Medscape has a rather good write-up on the ATAs recent annual meeting. There are some interesting comments in the article. PR
The conclusion — that evidence is still insufficient to choose 'to T3' — specifically, to routinely combine triiodothyronine (L-T3) with synthetic thyroxine and levothyroxine (L-T4) in the treatment of hypothyroidism — was not, in the minds of some, the nobler of choices, and the ATA subsequently found itself the target of more than a few slings and arrows.
"The use of combination therapy is clearly a very emotive issue," said presenter Jacqueline Jonklaas, MD (Georgetown University Medical Center, Washington, DC), head of the ATA task force on the new hypothyroidism guidelines, underscoring her point with a sampling of postings on the ATA's Facebook page following the recommendation: some calling the decision "shameful," others accusing the ATA of being in the pockets of the pharmaceutical industry, and at least one battle cry for a class-action lawsuit.
Dr Jonklaas noted that even some of the guidelines' own reviewers questioned the decision. She shared a couple of their comments, including: "I do not understand why the authors would not recommend a therapeutic trial of low-dose T3, even though the benefits may be unproven," and "I (personally) think that not mentioning a therapeutic trial with low doses of T3 is unnecessarily rigid, if these guidelines are for practicing physicians."
In a stance seen as somewhat bolder than the ATA, the European Thyroid Association (ETA) has specifically addressed combination therapy in guidance published in 2012 (Eur Thyroid J. 2012;1:55–71) , which opened the door for L-T4 and L-T3 combination therapy "as an experimental treatment modality" for hypothyroidism in compliant L-T4–treated hypothyroid patients who have persistent complaints despite serum thyroid-stimulating-hormone (TSH) values within the reference range.
But among the most important phrases in the new ATA guidelines that should be underscored — loud and clear — is that they "recommend only against the routine use of combination therapy," said ATA president elect Antonio C Bianco, MD, PhD (chief of the division of endocrinology, diabetes, and metabolism, University of Miami Miller School of Medicine, Florida), who cochaired the hypothyroidism task force along with Dr Jonklaas.
"At the same time, there are multiple instances in which combination therapy is supported," he told Medscape Medical News.
Those instances include when patients' serum TSH levels are normal but they are still symptomatic — which is when most clinicians are likely to consider the option.
"I suggest Armour to patients because it's economical and it's simple," said Gary Pepper, MD (Palm Beach Diabetes and Endocrinology Specialists, Jupiter, Florida), a strong proponent of the use of desiccated thyroid. "One problem with combination therapy [with synthetic T4 and T3] is that people find it to be very hard to take three pills a day, and you only have to take one Armour," he told Medscape Medical News. "Furthermore, the synthetic T3 is very expensive, so I'm really looking at it from a more practical point of view."
Dr Pepper, who regularly treats patients with Armour — but underscored that he has no relationship with the makers — responded that the T4:T3 ratio is not as fixed a ratio as the guidelines suggest.
"It's important to remember that the ratio is just an average, and anyone who has done research on this knows that the ratio doesn't apply to everyone," he said. "There are some, particularly patients who don't create T3 as well, who don't fit into those margins, so the argument is extremely weak.
"Furthermore, we are specialists, after all," he added. "You monitor the patient's blood levels and adjust the dose as is appropriate."
The same applies to the risk for thyrotoxicosis, Dr Pepper said.
"Regarding the theory that it could be dangerous — where are the case reports of people getting sick? You will not find a single scientific paper stating any real danger from desiccated thyroid, and as far as I'm concerned, the [medical societies] are scaring people away from this."
"I have patients who are 60 and 70 years old who are taking this medication, and I can tell you they are delighted with it."
This link should be the public access version.