How to Collect a 24-Hour Urine Sample (Quest & LabCorp)

Follow these steps carefully to ensure accurate results:

  1. Start at 8:00 AM (or consistent morning time):
    • On Day 1, void your bladder and discard this urine. Do not collect this sample.
  2. Begin collection:
    • Use a lab-provided jug marked for 24-hour urine volume (often containing a preservative like boric acid).
  3. Collect all urine for the next 24 hours:
    • Keep the jug refrigerated between voids.
  4. Final sample:
    • On Day 2 at 8:00 AM, collect your first morning urine and add it to the jug.
  5. Label the jug:
    • Include your full name, date of birth, and start/end times.
  6. Document total urine volume:
    • Write it on the lab requisition and ensure the lab records it too.
  7. Freeze if needed:
    • If unable to drop off the sample within 48 hours, freeze it to preserve cortisol stability.
  8. Drop off at a certified LabCorp or Quest location:
    • Use their websites or call ahead to confirm hours and specimen drop-off policies.

Lab Contact Info:

What About 17-Hydroxysteroids (17-OHS)?

In addition to UFC, Dr. Friedman often orders 24-hour urine 17-hydroxysteroids (17-OHS) to detect cortisol metabolites, which can be elevated in mild or episodic Cushing’s even when UFC levels are normal.

  • Test Code for 17-OHS:
    • Quest: 0070490
    • LabCorp: 806730
  • Normal Range: 4–14 mg/day
  • Dr. Friedman uses the 17-OHS/day result, not the creatinine-adjusted value (17-OHS/Cr).

If the lab tells you this test is unavailable, request that the staff contact their supervisor or customer service—it is still performed and sent to ARUP labs.

How Long for Results?

Results typically take 2 weeks. You can access them through the Quest or LabCorp patient portals. Dr. Friedman recommends collecting all required 24-hour urine and salivary cortisol samples before scheduling your follow-up to ensure a comprehensive review.

Recognizing High vs. Low Cortisol Days

For accurate diagnosis, it’s important to test on both “high” and “low” cortisol days. Here’s how to tell the difference:

Signs of a High Cortisol Phase:

  • Wired at night or trouble sleeping
  • Unexplained weight gain
  • Acne or oily skin
  • Anxiety or irritability
  • Euphoria or bursts of energy
  • Feeling physically better than usual
  • High blood pressure or blood sugar
  • Swelling or water retention (edema)
  • Energy peaks after sunset
  • Rapid speech or racing thoughts

Helpful Tip: If you have diabetes, use a continuous glucose monitor (CGM). If not, consider over-the-counter options like Stelo or Lingo to detect nighttime glucose spikes, which may indicate a cortisol “high.”

Signs of a Low Cortisol Phase:

  • Fatigue or exhaustion
  • Nausea or loss of appetite
  • Depression or mood lows
  • Muscle or joint pain
  • Weight loss

Track how you feel each day you test. Noting symptoms can help identify cortisol patterns and guide future test timing.

Final Thoughts

Diagnosing episodic or mild Cushing’s syndrome can be a long and sometimes frustrating journey, but accurate and consistent urine cortisol testing is critical. Be patient, keep detailed notes, and work closely with your endocrinologist to uncover patterns that lead to a diagnosis.

Need Help?

  • Contact LabCorp or Quest for questions about specimen pickup or test processing.
  • Dr. Friedman’s office is also available to guide you through this process during your evaluation.

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Fludrocortisone for Adrenal Insufficiency Treatment | Good Hormone Health

November 25, 2024TfriedmanPosts
Fludrocortisone for Adrenal Insufficiency Treatment | Good Hormone Health

Understanding Adrenal Hormones

The adrenals make 2 important hormones, cortisol (a glucocorticoid) and aldosterone (a mineralocorticoid). Patients with adrenal insufficiency from an adrenal cause such as an adrenalectomy or Addison’s disease require replacement of both hormones, Although the natural mineralocorticoid is aldosterone, we give fludrocortisone or Florinef as a replacement. Florinef is the brand name and is no longer available. The glucocorticoid and mineralocorticoid axes are 2 different axes and in patients with Addison’s disease or who had an adrenalectomy, both hormones (cortisol and fludrocortisone) need to be replaced. Patients with pituitary cause of low cortisol usually do not mineralocorticoid replacement, although patients with low blood pressure and symptoms such as dizziness on standing and salt craving may benefit from fludrocortisone replacement.

