Sorry - but this appears to be the same poorly conducted "research" we have seen so often. Just 180 patients. What was the definiton of "restoration of euthyroidism"? Is it really feasible that TSH, FT4 and FT3 were all "restored" every day of the week? Or can we assume that the results were within range for at least one day a week?
Lack of access to the full paper forces me to make assumptions.
Can it be remotely acceptable to proclaim weekly dosing as a proved "valid therapeutic option and can also be considered as a first line therapy," and then comment that they still need to do work on cardiac safety because of risk of sudden cardiac death?
Significant differences were also reported for LDL and triglyceride levels among groups 2 and 3. However, the authors added that some literature has linked higher FT4 levels with increased risk of sudden cardiac death, and recommend future studies on one-weekly dosing measure cardiac safety.
Why on earth did anyone see fit to throw in an anti-T3 comment? (I cannot see this as anything but that.) What "method of absorption" is so very different between T3 and T4? Both get absorbed in our gut in the few hours after ingestion. What is this "Cytomel or T3"? Doesn't the buffoon know that one is a brand name the other a generic approved name?
"If we did the same experiment with Cytomel [liothyronine sodium], or T3, it would be very dangerous," added S. Sethu Reddy, MD, chair of the AACE annual program committee and the moderator of the oral session, highlighting that the method of absorption of this treatment was vital.
I am absolutely NOT convinced of the safety or efficacy of weekly dosing of thyroid hormones.
[ Edited to add this:
The page contains this "disclaimer" - Note that this study was published as an abstract and presented at a conference. These data and conclusions should be considered to be preliminary until published in a peer-reviewed journal. Which, as so often, will likely be behind a paywall so people like us will not have ready access. ]
[ Edited to add this:
Most patients normalized thyroid function with 12 weeks of higher dose
Sorry folks - but dosing with thyroid hormone does not and NEVER CAN normalize thyroid function. At best it can approximately normalize thyroid hormone levels. It doesn't magically make the flaming thyroid work again, does it! ]
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helvella
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My Goodness - don't they have good Promotion Managers.
Pay some people enough money and they'll give the results for which you paid.
Why don't they use guinea pigs from those of us who remain very unwell on levothyroxine and it is a nightmare you think you'll not get out of and being told 'your bloods are fine'. We don't want 'bl**dy fine' we want relief of all symptoms with thyroid hormones alone (ones that suit us) and not additional tablets for symptoms.
Why do they waste money on unnecessary trials to prove what! To also throw in the T3 comment. They seem to be driven to desperate attempts to prove they were right to discontinue T3 to vulnerable patients.
Helvella, you are also right in 'Cytomel or T3' they probably think levothyroxine is T4 also.
Unfortunately there are too many arrogant and ignorant con artists "doing research" on thyroid diseases! They haven't got a clue and yet think they should speak on such matters.... the God Complex is never ending.... Despair!
Quite! But how to change such an attitude? Patients need to fight their corner unfortunately and some may not be able to communicate clearly what they require to lead a better quality of health and life.
Pah - I don't think this would be possible at all - or at least not healthy and totally agree with you. They probably took the blood tests right after they dosed - yeah see look euthyroid - as usual based only on tsh! I'd love to see what their tsh, t4 and t3 levels were on day six.
Considering they mention a baseline of 4.2 tsh - I expect this is what they determine as euthyroid - as if often the case
I'd hate to have sudden heart issues half a day after dosing - great I've got a weeks worth to get out my system! Sounds dangerous to me?
If I use my common sense, everything in our systems are designed to keep all hormones and most substances completely stable within a very fixed parameter (if it is working properly). This is what our bodies prefer so I will agree with my body. Our systems have many procedures in place to make the right amount of stuff, stop making it when necessary and even has back up plans in case it accidentally gets it wrong and goes awry. Weekly dosing is going in the exact opposite direction and I don't believe that the T4 levels were acceptable on day 1 and that it wouldn't cause problems after a while. As we have seen on here again and again, people already have too many issues getting this right even on a daily dose as we can't work as well as own bodies. I imagine it would cause a lot of pressure on some our body parts, which yes, may be fine for a month or two, but in the long run, I very much doubt it. Many of our body parts cave after putting too much pressure on them too often.
If I imagine myself as one of those researchers, I imagine I would have been taking daily blood tests even if just to ease my own mind on the possibility of killing too many people at once via heart attack and being held accountable and if for some miraculous reason their results were stable from the beginning to the end of the week, this would have been in the first line of my findings! It is not, so I can only assume it wasn't. I imagine the results would have been within their acceptable parameters whatever they were - which as we know, is generally not the same as the patients lol!
