What Should The Ratio Of T4 to T3 Be In Thyroid Medication?

Recently we were having a discussion about thyroid matters and I was having a hard time understanding the rational for the higher ratios like 20 to 1 or even 50 to 1. Diogenes was kind enough to walk me through the arguments and how the numbers were arrived at. Diogenes is worried about the effects of high T3 and is in favor of the higher ratios and also of using time release medications. I pointed out that I knew of no studies showing damage from the 4.22 to 1 ratio of NDT over its 119 year history and that some studies using the higher ratio showed no preference by patients. I thought this was due to the low amounts of T3 used. Every time I have a discussion with Diogenes I always learn something and he is always challenging me to think and grapple with new concepts.

I just finished a book by an endocrinologist who has been doing exactly what Diogenes proposed and has apparently achieved highly satisfactory results. Dr. Kenneth Blanchard is an endocrinologist with a PhD in Chemistry from Princeton and he is not your usual endo. "In summary, I would state that there has never been a situation in the history of medicine where fundamentally wrong teachings have held sway for so many years and hurt the quality of life of so many patients." He believes that about 20% of patients on T4 monotherapy do quite well and that about 80% would improve their QoL with the addition of a little T3, and I do mean little. He is using T4 at a 98.5 % and T3 or thyroid extract at a 1.5% plus or minus about 0.5% on either side. He is also using time release on the T3 or thyroid extract portion. He has treated about a 1000 patients or more and I believe his results are credible. He is a doctor who looks for results in the patient, not the blood tests.

Mary Shomon did a piece about him back in Oct of 2003 thyroid.about.com/b/2003/10... but I had completely missed his earlier book and the work he has been doing. It is next to impossible to read everything in a given field although Rod does a better job of keeping up with the journal articles than anyone else I have ever come across.

Now he did make a comment, "I don't think that anyone is well served by using T3 only" that Dr. Lowe reacted very strongly to. thyroidscience.com/Criticis... But I don't think that detracts from what Dr. Blanchard has accomplished. One thing that is interesting to note is that he adjusts for seasonal variation in many of his patients. This is not uncommon in thyroid patients but seems more prevalent in Dr. Blanchard's patients. For those that enjoy exploring the many facets of the thyroid world I strongly suggest reading his small (111 pages) book. He has quite a few interesting ideas expressed in it. It is available on Amazon UK. Dr. Kenneth R. Blanchard "The Functional Approach To Hypothyroidism"

ISBN 978-1-57826-387-5


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28 Replies

  • Very interesting.

    People might pick up a slightly cheaper copy on ABE Books than on Amazon.


    It is entirely possible, in my view, that a small number of patients need T3 only - despite the majority, perhaps, needing combinations of some sort. So both of them could be right in their own ways! :-)

    Sorry - I have just bought the cheapest available copy... :-)


  • Rod, I'll be interested to hear your thoughts about his work when you finish reading the book. PR

  • The best place to look is addall.com, it searches all the databases of all the major on-line bookstores. 20 copies for sale at present. Just click on 'Used Books', less is more when using search terms, title only on the first try, then if that doesn't bring a result, add author's surname, etc etc. Just the title will bring the results for Dr Blanchard's book.

  • And still ABE works out least expensive! :-)

    But it could well be otherwise.

  • Haha. £4.28 on Amazon isn't bad though, don't know what the postage is compared to abe. (Don't forget to buy through ThyroidUK's link people!)

  • I read the previous book - What your Doc may not tell you about Hypothyroidism - way back when I was diagnosed in 2005. Someone else now has the book ! I did mention it a few times in posts here but did not receive any feedback/comments....mostly in connection with ratios of T4/T3. Guess I lost confidence as it was not mentioned by others either. Maybe time to read again :-) I am T3 only and feeling OK - having felt unwell on T4/T3 combination.

    Thank you for posting....

  • Marz, I missed the first book so I just ordered it yesterday. I'm curious to see if it adds any more detail than the one I read. There is no question that for some people T3 is the answer that works. Unfortunately it will probably be years before we can get science to study why people can react so differently to the various thyroid medications. I am interested because it appears to be another successful option for thyroid patients. I'm all in favor of options that actually work. PR

  • Do his patients recover their health with this additional low dose T3 and are they happy? Has it removed all of their clinical symptoms?

  • shaws, as far as I can tell it is a successful treatment modality. I did find some patient comments on the web and they were very positive. There is no one size fits all, as we all know, but there are apparently more options than just the standard ones we have known about. PR

  • Thanks and anything that improves people's health is another step forward.

  • It's great to bring forward fresh new ways of looking at thyroid treatment but it's arrogant and untrue to barge in saying T3 monotherapy is a temporary fix which will lead to eventual decline. Another blinkered one size fits all approach to my mind, and Dr. Lowe's, judging by his passionate rebuttal :-D

    Dr. Lowe's wash it all down in one dose suited me. I only split dose my T3 as my endo thought it would be better and Diogenes view that small periodic overdoses may be less damaging than one large one.

    I incline to 3:1 ratio for reasons outlined in ncbi.nlm.nih.gov/pubmed/204...

  • Clutter, as I said I don't think his remark on T3 should negate the positive work that he has done. I am always amazed at the variety of treatment options that seem to work for various people. T4 only, T3 only, T4 + T3 in various ratios, NDT only, NDT with a T3 kicker, NDT with a T4 kicker and raw glandulars sometimes. I'm in favor of having as many workable options as possible since we seem to have almost an infinite variety of variations in the human biochemistry. He has some very insightful comments in his book that are worth thinking about. It always comes back to rule number two: There is no one size fits all, each of us has to find what works in our own body. PR

  • I don't doubt his insight and wish him every success because his methodology is successful and will undoubtedly help thousands more. It just disappoints me that the new boy feels he has to slag off the old guard to promote his views. It totally ignores rule number two.