Differences in Glucocorticoid and Mineralocorticoid Replacement

The symptoms of glucocorticoid insufficiency include nauseousness, vomiting, diarrhea, abdominal pain, joint pain, muscle pain, weight loss, and low energy and fatigue. Patients with mineralocorticoid insufficiency have low blood pressure, dizziness on standing, palpitations, salt craving, lightheadedness, low blood pressure, and a high pulse, and they often feel like they have brain fog because they do not get enough blood to the brain. They may do worse after exercising as exercise causes more blood to go to the muscles and less towards their brain. It is important to distinguish when the symptoms are due to not enough cortisol or not enough aldosterone, or both.

Symptoms of Adrenal Insufficiency

Dr. Friedman has been treating patients with adrenal insufficiency for about 40 years, and he notices most patients treated by outside Endocrinologists are over-replaced on glucocorticoids or cortisol and under-replaced on mineralocorticoids or fludrocortisone. A patient on too little fludrocortisone often is often symptomatic, and the typical doctor will often give him more glucocorticoid and they might feel a little bit better, but then they start getting cushingoid symptoms including weight gain and central obesity and increased chance of infection and increased chance of getting diabetes. This is because they should have been getting more fludrocortisone instead of more hydrocortisone.

Measuring Fludrocortisone Effectiveness

There is a very accurate test to determine whether the patient is getting enough fludrocortisone if they have primary adrenal insufficiency, and that test is the plasma renin activity (PRA) test. Dr. Friedman uses LabCorp and Quest which measures plasma renin activity while some labs use a direct renin assay. The laboratory director at LabCorp discussed with Dr. Friedman that the plasma renin activity test is more accurate than the direct renin level. The plasma renin activity should be collected in a chilled blood sample and kept cold and spun immediately. Otherwise, it will be falsely low. Unfortunately many labs don’t do that, but a high PRA does mean the patient is not on enough fludrocortisone.

What Plasma Renin Values Mean

A high plasma renin activity indicates not enough mineralocorticoids, and a low plasma renin activity indicates too much, and therefore the dose of fludrocortisone should be adjusted to normalize the plasma renin activity. This is much more accurate than looking at electrolytes, such as potassium, which are a later change and usually are not that affected by too much or too little fludrocortisone, unless severe. 

Substantial mineralocorticoid excess can lead to low potassium, but usually this does not happen too frequently, and therefore Dr. Friedman recommends the plasma renin activity and not electrolytes to be measured routinely until the Florinef dose is stabilized and the patient’s plasma renin activity is normal. Potassium levels can still be monitored. 

Measuring Plasma Renin Activity by Position

Dr. Friedman has looked at measuring standing or lying down plasma renin activity and feels that the sitting value is accurate and does aim for a value in the middle or upper part of the range. However, if a patient is still having symptoms of mineralocorticoid insufficiency and the value is in the middle of the range, he might increase the dose a little bit. Remember that fludrocortisone is much better tolerated than hydrocortisone. When patients are cutting down on their glucocorticoids, they need more mineralocorticoid requirement, and Dr. Friedman will often add extra Florinef as he is trying to taper a patient down who is on too much glucocorticoids.

Optimizing Fludrocortisone and Hydrocortisone Dosing

It is known that the glucocorticoid, hydrocortisone, has to be given in divided doses because it has a short half-life. Dr. Friedman has also researched that fludrocortisone has a pretty short half-life and also should be given twice a day. Most doctors just give it once a day, although Dr. Friedman experience is that patients do better if the dose is split up to twice a day, with the first dose first thing in the morning and the second dose in the mid-afternoon. Patients will often need more fludrocortisone in the summer when it is hot and they are sweating and less in the winter.