I would have loved to have heard what the patients decided about it and whether they would choose to go back to weekly dosing
I can't get back on there to read again and check but I'm sure it mentioned something about being useful for those who have difficulty taking daily meds - the elderly with carers kind of thing was my first thought.
I'm sure I read a post on here earlier questioning crap thyroid treatment as being a form of population control. Well here you go, it is now - a very good solution to the increasing elderly population and they of course would have died of very common natural causes for people their age lmao!!!!
And the young - well they're probably strong enough to survive ten or twenty years to make it not clear what the cause was
The second sentence tells you the patients were non-compliant. These patients don't take their levothyroxine and are at risk of falling into a coma. There are a number of papers that describe once weekly supervised levothyroxine treatment, by tablet or injection, for patients who are non-compliant either becasue they forget or cannot take tablets. The treatment is sub-optimal but better than nothing. Euthyroidism is sadly, as always, defined in terms of the blood tests, but some of the target patient group are unable to communicate their symptoms.
But the abstract seems to be pushing it for people who are newly diagnosed!
I'd argue that for many who are non-compliant, the appropriate action would be to find out why and address the causes. For goodness sake, they included this sentence: They added this may be particularly suitable to working-age adults who may experience impaired absorption due to mealtimes.
If mealtimes really are an issue, then maybe suggesting bed-time dosing would be sufficient for at least some patients?
"Cannot take tablets" - depending on the reasons, possibly the simple expedient of dispsersing the tablets in some water would work?
Also, the basic concept of explaining why the patients are taking the medicine would help? Education has a huge role.
In this case, euthyroidism may be defined by TSH - but is that TSH on day zero? or day 7?
We could expect a bit of a roller-coaster look to TSH over the weeks. If a dose adjustment is required, just where do you look to determine that?
Inability of a patient to communicate does not, of itself, seem to be a justification for sub-optimal treatment. Also, it is not stated as applying to those treated in the study. In my view, the correct approach is to endeavour to give those who cannot communciate just as good treatment as anyone else.
We see a number of people on this forum who find just one tablet of a make that does not suit them has horrible effects. Not sure that seven times that would be desirable in any circumstances. Especially if the effects are true allergy.
Many of us had issues had first - it's hard to remember every morning until it becomes a habit but I imagine the majority of us tend to buck our ideas up once we are able to associate the way we are feeling with a missed dose apart from the most vulnerable. Not initially, but after a while, I always knew when I've missed one now and never too late to take it although I'm on T3 so may be a little different.
In regards to working people, my endo said when I first saw him that if I can't wait for food in the mornings and must have breakfast shortly after in order to go to work, that I just need to make sure I do the same every day so that my dose will be at the right amount to compensate so I'm not sure if truly a problem? Please bear in mind this was a couple of decades ago and not sure if he would still advise this or if this is a suitable method lol.
Yes, you're right 'defined in blood tests' which they do all the time i.e. 'you're normal' said to many, many patients who are very symptomatic. It must be a worldwide method and ignorance of clinical symptoms and prescribing 'other' for these symptoms.
Don't wish to be judgemental but this study has an Indian origin where sometimes the science can be let's say somewhat dodgy. Giving huge once-weekly doses of thyroxine will give the following dangers: temporary over-production of T3 for those whose body conversion is easily capable of adequate T4-T3 production and who typically live well on lower FT3 levels: inefficient use of T4 owing to initial overdose, leading to rT3 elevation to remove excess T4: actual inhibition of T4-T3 conversion by overlarge T4 doses at the start of the week (this won't prevent good converters still getting too much T3 but will give problems for poor converters). This suggestion is about as nonphysiological as could be envisaged - the working thyroid adjusts moment by moment and a weekly "blast" is utterly unhelpful. Spiking is a feature that should be minimised in thyroid treatment at all costs. What the longterm indications are for the patients by the bolus regime is a very moot point. And you can wave TSH measurements out of the window as a control measure. And what about FT3 - hasn't been measured and nobody knows.
diogenes, I have a troubling question. It's personal because I only live in my own body. My fT3 has always been in the low range. I think this is genetic as opposed to situational. Adding more T4 indeed did not raise the fT3. However, it did stop the cardiac 'feels like I'm going to die' flippity flops (if these are palpitations, i don't know because I never reported them). So somehow the heart got more of what it needed by raising the fT4 and the T4 dose. Blood pressure went down with the increase as did ability to climb stairs without becoming breathless. There's not much information (is there at all?) about how much or if the cardiac muscles metabolize T4 into T3.
