Part 2—protocols for treating an under active thyroid—despite normal blood tests - Highly Effective Treatments for Pain and Fatigue

Townsend Letter for Doctors and Patients, August-Sept, 2003 by Jacob Teitelbaum

We are constantly learning powerful new tricks for treating hypothyroidism and there are many reasonable treatment approaches. Our treatment protocol information checklist for patients (see below) gives the "nuts and bolts" of some approaches. Non-prescribing practitioners can get prescriptions for lab tests for their patients by having them go to www.vitality101.com (click on "online program," then laboratory requisition form." We do not charge for this. We feel patients are entitled to get whatever non-invasive tests they want). They can then take the lab requisition to their local lab.

Thyroid Hormone

Most non-holistic doctors prescribe T4 (Synthroid) to treat an under active thyroid. T4, though, is fairly inactive until the body converts it into T3, or activated thyroid hormone. If the problem is only with the thyroid gland itself, prescribing Synthroid will work just fine. However, if the body has trouble turning inactive T4 into active T3, taking Synthroid can make the problem worse. Because of this problem, many CAM physicians prefer to use Armour Thyroid, which is a mix of T4 and T3. I find Armour to be far superior to Synthroid.

Why might the body have trouble making active T3 from inactive T47 During periods when the body wants to conserve energy (for example, during times of infection or famine--which is how the body views an overly restricted diet), the body slows down metabolism. It does this by decreasing the production of active T3 from T4, which is turned into inactive "reverse T3" instead. The body may get "stuck" in this mode, and becomes unable to make adequate T3.

I prefer to start with a trial of Armour thyroid. I begin with 1/4 grain (15 milligrams) a day and increase it to 1/2 grain (30 milligrams) a day in one week. Then, I increase it by 1/4 to 1/2 grain each two to six weeks until the patient finds a dose that feels best. If the patient is shaky, hyper, or has a racing heart (for example, a resting pulse over 90 beats per minute), lower the dose. I check a free T4 about one month after the 2, 3-1/2, and 5 grain levels are reached. Do not check a TSH test. It will be low (because of the hypothalamic dysfunction) even if the patient is on inadequate thyroid replacement. Adjust the thyroid slowly to the dose that feels the best to the patient, while making certain to remain within normal range for blood free T4 levels. When on a stable dose, consider checking the thyroid blood levels every 6-12 months. Although many patients can stop taking thyroid Zhormone after twelve to twenty-four months (unless they have Hashimoto's Thyroiditis-check a TPO Antibody to look for this), they can stay on Armour Thyroid or Synthroid for as long as it is needed.

One can also try prescribing Synthroid (T4). One hundred micrograms (0.1 milligrams) of Synthroid ~ 1 1/4 grain (75 mg) of Armour Thyroid. Often, one hormone treatment works when the other does not. Adjust the dose as above.

Another approach, used by the research center of John Lowe, DC in Boulder, is to use the T3 in the short acting form (Cytomel-by prescription) only in the morning. He feels that FMS patients have "thyroid resistance"--that is, it takes a much higher level of thyroid to obtain the normal effect. Even though the body may only make about 25 to 30 micrograms of T3 a day, his studies found it took an average of 125mcg a day to make FMS patients feel healthy. Try giving the full dose of thyroid in the morning or half the dose twice a day to see which feels best (Dr. Lowe generally gives the full dose in the AM). Do not give thyroid hormone within several hours of iron or calcium, or the patient won't absorb the thyroid. This is one reason these 2 nutrients are left out of the vitamin powder. Take thyroid on an empty stomach (for example, first thing in the morning).

Unfortunately, many doctors are (incorrectly) trained to stop increasing the dosage of thyroid hormone once an individual's thyroid tests are in the "normal" range--even if the dose is inadequate for that person. Even the guidelines of the conservative National Association of Clinical Biochemistry-which sets guidelines for performing lab testing--notes "In the future, it is likely that the upper limit of the serum TSH euthyroid reference range will be reduced to 2.5.... A serum TSH result between .5 and 2.0 ... [and] a serum FT4 in the upper third of the reference interval is the therapeutic target for L-T4 replacement therapy when patients have hypothyroidism." (www.nacb.org/lmpg/ thyroid_LMPG_PDF.stm). In addition, the American Association of Clinical Endocrinologists has lowered the upper limit of normal for TSH to 3.0 (www.aace.com/pub/tam2003/press.php)

Potential Side Effects

If someone has blockages in the arteries that feed the heart and is on the verge of a heart attack, taking thyroid hormone can trigger a heart attack or angina, just like exercise could. Thyroid treatment can trigger heart palpitations as well. These are usually benign, but atrial fibrillation is possible. Because of this concern, and because using T3 or treating for hypothyroidism with a normal blood test is still controversial, I often recommend that patients at significant risks of angina--people who smoke, have high blood pressure, are over forty-five years old, have cholesterol levels over 260, and a family history of heart attacks in individuals under sixty-five years old--have an exercise treadmill test done before treatment, even if they can't complete the test.