Seeking Expert Care for Adrenal Insufficiency

If you have adrenal insufficiency and want an expert to treat you, please contact Dr. Friedman via his website at goodhormonehealth.com.

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Guide to Weight Loss Drugs & Medications | Good Hormone Health

November 21, 2024TfriedmanPosts
Guide to Weight Loss Drugs & Medications | Good Hormone Health

Dr. Friedman’s initial approach as an Endocrinologist regarding weight loss is to first rule out any endocrine problems, such as hypothyroidism, Cushing’s syndrome, or growth hormone deficiency, that may lead to weight gain. He then encourages the patient to consume a low calorie diet, and he often recommends eating an increasing amount of vegetables, as they are low in calories with a large amount of nutrition, as well as to increase exercise. However, many patients need a jumpstart for the weight loss, and this is where weight loss medicine comes into play. There are 2 new weight loss medicines that have been FDA approved in 2012, although it is unclear whether these medicines have an advantage over existing weight loss medicine. Prior to these two FDA approvals, the only weight loss medicine FDA approved for long-term use is Orlistat which is also available over-the-counter as Alli. The prescription version contains 100 mg of Orlistat and is usually given 3 times a day while the over-the-counter form, Alli, contains 50 mg of the drug and the patient can take 1 to 2 pills before each meal. Orlistat works by decreasing fat absorption so in a patient who is consuming a high-fat diet, that fat will not be absorbed and the patient will not get those calories. The patient will also experience diarrhea when eating a high-fat diet, and this may condition the patient not to eat a high-fat diet. However, most of Dr. Friedman’s patients know about eating a low-fat diet and therefore, this drug is not that helpful for most of the patients.

The second drug that has been around for over 50 years is FDA approved for short-term but not for long-term weight loss. This is Phentermine of which the brand name is Adipex. Phentermine was part of the Fen-Phen combination that was quite popular about 20 years ago. Fenfluramine, the drug that is abbreviated Fen, was pulled from the market in 1997 due to valve and lung problems. However, the Phentermine, which is the Phen drug, has remained in use and is actually a quite-effective weight loss medicine. Phentermine works by decreasing appetite and also may have some effects on increased metabolism and is in the family of amphetamine-like drugs. Therefore, the side effects of Phentermine include feeling hyper or jittery, rapid heart beat, increased blood pressure, and trouble sleeping. The drug works quite well short-term in reducing food intake and can often be given before lunch and dinner. The tablets are 37.5 mg in dose and therefore, Dr. Friedman often gives 1/2 tablet before lunch and dinner. In some patients, this keeps them awake at night and therefore, Dr. Friedman may give them a full pill to take in the morning. However, as the drug is only FDA approved for short-term use, Dr. Friedman usually gives this for a period of 2 to 4 months.

One of the 2 new drugs the FDA approved is called Qsymia, which contains Phentermine plus extended-release Topiramate. The Phentermine in the drug is actually a lower dose than in Phentermine itself and is usually given as either 15 mg or 7.5 mg of Phentermine compared to the 37.5 mg which is available as Phentermine alone. Topamax is a drug that was originally developed as a seizure drug that was found to have weight loss properties; however, this drug has a lot of side effects and is actually nicknamed “Stupamax” as it often makes people have decreased memory. Qsymia came out in 2012 and has only recently been used. It is available, but there is some difficulty getting it and it is about $160/month, with only about 1 out of 5 prescriptions covered by insurance. Dr. Friedman does not see any advantage of this drug over Phentermine itself. Therefore, Dr. Friedman has not started using Qsymia in his patients.

