Another paper showing that free T3 is not normalised unless TSH is suppressed, in T4-therapy patients.

[diogenes]

I'm just informing the TUK forum of the emergence of a new paper by Ito et al in the journal Thyroid. It shows as per the heading, that TSH has to be suppressed to get FT3 normalised in T4-only therapy. It confirms all we've written. However, a definite fault is that it looks at populations statistically as a whole and doesn't really discriminate the different reponses of individuals within a population that might indicate T3 therapy. The paper is

Ito M et al., Thyroid: 2016: DOI 10-1089/thy.2016.0426

I've sent a copy to Louise at TUK because the paper is behind a paywall.

Yet another bit of ammunition for TUK members to wave at doubters in the medical profession.

[loueldhen]

What do they call suppressed? I guess no study yet on the same for T3 treated folk?

[Clutter in reply to loueldhen]

Loueldhen,

<0.1 is considered suppressed.

[diogenes Remembering in reply to loueldhen]

Two descriptions of "suppressed". One is TSH right down to just above the lowest detection limit - giving "population-wise" normal adequate FT3. Heavily suppressed TSH are those with undetectable TSH and mildly high FT3. BUT we must always remember that these descriptions are based on a population and do not address the individual case. It may well be within the latter population that there are a minority with undetectable TSH and normal=high-in-the-range FT3. As I said this is a drawback of the study. Studies on joint therapy so far are not worth the paper they are written on, but for reasons it would take me too long to describe.

[Clutter]

Thanks, Diogenes.

There'll soon be enough papers to bury the doubters!

[jimh111]

Thanks for posting this. A good point of this study is that they looked at some markers of thyroid activity. As you point out it looks at a whole population rather than individual responses. It will be interesting to see if combined L-T3 / L-T4 therapy produces similar results.

loueldhen - this defines the degree of TSH suppression the paper found to be appropriate:-

"In the patients with mildly suppressed TSH (0.03 < TSH ≤ 0.3 μIU/mL) and FT3 levels equivalent to their preoperative levels, all metabolic markers remained equivalent to their preoperative levels."

[diogenes Remembering in reply to jimh111]

That point about TSH ranges is very pertinent, in that it suggests a range for adequate treatment on T4 therapy which is very much lower than the "healthy" range which GPs and endocrinologists use as a pointer for diagnosis. In fact even a TSH of 1 is above the suggested range for achievement of normality. The reason of course is that, in the absence of any T3 produced directly by the thyroid, you need more T4 to achieve an adequate FT3 from the body T4-T3 conversion alone. This suppresses TSH. As regards the situation for joint therapy, the situation will be different again and I suspect the ideal TSH's will have a range between the healthy and T4-only group. This is because you do not need as much T4 and T3 to achieve optimum dosing, compared with T4 alone, but again in the absence of thyroid gland, the effects will still be the same..

[diogenes Remembering in reply to diogenes]

Just another point to show that TSH cannot be used in therapy. Patients come with all levels of thyroid loss, from the minor through to the absolute. The TSH range will change steadily from the healthy range to the extreme of the "no-thyroid" range with all points in between according to how much thyroid you have left. This means that there is a TSH range specific to each fractional loss of thyroid. Thus you need to know the exact percentage of active thyroid left to know what the TSH range should be. That is practically impossible except at very high cost of examination.

[dolphin5]

Brilliant!!!! Thank you again. Another one to take to my endocrinologist.

[shaws]

We are forever indebted to researchers/scientist who prove what the patients have been saying for years now. Only to be told levo alone is perfect for everyone when we, the patient, knows otherwise.

If only the Endocrinology Associations worldwide would open their eyes and look at the patient first and foremost and ask them how they are feeling, instead of not looking up from the blood test results on which they have already made up their minds due to the results alone.

Thanks for this Diogenes.

[Hidden in reply to shaws]

Since 2002 once finally diagnosed, my GP has never once asked me how I feel!! He spends a majority of my appointments looking at his screen.

At my last appointment I was told I think about it too much.When I then told him it had been a long up and down journey....he nodded....still looking at his screen!!

I despair !!

[shaws in reply to Hidden]

If nothing else, it is extremely bad mannered. He's in the wrong job. His job is to put his patients' minds at rest and as I put in a post a few days ago, before blood tests, doctors touched their skin, looked at tongue, took pulse and reflex etc etc. I doubt anyone but a holistic doctor would take the time to do so.

They are instructed to only look at the TSH and if in range not to increase hormones. Have never taken notice of clinical symptoms.