Other functions also have improved even though the blood level of fT3 didn't change.
So how valid is the fT3 blood test? I know T4 is metabolized to T3 in the liver and that the kidneys store T4 (okay, I know, T3 is liothyronine but let's ignore this and just call the three iodine metabolite of thyroxine T3.) But clearly other organs and the brain are busy as well.
When the endocrinologist decided to experiment with Liothyronine and my fT3 blood test was where everyone says is optimal, I had some serious issues with blood glucose fluctuations and ringing in the ears. (Got worse with higher doses and when blood glucose would rapidly rise to alarming levels and then crash to low levels. 18 to 3.) My gut functions very well and absorption is excellent.
These days I take 150 mcg T4 for 13 days and leave it out on the 14th day. Muscles were suffering at 150 mcg. 140mcg net dose is better for the muscles and the brain. I'm not having to fruitlessly search for words. Conclusion is that too high fT4 was not beneficial to the brain.
So, how valid is the fT3 blood test? To what extent does it actually indicate how well someone is doing? Shouldn't the focus be more on how the patient is functioning? And is waiting only 6 to 8 weeks appropriate when it appears, at least to me, that it can take 6 months to realize there's been a positive change?
Plus how is it that some people can take 50 mcg of Liothyronine once in the morning and feel just fine? Doesn't that imply their absorption is poor? If I would take that much, I don't even want to think about it because taking 12.5 mcg in the a.m. and then another 12.5 mcg in the early afternoon was a blood glucose disaster. The Cicadas were very busy singing loudly in my brain. (I only did this once and once was plenty.)
Everybody is a genetic unique individual. If you look at a panel of healthy people for TSH, FT4 and FT3, in each case there is a range of normal results. But individuals don't cover the whole of the ranges, just their little narrow windows, called the set point. So some people thrive on half the FT3 that others need and similarly half the FT4 (not necessarily the same people). This is the result of different balances between thyroid output of T4 and T3, T4-T3 conversion in the body and TSH response to this. This is why personal presentation of symptoms to the doctor is paramount over crude readings. It's also the reason why individuals respond differently to lack of thyroid. Some are fine on T4 only, because they only needed lower T3 levels in health. But those who needed high T3 levels don't do so well, because the thyroid isn't there any longer to help out the body's conversion to get the higher FT3. Thus they need T3 as well. So if you ask about the validity of tests, I can only reply in the context of individuality. And this means knowing where you've come from in health to your present sick state. And that isn't known because no one measures FT4, FT3 and TSH when you are perfectly well. If they did then there'd be a transformation in diagnosis because the doctor would have a target to aim at instead of the vague "you're OK because you're in the normal range". That means nothing in the context of the individual's place in the range and their working set point.
I had my employee tested for TSH, fT4 and fT3 on more than one occasion. (this is Canada, so it's easier to get these things done). Her results were stellar. fT3 was 5.4 (regular range), TSH 1.4 (etc up to 3.0) and fT4 was 12. Thyroid function is totally fine. In her case we know what 'normal, healthy' looks like.
Based on survival of the 'fittest', possibly in areas of the world where waves of starvation occurred in the past, a low in range fT3 has been selected for genetically and there's nothing wrong with it.
But as you say, baseline for healthy individuals is not established so comparisons are not being made. Plus people are chopping and changing doctors all the time and there's no linear retrospectives or followups.
Definitely, the most important thing is 'how do you function'? Except based on what i see here in regards to vitamin and mineral testing, it doesn't always matter what dose a person is taking if the other things indicate malnutrition. And it is malnutrition because taking B12, folate, ferritin in isolation does not indicate all that much about the rest of the nutrition. Taking supplements in isolation is pretty well pointless if so many other nutrients are inadequately supplied by the diet. There's people who report their blood test results in regards to these vitamins and iron, their thyroid blood tests are good to excellent and yet they still feel lousy.
This study was presented at an AACE meeting so is of a similar quality to other thyroid studies (a loaded comment). There have been a number of such studies, so this one is not novel but its usefulness is overstated. I overlooked the issue of excessive type-1 deiodinase (T4 -> T3, T4 -> rT3) as pointed out by Diogenes. As far as I know all such studies have overlooked this issue.