The other new drug is called Belviq, of which the generic name is lorcaserin. This is a serotonin 5HT2C receptor agonist that is similar to the fenfluramine that was removed from the market; however, fenfluramine was a 5HT2B receptor agonist and Belviq is a 5HT2C receptor agonist. Therefore, this is likely to be much more safe than the fenfluramine which was removed from the market. However, as of April 2013, this drug is not yet clinically available in the United States due to issues related it being a controlled substance. This drug does seem quite promising, and Dr. Friedman would be interested in prescribing this drug once it becomes available.

In summary, weight loss medicines can be used to help patients lose weight who have already tried diet and exercise and have already had their endocrine problems treated. The drug that is most successful as a weight loss medicine is Phentermine, although the new medicine, Belviq, looks promising.

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Vitamin D Deficiency and Thyroid Disease

November 19, 2024TfriedmanPosts
Vitamin D Deficiency and Thyroid Disease

Vitamin D Deficiency and Thyroid Diseases

Vitamin D is an important vitamin that not only regulates calcium, but also has many other beneficial actions. Not many endocrinologists realize this, but several articles published over 20 years ago showed that patients with hypothyroidism have low levels of vitamin D. This may lead to some of the bone problems related to hypothyroidism. Two mechanisms may explain the low levels of vitamin D in patients with hypothyroidism, 1) the low levels of vitamin D may be due to poor absorption of vitamin D from the intestine or 2) the body may not activate vitamin D properly. Other articles have demonstrated that patients with Graves disease also have low levels of Vitamin D. Importantly, both vitamin D and thyroid hormone bind to similar receptors called steroid hormone receptors. A different gene in the Vitamin D receptor was shown to predispose people to autoimmune thyroid disease including Graves’ disease and Hashimoto’s thyroiditis. For these reasons, it is important for patients with thyroid problems to understand how the vitamin D system works.

Sources of Vitamin D

Vitamin D is really two different compounds, ergocalciferol (vitamin D2), found mainly in plants and cholecalciferol (vitamin D3), found mainly in animals. Both of these hormones are collectively referred to as vitamin D, and they can either be obtained in two ways. One is by exposure of the skin to the ultraviolet (UV) rays of sunlight or from dietary intake. Vitamin D is found naturally in fish (such as salmon and sardines) and fish oils, eggs and cod liver oil. However, most Vitamin D is obtained from foods fortified with Vitamin D, especially milk and orange juice. Interestingly, as breast feeding has become more popular, the incidence of Vitamin D deficiency has increased as less fortified milk is consumed. Vitamin D deficiency may also occur in patients with malabsorption from their intestine, such as in the autoimmune disease called Celiac Disease, which occurs frequently in patients with thyroid conditions. Multivitamins also contain Vitamin D, as does some calcium supplements like Oscal-D and Citracal plus D.

Different Forms of Vitamin D and How To Diagnose Vitamin D Deficiency

Vitamin D itself is inactive and needs to get converted to the liver to 25-hydroxy vitamin D (25-OH vitamin D) and then in the kidney to 1,25-hydroxy vitamin D. It is only the 1,25- OH vitamin D which is biologically active. This form of vitamin D acts to allow for absorption of calcium from the intestinal tract. Therefore, patients with low vitamin D levels will have low calcium and in severe cases get rickets (in children) or osteomalacia (in adults) which is when the bone bows out and is poorly formed. In mild cases of vitamin D deficiency, osteoporosis can occur, but low calcium is rare.

The conversion from the 25-OH vitamin D to the 1, 25-OH vitamin D that occurs in the kidney is catalyzed by parathyroid hormone, also called PTH. Therefore, patients with very low vitamin D levels will have relatively high PTH levels often with low calcium levels. This is similar to patients with primary hypothyroidism having elevated TSH levels while having normal thyroid hormone levels. Additionally, the 25-OH vitamin D form which is the storage form and is much more abundant that the 1,25-OH vitamin D form which, although is active, is less abundant. Therefore, in states of vitamin D deficiency, low levels of 25-OH vitamin D are found, but the 1,25-OH vitamin D levels are either normal or actually slightly high. They are slightly high because the excess PTH that is stimulated by the low 25-OH vitamin D levels stimulates the conversion up to 25-OH vitamin D to the 1,25-OH vitamin D. Thus, patients that are vitamin D deficient usually have a low 25-OH vitamin D level, a high PTH level, a low normal calcium, and a normal or an elevated 1,25-OH vitamin D level. However, some patients may actually have a high normal calcium as the elevated PTH, and 1,25-OH vitamin D may cause increased calcium absorption from the GI track and reabsorption from the kidney. If 25-OH vitamin D levels were not measured, these patients might have been incorrectly diagnosed with mild hyperparathyroidism as they have a high normal calcium and a high PTH.

