Triiodothyronine replacement in critically ill adults with non-thyroidal illness syndrome

[helvella]

We have read in the past that addressing T3 levels in non-thyroidal illness is of no value. At last a paper which provides some evidence that this view that at best, that view is highly questionable. Indeed, it appears to assess treatment as positive.

I think many of us have instinctively questioned whether failure to treat the T3 issue could possibly be right.

Can J Anaesth. 2018 Jul 2. doi: 10.1007/s12630-018-1177-0. [Epub ahead of print]

Triiodothyronine replacement in critically ill adults with non-thyroidal illness syndrome.

Kanji S1,2, Neilipovitz J3, Neilipovitz B3, Kim J3, Haddara WMR4, Pittman M3, Meggison H3, Patel R3.

Author information

1 Department of Pharmacy, The Ottawa Hospital, 501 Smyth Rd, Ottawa, ON, K1H 8L6, Canada. [e-mail].

2 The Ottawa Hospital Research Institute, Ottawa, ON, Canada. [e-mail].

3 Department of Pharmacy, The Ottawa Hospital, 501 Smyth Rd, Ottawa, ON, K1H 8L6, Canada.

4 Schulich School of Medicine, Western University, London, ON, Canada.

Abstract

PURPOSE:

Non-thyroidal illness syndrome is commonly encountered in critically ill patients, many of whom are treated with thyroid hormones despite uncertainty regarding their safety and effectiveness. This retrospective observational study sought to evaluate the utilization, safety, and effectiveness of triiodothyronine (T3) supplementation in critically ill adults admitted to either of two non-cardiac surgery mixed-medical/surgical intensive care units (ICU).

METHODS:

Consecutive adults admitted to an ICU and treated with enterally administered T3 were identified over a two-year period. Data pertaining to demographics, T3 utilization, safety, and clinical outcomes were collected.

RESULTS:

Data were extracted from the medical records of 70 consecutive patients. All had baseline serum free T3 concentrations below the lower limit of our laboratory's reference range and 22 (31%) patients also had low thyroxine (T4) concentrations. The most commonly prescribed replacement doses were 25 and 50 µg for a median of seven days and almost half of the patients also received concomitant T4 supplementation. Serum thyroid hormones were available in 48 of 70 patients (69%) at a median [interquartile range (IQR)] of 7 [6-38] days. Normalization of free T3 serum concentrations occurred in 30 of 48 patients (63%) at a median [IQR] of 8 [7-33] days. A dose-response relationship was identifiable. New adverse events (atrial fibrillation/flutter, hypertension, sinus tachycardia, myocardial infarction) during therapy were less frequent than at baseline.

CONCLUSIONS:

This study suggests that with T3 supplementation there was evidence of serum free T3 normalization without evidence of associated harms. A definitive trial is needed to evaluate clinical effectiveness.

PMID: 29968209

DOI: 10.1007/s12630-018-1177-0

ncbi.nlm.nih.gov/pubmed/299...

[Hidden]

All I know is that after years of feeling unwell from a multitude of hypo symptoms and inadequate treatment with just levothyroxine and being denied full thyroid workups because they 'weren't necessary' as my labs (TSH and FT4 only) were 'fine' I' m beginning to feel better than I have since age 39 when my thyroid was knocked out from radiation for larynx cancer. I finally found a compassionate, intelligent endo in early April who worked me up, remedied my vitamin deficiencies and started me on T3. I was able to find this doctor because I knew what questions to ask from information I learned on this forum. Too bad it took until age 74 to achieve this. Surely anecdotes similar to mine should demonstrate to doctors that what they've passed off as treatment for years hasn't worked. irina

[crimple in reply to Hidden]

Irina the problem is medics don't like "anecdotal evidence". I get the distinct impression that when we report better health we are not believed because they can't explain how T3 works. 6.25mcg T3 added to my 100mcg levo has made a big difference to me in the last 5 months

[helvella in reply to crimple]

It is true that they do not like what they think of as anecdotal evidence.

Doesn't stop them claiming that saturated fat increases cholesterol.

[Angel_of_the_North in reply to helvella]

Which is metabolically impossible.

[Hillwoman in reply to helvella]

And yet detailed, systematic case studies were once regarded as providing useful evidence.

Can't help feeling we've gone backwards.

[SilverAvocado in reply to Hillwoman]

I think it's purely fashion.

There is nothing wrong with case studies as a form of evidence, and I'd argue they are a lot safer from all kinds of bias that can creep into large samples.

[Hidden in reply to crimple]

I agree with you. They don't like and tend to dismiss anecdotal information. But what they forget is that much of scientific info obtained by research and considered proven and valid was once, in my opinion, anecdotal. The ideas and theories had to start somewhere before anyone could realize there might be valuable facts that could be proven. Much like an action doesn't just pop into existence on its own but is always preceded by a thought. Anecdotal information has to, in my opinion, exist before men of education and letters can turn it into useful guidelines for care. We can't accomplish step 2 until we complete step 1. Some researchers use logical progression of ideas only when it suits their agenda. I believe this is a fundamental problem with thyroid patient's experiences for years.