[Hidden in reply to shaws]

Yes you are right Shaws.I have lost confidence in my GP. We suffer enough as it is ,never knowing what each day is going to bring.It is a continual struggle with this condition.Negative remarks are the last thing I need.I am thankful to have a Endocrinologist's team that I can at least talk to about symptoms when I attend clinic.

[shaws in reply to Hidden]

When medical personnel are sympathetic it makes the patient have confidence in them and that doctor will do their utmost or enquire elsewhere on how to best to help patient. Listening to someone is an art, I think, especially for anyone who deals with the public.

[Hidden in reply to shaws]

Sorry I didn't come back to you Shaws.....have just come back from 5 hrs at A&E .......hubby had a very bad nosebleed first thing this morning and had to eventually go in by ambulance as we couldn't stop it.Keeping fingers crossed for a night's sleep tonight as I have to set off to my thyroid blood test in the morning leaving home at 7am.for a different hospital......they say that variety is the spice of life!! 😄😄

[shaws in reply to Hidden]

I have just come on now Marfit74 and was sorry to know your husband had a serious nose bleed and hope you both have a settled night and hope you get the blood tests you deserve.

[Hidden in reply to shaws]

In 25 years I had never been referred to an endo. I pushed for it and the endo was staggered I'd never been referred earlier. I don't even know what type of hypo I have, bog standard I think, I'm going to ask at next app.

[shaws in reply to Hidden]

The fact is that dealing with dysfunctions of the thyroid gland are 'simple', especially hypothyroidism so the guidelines state, i.e. Get the TSH 'in range' and anything else the patient complains of is 'nothing to do with the thyroid gland'. That is a fact. Instead of a decent dose (and many do fine on levothyroxine) but those on this forum and others do not, particularly if the doctor is fixated on the TSH to make an 'assumption'. I hope your Endo is kind and sympathetic and wish you well.

If you have thyroid antibodies that means you have an Autoimmune Thyroid Disease also called hashimoto's the commonest form of hypothyroidism. Antibodies attack the gland until patient is hypothyroid. Both 'hypothyroidism and hashimoto's are treated with levothyroxine.

[JadeJ in reply to Hidden]

How did you even get your GP to refer you to an endo!? That's my issue ...

[Hidden in reply to JadeJ]

When I first joined HUTUK I saw a member asking if anyone knew of a good one in my area,so I asked for his name too. Then at a GP appointment I asked about T3 which was being discussed here and was told " Don't go down that avenue you'll lose me " I was then referred and asked to see the Endo I had heard of here, who came recommended.It was the best thing that happened for me.

[Hidden in reply to JadeJ]

I insisted after listing my symptoms. Being on 200mcg and symptomatic something was up and she reluctantly referred me.

[JadeJ in reply to Hidden]

As I'm in "normal range" my doctor said the endo unit wouldn't consider seeing me. I just want the full thyroid testing done, t3 etc! I'm not to bad on levo. I have Anxiety issues but that comes from stress and past life events and I'm treating that separately and see a CBT therapist. I have a scabby scalp though, doesn't help that I aggravate it by picking at it!

[Hidden in reply to JadeJ]

If you think you are symptomatic print this off to show your GP or do a screen shot on your phone. Stark reality might hit her. My best wishes to you.

thyroiduk.org.uk/tuk/about_...

[Sandra600 in reply to JadeJ]

I had a private blood test done which showed that my FT3 was under the range. I then asked my GP to refer me to an endo from Louise's list, which he agreed to.

[silverfox7]

Interesting though not surprising! Thank you for letting us know.

[AshleyR]

Hello - do you have the name of the paper diogenes ? I've asked Louise for a copy with the details listed above but she said she'd need the whole title of the paper to perform a search.

[diogenes Remembering in reply to AshleyR]

The full title and authors in the Thyroid journal are:

Biochemical markers reflecting thyroid function in athyreotic patients on levothyroxine monotherapy

Mitsuru Ito MD, Akira Miyauchi MD, Mako Hisakado MD, Waka Yoshioka MD, Akane Ide MD, Takumi Kudo MD, Eijun Nishihara MD, Minoru Kihara MD,

Yasuhiro Ito MD, Kaoru Kobayashi MD, Akihiro Miya, MD, Shuji Fukata MD, Mitsushige Nishikawa MD, Hirotoshi Nakamura MD, and Nobuyuki Amino MD

Ito M et al., Thyroid: 2016: DOI 10-1089/thy.2016.0426

[AshleyR in reply to diogenes]

thank you so much.