Dr. Friedman usually recommends measuring a 25-OH vitamin D to determine if a patient does have vitamin D deficiency. Occasionally, PTH and calcium, can also be ordered. The 25-OH vitamin D assay has a normal range of approximately 20-60 ng/mL. However, this range may be too low for many patients. In general, Dr. Friedman would recommend treatment of patients that have a 25-OH vitamin D of less than 30 ng/mL. Optimal levels of 25-OH Vitamin D for patients with thyroid diseases are probably 35-60 ng/mL.

Treatment of Vitamin D Deficiency

There are several ways to correct for the depletion of vitamin D, and these would involve either increasing sunlight exposure or increasing dietary intake. In general, Dr. Friedman feels there is an ongoing battle between endocrinologists and dermatologists about sunlight exposure, as mild sunlight exposure probably does not have that much of an increased risk of skin cancer yet would be helpful to prevent vitamin D deficiency. Dr. Friedman encourages his patient to be outside and get sunlight, but sunscreen can be use if needed. Because of our busy schedule, many of us do not go outside during the day much and our sunlight exposure is minimal. When we do go outside, we are usually covered up with clothes. Blacks and other dark-skinned patients absorb less Vitamin D and need more sunlight exposure. Dr. Friedman recommends a patient to be exposed to the sun for 15-30 minutes a day, especially in the morning, to correct for vitamin D deficiency. However, in northern latitudes, little light of the proper wavelength goes through the atmosphere in the winter, so this exposure needs to occur in the spring and summer at which time stores of vitamin D are built up. The body has mechanisms so that too much vitamin D can not be synthesized by prolonged sun exposure.

Replacing Vitamin D

When it comes to replacing Vitamin D, again we have to understand the difference between D2 (ergocalciferol, available by prescription) and D3 (cholecalciferol, available over-the-counter). Even though both forms of vitamin D are fat soluble, studies have shown that if you take D2, your levels rise, but then fall back to almost baseline in a few weeks. In contrast, after D3, the levels stay high for a longer period of time. Therefore Dr. Friedman only recommends D3 which can be purchased online at various doses. Multivitamins and preparations like Oscal D contain D3, however the amount in these preparations are small. For example, each multivitamin contains 400 international units of vitamin D3 so a total of 800 international units of vitamin D will probably not raise 25-OHD levels.

There are several options for vitamin D3 replacement. 5000 iU a day is a convenient option as its hard to get over or undertreated on that dose. For lower levels of 25-OHD the 50,000 iU dose can be taken once or twice a week, although occasionally patients need higher doses. Bio-tech has several excellent products including 50,000 iU o D3 is sold in bottles of 12 or 100 by bio-tech-pharm.com. Order at shop.biotechpharmacal.com. However, most brands are excellent.

Side Effect and Optimal Levels

The main side effect of vitamin D therapy is overtreatment leading to hypercalcemia. Because of this concern, Dr. Friedman usually recommends keeping the 25-OHD level less than 60 ng/mL.  Patients with kidney problems cannot convert vitamin D to the active 1,25-OH vitamin D levels and need to take calcitriol which is 1,25-OH vitamin D. Additionally, patients with hypoparathyroidism are usually placed on the calcitriol as well.