As there have already been studies on this issue the money would be better spent on finding ways of delivering levothyroxine to patients who are unable to comply with daily dosing, as already pointed out. I'm in favour of steady level dosing of thyroid hormone (within reason). Once weekly dosing of levothyroxine is no better than once daily dosing of liothyronine and might be worse.
Seeing as how T4 is stored in places like the kidney, the net potential adverse effect of once weekly dosing is probably not all that serious. There would be a temporary initial high blood level but what importance is that when the stuff is stored and then released as needed?
The liver most likely puts the brakes on conversion. I'm sure organs are not just willy nilly metabolizing without some feedback mechanism.
What concerns me more are the dough heads who don't realize how important it is to take their thyroxine appropriately on a daily basis: what gives anyone the idea that these people will 'remember' to take the bolus dose once per week?
Daily dosing is a lifetime 'routine'. Is once per week easier to establish as part of the routine?
How much T4 is stored in the kidneys? I always thought the majority of the stored thyroid hormone was in bound form in the bloodstream?
I think calling those who are do not appreciate the importance of taking their levothyroxine reliably "dough heads" is somewhat unfair. That would, in my view, only approach acceptability if they have had the issues properly explained to them, are able to understand, can act on that understanding, and have the environment in which to do so - and still don't.
Many of us are used to taking medicines such as paracetamol on an as-needed basis - even being encouraged to skip doses when not needed.
Your provided definition of dough head is correct.
There are people who somehow do not internalize the need to take their medication appropriately. Maybe they are in denial? Or resistant to the concept that they need to continue for life?
It reminds me of my parents who thought that anyone who required prescription corrective lenses were defectives and a shame on the family. You must have heard the saying 'no one makes passes at a girl who wears glasses'. That sort of thing.
Yes, what about people like my mother. She went for general blood tests last month and the surgery receptionist called her to say there was a prescription to pick up (turned out to be levo) - not an iota of a explanation as to what she's been diagnosed with, what it is, what it means, what the meds are for, how to take them. Luckily I was able to explain to her.
I imagine many others in the same situation thinking oh what's this, take them and then after a week or so think well it's not doing anything so what's the point?? Or think ooh it's making my heart racey, don't like this, not taking them? There will be those out there who have no idea of the importance of them or what their illness entails or like in my mum's situation, not even provided with the basic name of the thing they've been diagnosed with to even google it - there was a post a few days ago presenting this exact problem. Many drugs people have had experience with prior to diagnosis are used for multiple causes on a temporary basis so they may not even think to check the little bit of paper in the box.
Also, even though I knew what they were for when I was diagnosed, it did take me a few months to figure out a way to remember to take them as not something I've had to do before - easy once becomes a habit but not before when rushing to work etc so maybe a bit unfair.
Anyone who has been fully informed - well yes, very silly lol!!
We have seen far too many people getting a prescription and absolutely no information. It would be sensible for them to read the patient information leaflet - but that is not always reasonable.
I am convinced that GPs should be able to provide an "information prescription" - I am thinking of a small book something like the Toft book often mentioned here (but hopefully much better). Could be sent out automatically! And if a book is inappropriate - even a YouTube link!
Yes, I think a little leaflet/book should be given to them as an essential with any first prescription - even if sent to them with their free prescription card - better late than never lol!
Oh and I can vouch for how much young children get in the way of any formed habit in the morning lol. The amount of times I've had a poo issue (even smeared where it shouldn't be)/ hunger scream episode / crying for various illogical reasons and even vomiting and then 30 mins later thought crap, can't remember if I took my pill or not during that nightmare. Once my daughter hit five, she was put under strict instruction not to talk to me until I've peeled my comatosed zombie-like body from the bed, gone to the pill cupboard, found the key to unlock the pill safe (long story), walked to the sink, filled a glass of water and drank it. Any interruption in that process, opens up the chance of a missed pill. She follows me the entire way looking like she's going to burst and as soon as that glass has hit my mouth - mummy i'm hungry, I want breakfast, can I have a glass of milk, my knees hurt, I don't want cereal today, I want toast but not butter, peanut butter, can I take a toy to school with me today, some of the kids do and sneak them in their bag, please let me ride my scooter today (even though I absently minded crash into everyone and therefore banned) - all in one puff
I find it a puzzling idea that one-weekly dosing is easier to remember. Surely nobody will remember it without using a tool like a calendar or setting a reminder somewhere.
And if you're willing to set reminders, what's wrong with a daily alarm? I have a friend who has been set weekly dosing of Vit D. She knows that she rarely takes it, and of course doesn't see it as important enough to make the effort with calendars.
