How we should be diagnosed and treated!
PE1463/QQQQ
Dr Henry H. Lindner submission of 27 September 2017
Dear Women and Men of the Scottish Parliament,mI am writing again at the request of the petitioners about the ineffectiveness of the current approach to the diagnosis and treatment of hypothyroidism as expressed in guidelines produced by professional medical associations(1).
I will show that those guidelines are the product of false assumptions; not of the evidence.
I am a physician who has diagnosed and treated hypothyroidism in over a thousand patients according to their signs and symptoms.
Few have such experience in clinical thyroidology. Because I did not follow the guidelines, I was able to produce remarkable improvements in patients who would never have been diagnosed, and who were diagnosed but undertreated.
Gordon B.F. Skinner, a Scottish physician, reported similar experiences and conclusions (2,3). Also, it was only by trying to help suffering patients with effective T4/T3 therapy that I came to appreciate the prevalence of dysfunctional hypocortisolism, especially among women (4).
In what follows, I will argue for the following recommendations for improving the care of patients with hypothyroidism:
1.
Define hypothyroidism correctly, as “insufficient T3 - effect in some or all tissues of the body”.
2.
Endorse the patient’s signs and symptoms as the only true indicators of T3 - effect.
3.
Endorse the free T4 (FT4) and free T3 (FT3) levels, together,as the best indicator of T3 availability.
4.
Acknowledge that the TSH test is an indirect and fallible indicator of a patient’s T3 status.
5.
Acknowledge that effective thyroid replacement therapy produces different TSH, FT4 and FT3 levels than seen in healthy controls. No blood test can tell a physician what dose the patient needs.
6.
Demand that laboratories base their FT4 and FT3 reference ranges upon healthy non-patients who have been carefully screened for hypothyroid symptoms.They must also provide separate ranges for patients on levothyroxine therapy—as informed by clinical studies. (See below.)
7.
Endorse the practice of clinical thyroidology: the diagnosis and treatment of hypothyroidism according to clinical criteria first (signs and symptoms), and according to the relative FT4 and FT3 levels second.
This is precisely what patients want and need.
8.Uphold a physician’s right to practice clinical thyroidology and to prescribe effective T4/T3 combination therapy, including natural desiccated thyroid.
This is necessary to prevent persecution by the medical board and thus remove a major impediment to the practice of clinical thyroidology. The endocrine profession remains stuck in a simplistic laboratory-based paradigm that was invented in the 1970s. I call it the“TSH-T4 reference range paradigm”.
All of the thyroid research of the past 5 decades has been performed within and interpreted according to this paradigm.
All evidence that contradicts the paradigm has been ignored, minimized or re-categorized. The dominance of such paradigms in our sciences was described by Thomas Kuhn (5).
The TSH-T4 reference range paradigm is defined by these assumptions:
1.Hypothyroidism is an underactive thyroid gland producing low T4 levels.
2.Almost all hypothyroidism is primary (thyroid gland failure), detectable by an elevated TSH level.
3.A normal TSH test, in both untreated and treated persons,equals “euthyroidism”.
4.Hypothyroidism is perfectly treated by normalizing the TSH and/or FT4 with levothyroxine (T4).Because reliance on the TSH for diagnosis is problematic, an add-on assumption is required:
5.
Hypothyroidism must be confirmed by a FT4 level that is below the laboratory’s reference range.
The paradigm requires that all of the following unstated assumptions be true:
1.
TSH secretion is perfect in every person — absent any obvious hypothalamic-pituitary (HP) disease.
2.
Perfect TSH secretion reacts to once - daily T4 therapy exactly as it reacts to thyroid gland output: so the TSH level is also the perfect guide for therapy.
3.
T4-to-T3 conversion is perfect in every person, so physicians need only to prescribe T4.
4.
The FT4 reference ranges reported by laboratories represent “euthyroidism”.
Nothing should be presumed perfect in biology.
These assumptions are not just improbable;they are illogical and/or contradicted by the evidence.
(See below.)
They are nothing but the wishful thinking of a few influential physicians in the 1970s (6,7,8,9).
They hoped to simplify the diagnosis and treatment of hypothyroidism to TSH and FT4 tests and their reference ranges.
In fact physicians know better than to try to use pituitary hormone levels, follicle-stimulating hormone (FSH) or adrenocorticotrophic hormone (ACTH),to diagnose or treat hypogonadism or adrenal insufficiency. They know that in these deficiencies, HP dysfunction is common, and the pituitary hormone levels are of no help to guide therapy.
They diagnose and treat these deficiencies based upon signs, symptoms and end- hormone levels. They check the pituitary hormone level only to determine the cause of the deficiency.
The TSH should be used only in this way.
To rely on the TSH as a surrogate indicator of T3-effect is illogical. It is like insisting that one’s home-heating thermostat is working perfectly even as the house gets colder and colder. Indeed the guidelines’ authors know that the TSH test is misleading in many circumstances (it has “pitfalls”). Yet they still endorse it as the “best test”.
Consider: How were the TSH’s pitfalls discovered, and how can a physician avoid all pitfalls in all cases? There is only one way: by attending to the best indicators of T3-status—the signs and symptoms first,and relative FT4 and FT3 levels second.
The guidelines state that neither the patient’s signs and symptoms nor relative FT4 and FT3 levels can be used to diagnose hypothyroidism, and “do not have sufficient specificity to serve as therapeutic endpoints”. They have it backwards: it is the TSH and FT4 tests and reference ranges that are insensitive and non-specific indicators of the patient’s' T3 status. The guidelines thus violate one of the important guiding principles in medicine.
(To read the rest it is in the link below. I couldn't copy/paste and haven't done prtScn before so it has taken ages to get as far as I have 
about 2 and a 1/4 pages down after "patient’s’
T3 status' read on.
Paradigm shifts in thyroid hormone replacement therapies for hypothyroidism - Nature Reviews Endocrinology
lost in translation...