Conclusion

Vitamin D appears to have many effects besides being related to calcium and bone health, although many studies were done with correlations and did not show clear beneficial effect of vitamin D replacement. Nevertheless, Dr. Friedman recommends keeping 25-OH vitamin D between 35 and 60 ng/mL. Some patients with low vitamin D levels have fatigue and bone pain, which is easily reversible with proper replacement of vitamin D. Vitamin D may protect against heart disease and some types of cancer. Vitamin D may also have some role in regulating the immune system and may have mild effects in reducing blood sugar levels in patients with diabetes, although Dr. Friedman published a study in Diabetes Care that this vitamin D had no effect in patients with prediabetes. Proper vitamin D levels can prevent osteoporosis. In conclusion, proper vitamin D levels are essential for one’s health, especially if you have thyroid problems. Unless a patient is exposed to sunlight or foods containing vitamin D, screening for Vitamin D deficiency is recommended for all thyroid patients.

This article is not intended to offer medical advice and is offered for information purposes only. Do not act or rely upon information from this article without seeking professional medical advice. For more information about Dr. Friedman or to schedule an appointment, please go to goodhormonehealth.com.

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Hypothyroidism Diagnosis

November 15, 2024TfriedmanPosts
Hypothyroidism Diagnosis

Introduction to Hypothyroidism

Hypothyroidism is a relatively common disorder. It affects more women then men, but I happen to be one of the men who does have it. Symptoms of hypothyroidism include fatigue, gradual weight gain, constipation, muscle aches, joint pain, feeling cold, menstrual irregularities, weakness, hair loss, dry, cold skin and slow reaction time. Many patients will have a goiter (enlarged thyroid). Although it has received much discussion, I believe low body temperature is not a reliable sign of hypothyroidism.

Causes of Hypothyroidism

The incidence of hypothyroidism increases with increasing age. In other words, the older we get, the more likely a thyroid deficiency will show up. The most common cause of primary hypothyroidism (hypothyroidism originating in the thyroid gland itself), is Hashimoto’s Thyroiditis. Hashimoto’s is an autoimmune condition. The body’s own antibodies attack the thyroid gland and destroy it, leading to hypothyroidism. Hashimoto’s Thyroiditis may be a manifestation of multiple autoimmune syndromes and may occur in families. Hypothyroidism can also be due to a pituitary problem (central hypothyroidism).

The Importance of Diagnosis

Diagnosing all types of hypothyroidism is important, because treatment with thyroid hormone will improve symptoms in patients with hypothyroidism, but is unlikely to help those who do not have hypothyroidism. In primary hypothyroidism, the thyroid gland, located in the neck, is less able to produce the thyroid hormones, T4 and T3. The pituitary gland, located in the head, responds to this deficiency by secreting more TSH. Thus, in more mild cases of primary hypothyroidism, T4 and T3 levels are normal, but the TSH is high. In more severe cases, T4 and T3 levels drop. Although the normal range for TSH is often between 0.5 and 5 mU/mL, values at the high end of the normal range may be abnormal. T3 is the more bioactive hormone compared to T4, but T4 is more stable in the circulation.

My approach to diagnosing hypothyroidism is to start with a careful history and physical. Then an Endocrinologist should perform a hands-on thyroid examination to determine if the patient has a goiter. Blood TSH, free T4, free T3 and anti-TPO antibodies should be tested. Patients with an enlarged thyroid and/or a positive anti-TPO antibody test AND a TSH> 4.0 mU/mL should be considered to have primary hypothyroidism. Patients without an enlarged thyroid and without a positive anti-TPO antibody test but WITH a TSH> 7.5 mU/mL should also be considered to have primary hypothyroidism. Patients with a free T4 of < 0.9 ng/dL and a TSH< 1.0 mU/mL are likely to have central hypothyroidism. Patients with symptoms of hypothyroidism but who do not meet these criterion should be watched and retested in 6 months.