I think the idea is that the dosing will be supervised by a nurse or care worker, or by injection. Except for this study, this is put forward as an option for a few special cases.
It seems to be a mix. GPs prescribing vitamin D in weekly doses are intending the patient to take their own.
I find it a nightmare to imagine nurses administering my hormone replacement. In hospital I've never had the medication I'm supposed to have. I guess they have databases that beep up when patients need a medication, but in real life it doesn't seem to work.
I don't think the reference to taking Liothyronine once per week is anti-T3. It's like saying that if the usual dosing for codeine is 15 mg every 4 to 6 hours, it is not a good idea to take 1 week's worth of codeine in one dose. That's not anti-codeine. It's just taking into consideration the metabolism and effect of the drug. The only thing missing from this article is mentioning the half lives of T4 and T3. Plus the absorption, when Levothyroxine is absorbed at 80% and is affected by stomach contents when Liothyronine is not.
But if you were talking about codeine dosing, why would you make a comment about dosing with aspirin, paracetamol, gabapentin, or anything else? You simply would not do so unless you had some agenda for doing so.
I am not at all sure that we have any good evidence that someone who usually takes, say, 150 micrograms of levothyroxine a day and absorbs 80% of that, would absorb 80% of a 1050 microgram dose. Studies of healthy volunteers taking single large doses are not applicable to this situation.
Nor am I at all sure that we have good evidence of the effect of stomach contents on liothyronine absorption. We have some evidence that it is generally better absorbed and less affected - but how much research has there been into interactions with food, drink and other medicines and supplements? We keep seeing new interactions reported for the far more widely prescribed levothyroxine often reported with a "Now who would have though of that?" attitude.
No problem. I chose codeine but all the other drugs you mentioned would also be appropriate as a comparison.
From what I read on this forum, there's some wildly different absorption situations. For example someone recently mentioned that they take 175 mcg T4 and 10 mcg T3 per day but their blood tests look as if they are underdosed. A person whose guts are functioning well would end up with overdose. So yes, this sort of thing needs to be taken into consideration. In these circumstances it is better to seek out the reason for why absorption is severely subnormal.
I think it is difficult to be sure that the issue is absorption alone.
Our bodies have various ways of handling thyroid hormones including glucoronidation and sulfation pathways. To be absolutely sure it is absorption, it is necessary to do something like take a tablet and see the effect on blood levels something like two hours later. Fat chance of that happening in any but wholly exceptional cases.
Not sure if one tablet of a usual therapeutic dose would work for this experiment. Maybe getting a patient to take 1000 mcg T4 on an empty stomach and then check blood levels would be better.
But they do these things for patients who they suspect are non-compliant according to the article I linked on this forum some major time ago so don't ask me to search for it. I've got to go out to the allotment. A miracle has happened: we didn't get any rain or snow today!
When checking for compliance they can simply observe the patient taking the tablet.
When checking for absorption, you really need to test before and after. And not just TSH. The reluctance to test will doubtless overcome any desire to prove anything.
To give someone a weekly dose of Thyroxine all in one go is downright dangerous! They could end up having a heart attack or stroke,especially if they were older patients.What a ridiculous trial. I only increased from 75 mcg to 125 mcg for a couple of days and my heart was hammering,blood pressure and pulse were sky high.
I haven't read every word of previous comments, but have seen no mention of the blindingly obvious fact that "euthyroid" does not necessarily mean "feeling good". You can be both Euthyroid and feel rotten at the same time. I know that and my doctor knows that after I complained to him bitterly for 8 years that levo was the wrong medicine for me.
(Actually, I'd love to see the word euthyroid thrown in the bin.)
I think the doubts expressed as to whether they can even get the patients' thyroid hormone levels in range imply no-one here thinks there a cat's chance in hell of them feeling well.
Hello to all,,I have read through the posts on the many aspects of taking medication,,,the cannot take tablet people, need to know the tablets are smaller than a five pence piece,,, and not the size of a two pound coin,,,,they likely had a bad experience as a child,,,,they have to learn what life would be like if they did not take the needed meds,,,explanations from a nurse is much better than the receptionist phoning and saying there is a prescription waiting for you,,this is bad patient care,,,far too many patients are poorly looked after when facing treatment changes,,,explanations should be demanded,,,so many people want their blood tests explained to them,,which should be done by feed back at the gp,practise,,,well my small view,,,,ttfn from karen.
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