    I wonder how such small doses will be contrived? I'm imagining hosts of people desperately trying to shave wafer thin slices off teensy 5mg T3 :-D

  • Clutter, he uses a compounding pharmacy to make up the time release T3 or thyroid extract. I'm afraid he is not so new, he is thinking about retirement except he can't find an endocrinologist who will take over his practice. His first book was published in 2004. I completely missed his early book and his work. And you are right, his statement does ignore rule #2 but that seems to be something primarily known by thyroid patients. PR

  • I did wonder about compounding pharmacies, that would be a problem here in UK as they're not very common.

    You're taking me very literally, I should have said new/er ideas instead of new boy :) I hope he finds someone worthy to hand over to when he retires. Good thyroidologists are as rare as hens eggs.

  • ...or teeth even ! :-) :-)

  • My analogies are suffering. I think they need more T3 or brain food :-D

  • :-)

  • I agree I have read a lot of Dr Lowe's work and he was for the higher doses, even saying that he took higher doses himself and felt well. Of course I realize that everyone is different but this man dedicated his life to all of this research, and especially with regard to Fibromyalgia which I am in the process of waiting to see if I have it.

  • marmaris, Dr. Lowe was unquestionably one of our best minds and is sorely missed. It is unfortunate that the doctors that actually treat the patient are so often ignored as to what they find successful when it doesn't agree with the accepted viewpoint. PR

  • I am taking Levo 50 mcgs with 30 mcgs....still hypo.....btw no thyroid at all..removed a year ago followed shortly by my gallbladder...and my ovaries were removed on 2007.....figure that one out....I'm a complete and utter mess...and on one gives a ****......... I'd be better off in the land of whatever.......but who cares ....no one.....my graves antibodies are very high...STILL....I'm almost blind with graves eye disease but still no one gives a *****.... What a wonderful caring world we live in...not!!!

  • Popeye,

    I'm sorry you feel so desperate. Post your recent thyroid tests with lab ref ranges on a new post for advice. Graves antibodies don't go away when they thyroid is removed. They seem to attack other organs, usually the eyes. You need to see an opthalmologist for help with your eyes. Moorfields have a radioactive eye treatment which apparently helps.

  • I understand my blood tests I posted them recently....but thanks for caring...... I have 5 specialists supposedly looking after me...Gastro, Endo, eye specialist , botty specialist( prolapsed bowel), and a specialist trying to sort out my incontience....oh I forgot a shrink too.....memory is also shot.....and I'm afraid it's too late for radiotherapy...and I can't use steroids either cos of my poor liver and kidney function ....hopeless case me....and my GP just thinks I am hypocondricat ....when I collapsed in his waiting room because I rushed down to my last appt..and burst into tears he forgot the fact that I had severe palpitations and very high blood pressure...but that's arrogant quacks all over!!....phew....

  • I should have hit the stupid quack with my white blind stick.....but I held back....why I will never know..... I'm nearly blind my TED is so bad..but does he care...NO....insensitive idiotic male ....needs better training or chucking out of the medical profession altogether.....the caring profession...I don't think so...he even told me off for taking too much sublingual B12!!! Said I was overdosing....tshhh foolish imbecile...

  • Oh and I saw my Endo last week...he told me my Graves' disease was ok now cos it had no thyroid to attack.....tshhh...I gave him what for...too...he's only too look at my TED eyes.....tshhhh...and my guts are a complete mess too...god help me...what a complete shambles the UK health system is in....and of course God help us poor thyroid sufferers all over the world...I speak to lots of support groups it doesn't get any better worldwide....

  • Popeye, I am sorry you have had so many problems, most probably due to inefficient treatment. Re your eyes, ask to be referred to Moorfields Eye Hospital. Some hospitals do have a Moorfields Eye Dept and you would be best to go to them.

  • Popeye

    I don't know if you've read this by Dr Toft re TED. It was in an article by him re questions/answers.

    4 How does thyroid eye disease manifest itself and how is it treated?

    Most patients presenting with the hyperthyroidism of Graves’ disease will have some evidence of thyroid eye disease, ranging from lid retraction with excessive lacrimation in bright light to marked exophthalmos with limited eye movements, diplopia and reduced visual acuity.

    The hyperthyroidism of Graves’ disease and thyroid eye disease are best considered as two separate, organ-specific autoimmune conditions, which frequently coexist. This explains why the eye disease may precede the hyperthyroidism or even occur for the first time years after successful treatment of hyperthyroidism.

    The eye disease has its own natural history – a period of deterioration, followed by one of stability and ultimately of some improvement. But the ophthalmopathy will worsen if thyroid function is not controlled – whether through inadequate or excessive treatment.

    The eye changes often persist for two to three years after successful treatment of the hyperthyroidism and although there may be significant improvement there is often residual disease, which can be improved by orbital decompression, strabismus surgery and eyelid surgery.

    Of all treatments of the hyperthyroidism of Graves’ disease, iodine-131 therapy is associated most often with a worsening of the ophthalmopathy. For that reason it is relatively contraindicated in patients with significant eye disease. For these it may be better to use combination therapy with carbimazole and levothyroxine for the best possible control of thyroid function.

    But if radioiodine is the chosen therapy, enteric-coated prednisolone 30-40mg daily should be prescribed for six weeks, as this has been shown to prevent deterioration of ophthalmopathy.

  • To late for all that but...thanks....

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