Hypothyroidism Treatment

Once hypothyroidism is diagnosed, there are many treatment options, including synthetic Lthyroxine (T4) preparations (Synthroid, Levoxyl and Unithroid), synthetic L-triiodothyronine (T3) preparations (Cytomel), synthetic T4/T3 combinations (Thyrolar) and dessicated thyroid preparations (Armour, Naturethroid, Bio-Throid, and Westhroid). All of the L-thyroxine preparations contain the same active ingredient, but contain different fillers and have different quality control. Until recently, Synthroid did not have FDA approval, but now all L-thyroxine preparations have FDA approval. Thyrolar and the dessicated thyroid preparations probably have a higher T3/T4 ratio than desirable and thus, I often give a lower amounts of these preparations supplemented with T4.

Most Endocrinologists use L-thyroxine preparations for the initial treatment of all forms of hypothyroidism. Although the use of L-thyroxine (T4) compared to L-triiodothyronine (T3) may be surprising as T3 is the more bioactive thyroid hormone, T4 is most frequently used. This is because tissues convert T4 to T3 to maintain physiologic levels of the T3. Thus, administration of T4 results in bioavailable T3 and T4. As T4 is more stable than T3, T4 therapy gives even blood levels, while T3 therapy leads to high levels after taking the medicine and low levels before the next dose. Armour thyroid is the least expensive preparation. Because Armour thyroid comes form pig thyroids, some Endocrinologists feel that there is high pill to pill variability, but this is unlikely to be true.

Personalized Treatment Considerations

A recent study published in New England Journal of Medicine in 1999 suggested that brain T4 to T3 conversion may be impaired in some patients and that a select group of patients should be treated with both T4 and T3. Other studies published in Journal of Clinical Endocrinology and Metabolism in 2003 suggested that addition of T3 to T4 treatment is not needed for most patients with primary hypothyroidism. I recommend that most patients be started on a T4 preparation, which improves symptoms in the large majority of the patients. I have found that most patients prefer Levoxyl or Unithroid to Synthroid, but this varies with each patient. After initial treatment with T4, I adjust their T4 dose until their TSH is between 0.5 and 2 mU/mL. If they remain symptomatic despite an optimized TSH, then low doses of T3 given two or three times a day can be added cautiously to T4. If patients start with a low blood free T3 level, then I am more inclined to treat them with T4 plus T3. On T4 plus T3 therapy, I use blood tests to make sure the free T4 and free T3 are in the upper-normal range. The TSH value is usually suppressed on combination treatment.

A percentage of patients will have symptomatic improvement on T4 plus T3 therapy. For those that do not improve, I occasionally recommend treatment with dessicated thyroid preparations, usually Armour, plus synthetic T4. This combination is needed as dessicated thyroid preparations have a higher T3/T4 ratio than desirable and need to be supplemented with synthetic T4 to achieve normal ranges of both hormones. Again, I aim for a free T4 and free T3 in the upper-normal range.

A Personal Case Study

Patients with central hypothyroidism can be treated with any of the preparations available for patients with primary hypothyroidism. The difference is that treatment needs to be monitored by aiming for a free T4 and free T3 in the upper-normal range, as TSH is suppressed with proper treatment. Patients with both central and primary hypothyroidism also needed to be treated by aiming for a free T4 and free T3 in the upper-normal range.

I was diagnosed with primary hypothyroidism in February 2003. An Endocrinologist performed an examination of my thyroid gland and I was found to have a goiter. My blood values showed a TSH of 8 mU/mL and strongly positive anti-TPO antibodies. I have a strong family history of Hashimoto’s Thyroiditis but I was lucky to be fairly asymptomatic prior to treatment. I am now on 150 mg a day of Levoxyl, have a TSH of 1.9 mU/mL and feel great. I have lost a few pounds on T4 therapy and my cholesterol profile has improved.

Contact Dr. Friedman for a Consultation

For more information about Dr. Friedman’s Endocrinology clinic, visit his website at www.goodhormonehealth.com. To schedule an appointment with Dr. Friedman, please email Kimberly at appointments@goodhormonehealth.com.

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