American Thyroid Assoc Latest Treatment Guidelines

[PR4NOW]

Haven't gotten thru the whole thing yet but there is some interesting verbiage about the thyroid system incorporating some of the latest science. Dr. Bianco is one of the co-chairs. Hope the link works. PR

online.liebertpub.com/doi/p...

[diogenes Remembering]

I've got it too. What I hope it says is that T4 monotherapy is the "default" treatment: that is, you try it first and if it doesn't work, try something else. You have to have a consistent "default" start -otherwise it's uncontrolled anarchy. and since T4 works for about 75-80% of people then this seems a sensible way to proceed to begin with. But if it is condemning other approaches outright, whatever the outcome, that's wrong. And that is the easy cheap line to take. As ever, the outliers suffer if the condemnation of alternative therapies is absolute.

[PR4NOW in reply to diogenes]

Diogenes, I think this is pretty much the same as the draft copy I read earlier. T4 is the default but if it is the same not much for any alternatives, further study is needed. It is 200+ pages with the citations so that will take a bit to get through. I have now come to think that T4 only works for about 50%, the 48% choice for NDT seems consistent. PR

[diogenes Remembering in reply to PR4NOW]

Well at least we got a paragraph to explain our findings in the guildelines. They didn't quote our newest work; it came out after publication I suppose. But wait till our review emerges + 1 paper to cement it all. Rudolf Hoermann said an interesting thing to me today. Up till the time we got together to sort things out, he thought T3 (FT3) testing was of little use- these recent experiences have taught him otherwise. But the FT3 tests are poor and inconsistent. We desperately need a shakeup in manufacturing to get consistent FT3 tests. Otherwise plenty of excuses for doing nothing.

[PR4NOW in reply to diogenes]

Diogenes, I will be looking forward to your review and additional paper. I find it curious that the guidelines present up to date (more or less) science but no changes in the treatment guidelines. Dr. Bianco has two papers saying maybe T3 might be useful in some but T3 doesn't even get experimental standing , like the ETA guidelines.

I think there is an area in the science that is sadly missing and that is 'nuance'. I have never read anything related to how far off a person's own individual reference range do they have to be before signs and symptoms start showing up and/or damage starts to occur. As we have discussed the TFTs don't pick it up until the extremes when it passes the top of the reference range and even then it might not be acted upon.

The second area I think this shows up is in T3/FT3. You could summarize Dr. Bianco's work with 'The biological imperative is to defend T3". We have no real idea how far off a persons normal T3/FT3 production a person has to move before the consequences are harmful.

This is said with the understanding that it probably will vary considerably just like everything else in the human body.

I fear most endocrinologists are like Dr. Hoermann was and don't understand the importance of T3/FT3. Even Dr. Bianco's work doesn't seem to have changed this in the wider picture. I'm afraid I don't have any bright ideas for changing this. PR

PS I read Dr. Thienpont's "Determination of Free Thyroid Hormones" from Oct 2013 and Progress Report from May 2014 but haven't heard anything else about the progress. Any news on that front?

[diogenes Remembering in reply to PR4NOW]

I'll conduct a little seminar with you as if you were a student. Imagine I'm a 30 year-old woman in good health. Ft4 19 (normal range 10-24). FT3 6.2 (range 4-7.5). TSH 1. Now I start feeling a bit under the weather in later years. I go to the doctor - he/she says I 'm depressed/any other disease and sends me off with drugs. They don't work and eventually I return worse than ever and the doc says OK we'll do thyroid function tests. Suppose the doc is enlightened - you get TSH, FT4 and FT3. Back the results come; FT4 15, FT3 5, TSH 2.2.

Trick question for you: would you treat and why and how.

[PR4NOW in reply to diogenes]

Diogenes, I will only ever be a student, nothing more. Even the choices I make for myself are nothing more than educated guesses, at best. I've spent some time this last year on a forum run by an ND. It has become painfully obvious to me that I have a very limited window on the human condition because I don't have 4+ years of medical training. The ND always gives better responses and sees possibilities that I miss because he does have the training and the clinical experience.

Please keep the seminars coming, I still enjoy learning.

Now lets look at the puzzle you gave me. The first thing that comes to mind is that although the pattern looks like an increase in TSH and a drop in FT4/FT3 the tests are years apart and suffer from all the problems we have discussed. They definitely are not good for 'nuance', only for 'possible' broad clues. Secondly, what drugs has she been on and what effect could they have had on her system. Thirdly, is she entering menopause with a corresponding change is hormone levels. Fourthly, diet and lifestyle, the foundation of health, what are they like. If it is the SAD, Standard American Diet, that could be a large part of her health problems. One of the most common problems seems to be stress and its effects so lifestyle information is important.

So for me not enough information yet. I'd want a full female hormone panel, check the basics, CBC, B12, full iron, folate, Vit D and TPO/Tg AB if not an ultra-sound along with a salivary adrenal stress test. I would also want a full physical and family background and possibly do some tests for gut problems and food allergies. I would want to find the root cause of her imbalance before determining the appropriate treatment. This, of course, would only happen with a 'private' practice in the UK or a cash basis practice in the US and is not always guaranteed then. The standard 7-15 minute appointment would probably end up with more drugs for something as opposed to finding the root cause.

And lastly of course, I would never treat another human being because I am not medically qualified. I would encourage them to take responsibility for their own health and read, read, read so that they can be an informed patient and an active partner in their own health care.

Even among the 'good' doctors there is a variance in their ability to troubleshoot problems, the old bell curve again.

