Optimizing Thyroid Hormone Replacement
Optimizing Thyroid Hormone Replacement
Dr. Friedman optimizes thyroid hormone replacement in all his patients. He bases this on 4 factors: patient’s history with thyroid medicines, symptoms, the patient’s thyroid function tests, and side effect profile.
Choosing the Right Thyroid Medication
The first issue is what thyroid medicine is the patient on? Dr. Friedman gives various combinations of thyroid hormone replacement to patients depending on their circumstances and conditions. In some patients who have never been on thyroid hormone replacement, he may start with T4 replacement that could be Synthroid, Levoxyl, generic levothyroxine, or a relatively new product called Tirosint, which is a liquid form of thyroid hormone in a gel that has no additives, preservatives, or dyes. If the patient is on T4 treatment who is doing well and wants to stay on it, Dr. Friedman primarily looks at the TSH and aims for a TSH between 0.5 and 2.0. He will also look at the reverse T3 and make sure it is not above range. Within this range, Dr. Friedman may adjust the thyroid hormone dose slightly based on the patient’s symptoms. If the patient is having some hypothyroid symptoms, he might increase it so the TSH is near the bottom of the range and if the patient is having some hyperthyroid symptoms, Dr. Friedman may decrease the thyroid hormone, so the TSH is near the top of this range between 0.5 and 2.0. At times, Dr. Friedman fine tunes the thyroid dosage by having the patient take one dose 5 days a week and another dose on weekends. For example, he may have a patient take 100 mcg of Levoxyl on weekdays and 112 mcg on weekends.
Combination Therapy with Desiccated Thyroid Extract (DTE) or T3/T4
Dr. Friedman is one of the few Endocrinologists with expertise in using Desiccated Thyroid Extract (DTE). Brand of Desiccated Thyroid Extract (DTE) includes Armour, NP thyroid and Adthyza. He uses DTE in many patients that are on L-T4 replacement and still having hypothyroid symptoms. Although T4 is long-lasting and many patients do fine on T4, including his low-income patients in Los Angeles County, there are many patients who do not convert T4 to T3 properly or have a high reverse T3 (rT3) and for this reason, Dr. Friedman uses DTE that contains T3. DTE has T4 and T3 in it in a fairly good mixture and also contains other thyroid factors that may be beneficial. Because the T4 and T3 in DTE is mixed in with other proteins, DTE’s half-life is a little longer than if the patient is just taking T3 which would have a very short half-life. However, DTE needs to be given twice a day because of the T3 in it that has a short half-life. Dr. Friedman sometimes adds T3 to DTE to raise the freeT3 into the upper normal range or to lower the rT3. He sometimes adds T4 to DTE if the freeT3 is low and if the rT3 is not too high. Dr. Friedman has found that Armour has slightly less T4 in it per mg of DTE compared to Adthyza or NP thyroid. If Dr. Friedman gives T3 plus T4, he gives the T4 once a day and the T3 dose two or three times a day, or he gives slow-release T3 compounded for daily use.
Monitoring TSH Levels with Combination Therapy
If a patient is on an DTE or T4/T3 combination, Dr. Friedman will often see a low TSH. Dr. Friedman is comfortable with the TSH being below the normal range, as long as the free T4 and free T3 are in the mid-to-upper normal range and not above the range. The suppressed TSH may occur because the T3 in either DTE or T3 quickly suppresses the TSH after its administered and often leads to a lower TSH even though the free T4 and free T3 are normal. It is unlikely the patient will have side effects from having this suppressed TSH, but Dr. Friedman would watch carefully for any heart problems (unlikely in a young or middle-aged person or osteoporosis (thin bones). Dr. Friedman often measures a marker of bone turnover called a urine N-telopeptide and if that is not elevated, he can assure his patient that the suppressed TSH will lead to osteoporosis. If the urine N-telopeptide is elevated, he will often reduce the thyroid hormone dose.
Evaluating Symptom Improvement
Dr. Friedman then evaluates the patient’s symptoms and is looking for an improvement in the patient’s hypothyroid symptoms. Most of the time, the patient sees a fairly rapid improvement in their symptoms if they were truly hypothyroid. Sometimes, the patient needs a little bit longer time or a little adjustment of either the dose or type of thyroid medicine before an improvement is seen. If there is no improvement seen, Dr. Friedman reassess the diagnosis of hypothyroidism and would look for other causes of some of the symptoms that may be overlapping with the symptoms due to hypothyroidism.
Dr. Friedman also carefully monitors patients for side effect. For example, too much thyroid hormone can give palpitations, jittery feeling, wired, trouble sleeping, and other symptoms of hyperthyroidism. If this is the case, Dr. Friedman would back down on the thyroid hormone replacement.
Dr. Friedman is aiming for optimal thyroid health and monitoring a patient on thyroid hormone replacement is crucial. For more information about Dr. Friedman’s practice, please go to www.goodhormonehealth.com.