I fear I may have missed the point of what you were trying to teach me. PR

[diogenes Remembering in reply to PR4NOW]

The question is a deliberate trick. The first lot of numbers for the healthy women are flights of fancy. WHY? Because unless you are ill and have heard of the thyroid, then you would be very unlikely to have gone to the doctor asking for tests to be done, and nor would the doctor have done them on a healthy person. I wouldn't think 0.1% of people would ask their doc for thyroid function tests when healthy. It's only when you are ill that you go and get tests done. BUT the doctor has no knowledge of your true setpoints for FT4.FT3 and TSH in health. All he/she knows is your present condition. Thus the doctor's dilemma - you are "a bit seedy" but your thyroid numbers are well in the reference range. With no knowledge of past numbers in health, why should the doc suspect thyroid problems. You are outside your comfort zone, but there's no evidence on the surface to tell. So the answer should be: do nothing now, but arrange followup for tests in the future to see if things worsen. That is all you can do given the evidence.

[PR4NOW in reply to diogenes]

Diogenes, this certainly points up the quandary many people face today. From the doctor's point of view he/she doesn't have enough actionable evidence from the primary screening tools, whatever TFTs they might use, so they adopt a wait and see position to see if things get worse. Unless the doctor is experienced with thyroid matters they will regard any symptoms as non-specific as per the guidelines. A common story on the forum. From the patient's point of view they know something is very different from what it used to be and just want help to get back to normal. So the problem is accuracy of diagnosis, which you pointed out previously, the situation has to fester until things are out of whack enough to show up on the screening tools, which can take a long and unpleasant time for the patient. I would say this is a common scenario in allopathic medicine. I think they are doing a better job in the non-allopathic world but it always costs more for the patient. PR

[PR4NOW in reply to diogenes]

Diogenes, on a different note I wonder if in the patient group where T4 monotherapy does not restore a normal T4/T3 ratio, could that contribute to more heart problems. I wonder how long it will be before cardiologists start experimenting with adding some T3 to those patients with low T3 levels to see if it improves outcomes. They have already done studies showing low T3 usually means worse outcomes. PR

circ.ahajournals.org/conten...

press.endocrine.org/doi/abs...

[diogenes Remembering in reply to PR4NOW]

T3 is a problem - both too little and too much are dangerous re heart and other things.

[diogenes Remembering in reply to PR4NOW]

Regarding Thienpont, she complains about the manufacturers dragging their feet re revising and rationalizing their FT4 and especially FT3 tests. The whole exercise is voluntary and once again the regulators are totally unaware of their roles an d responsibilities.

[diogenes Remembering in reply to diogenes]

Did you read that remark on page 89 of the new guidelines

The existence of the D2 pathway for conversion of T4 to T3, and the homeostatic function of D2 for maintenance of intracellular T3 in the face of mild T4 deficiency, explain why L-T4 monotherapy can be so effective in the treatment of hypothyroidism.

Generally I thought the guidelines are improved against last time.

However, the above statement is exactly what we found not to be true and why our pending paper is so important.

The homeostatic function of T3 is broken in L-T4 treated athyreotics, and that is why it may be ineffective.

[PR4NOW in reply to diogenes]

Diogenes, I read it but did not connect the dots. Thanks for pointing that out. PR

[PR4NOW in reply to diogenes]

Diogenes, I think the thing that concerns me the most is that they have codified somatoform disorder into the guidelines. I think this will turn out to be a nightmare for many patients and will only serve to widen the gulf between patients and endocrinology. PR

[PR4NOW in reply to diogenes]

Diogenes, I have to admit that I think it is a little scary that I can read a journal article and find a mistake. Maybe it is time to get a life. On page 15 which is actually page 16 of 207 they say'

"first, the isolation of T4 in 1927 by Kendall (31);" which should be '1915' which is what the reference they use says. Interesting that they think D1 is responsible for 24% of circulating T3 and D2 for 60% which leaves 16% for the thyroid? Then they go on to say total T3 production about 33mcg with 80% (26mcg) peripheral production and 20% (6.5mcg) from the thyroid. PR

[helvella Administrator Thyroid UK in reply to PR4NOW]

I think it is scary that the ACB/BTA/BTF guidelines still have a mistake in them that had never been reported (quite possibly never even noticed) by the many doctors who have used them in the years since 2006. I reported it but the correction disappeared.

They used nmol/L instead of pmol/L for FT3.

These guidelines also are not maintained so no-one can rely on their current status and yet doctors up and down the land DO rely on them. The review date is long past.

Rod

[PR4NOW in reply to helvella]

Rod, I've been working my way thru and it is the same old stuff. What is scary is

somatization disorder is now codified into the guidelines. Some of the updated science is interesting but that is about all that is new. PR

[humanbean in reply to PR4NOW]

Page 44 (or 45 of 207, depending on which way you read it) made my blood run cold.

[PR4NOW in reply to humanbean]

humanbean, I quite agree, the ripple effect from AP's work I'm afraid. PR

[shaws Administrator in reply to PR4NOW]

It's awful if people are told/treated for mental health issues instead of a lack of hormones. Is it no wonder that there are suicidal thoughts/deeds.

[greygoose]

They are saying on American forums that it's very disappointing. Nothing much new. Haven't read it myself - tried to but brain fog got in the way.

[PR4NOW in reply to greygoose]

Grey, which American forums do you find interesting? PR

[greygoose in reply to PR4NOW]

Beating Thyroid Disease with LDN on facebook is the best I've ever found. They don't just talk about LDN, they talk about all sorts of aspects of general health. There are some incredibly knowledgable people on there, kind and friendly, and I've learnt a lot. One day I might even try LDN! lol