[HLAB35 in reply to Hidden]

My approach is, 'If something works even if you cannot explain it, it works - don't try and fiddle with it as you never understood it in the first place.' Socrates said we are only wise when we know that we are truly ignorant. It was a big mistake when NDT was replaced. They actually believed they could finally understand thyroid using the very crude measures of TSH and T4 alone and could say you're well now you're in 'range' ignoring all symptoms ;... total and utter cobblers... they're none the wiser about how thyroid hormones work, but because it's all done with print-outs it 'must be true'....

[Hidden in reply to crimple]

I'm glad you are feeling better on the T3. That is my story too. Just beginning to feel human after 3 months of added T3.😁

[nightingale-56 in reply to Hidden]

Me too Hidden . After three months on my current makes of T4 and T3, just this week my hair has begun to feel in better condition.

[Millie22 in reply to Hidden]

Same happened to me at age 31. On levothyroxine only until about two years ago.

Always knew something was not right and had all sorts of symptoms. Could find no doctor who would prescribe NDT. So at the age of 75 did a lot of research, had my own blood tests done, an purchased from abroad. Also took lots of Vitamins and Minerals.

Could not believe the amazing transformation. What a waste of all the years in between though when I never felt well. And still they don't believe it! If we could only stop this happening to those who have the years ahead now.

[Hidden in reply to Millie22]

I think our stories are very common and it's sad doctors dismiss such powerful knowledge. And, I believe they do understand this on some level. Maybe they don't want to buck the system, lose their perks for compliance with rules and regulations, etc. It would be interesting to know how many doctors and their families are getting proper effective thyroid care because they have the tools to sidestep the system? Rhetorical question because We will never know.

[LAHs]

Thanks for posting this. I read a paper a while ago and, I am sorry, but I can probably not find it again, that recorded the recovery success after (any type of) serious surgery with the patient's level of T3. Their conclusion was that patients with low T3 often didn't recover (i.e. died) or their recovery was very difficult, took a long time and/or was very arduous. Patients with high T3 recovered quickly with no complications. The reason this stayed in my memory was that I remember my first Endo telling me that, "Even patients we have here in the hospital who have low T3, there is nothing we can do about it." That was a turning point in my recovery (from bad post thyroidectomy maintenance), I was not very well educated in the art of thyroid problems but that statement rang a very loud warning bell and got me studying my plight. T3 is the key to everything - unless, of course, your body can manufacture it, in which case you are OK. Thanks for the post.

[Justiina in reply to LAHs]

I think this could have connection to malnourishment that happens fast in hospital conditions a) because the food sucks b) long fasting leading to possible re-feeding syndrome. That could drop T3 dramatically with the trauma/shock caused by accident/surgery.

Just malnourishment causes high risk of septicaemia as certain peptides and protein are necessary for wound to heal, low protein intake causes loose tissues hard to stitch. Small intestine loses muscle mass making nutrient absorption harder etc etc. That would also easily affect levels of T3. So it's a combo of things that can fail but it's avoidable in my mind.

[Hidden in reply to Justiina]

I absolutely agree hospital food is not only not healthy but is actually harmful. One thing I think would help patients (but probably won't happen in my lifetime) is for small refrigerators to be available in hospitals for patients to bring in healthy food and keep it in their room. This would need a doctor's order and, of course, wouldn't be appropriate for everyone. But it should be under the doctor's control to decide that a patient would be better off choosing food within his ordered diet that he/she likes, is used to eating, and believes constitutes a healthy way to eat. I often bring in food for a hospital stay-maybe nuts, my own fruit. Unfortunately, my choices are minimal as there is no way to store perishable food. I rarely eat hospital food as it is so lacking in nutrition. In the emergency room I use if you are there a long time, are hungry, and are allowed food their standard snack is salty deli turkey on a white sandwich roll and a commercial packet each of mayonnaise and mustard with soybean oil, a packet of baked chips (crisps), and a fruit cup with added sugar. And the hospital I use is excellent but the food choices are dismal. How hard would it be for our doctor to write an order "Patient may bring in his own food." And order a mini refrigerator for the room. Last year my gallbladder surgeon thought this was a great idea and actually got me the information I needed to send this suggestion to the proper executives. I never heard anything. Someone probably had a good laugh when my letter was read. But here's a thought. How many healthy physicians do we see eating in hospital cafeterias? Not many. And often they have their own dining room away from the rank and file tables. And theiy're not eating the food that is served to employees and others who eat in the main area, Thanks for listening to my rant. irina

[Hidden in reply to Hidden]

PS I always bring my own supplements and meds which drives lots of staff crazy. They say I can't take them but my doctor writes an order for me to take my own meds from home if the hospital doesn't stock the brand, company or dosage I use. We have a lot more control over arbitrary rules and regulations than hospitals would have us believe. We are the customers, after all, and are the source of everyone's paychecks. Outlandish concept, huh!

[Justiina in reply to Hidden]

I agree! Or you could have bigger fridge in shared areas. My dad was in that type of ward, they had a kitchen and could make their own coffee. But it was a bit fancier brand new ward built just a year ago. Tho it was neurologic ward for those recovering from brain stroke so they are supported to do stuff to recover.

[Hidden in reply to Justiina]

That can also work. But cynical me prefers not to let my food brought in out of my sight. When I worked as a nurse, we usually had pretty nice shared kitchen area (microwave, fridge, etc) in the nurses' lounge but I have to tell you cleaning out the refrigerator oftem seemed to be a sore point and I have seen fridges I didn't want to put my own lunch in!

[Justiina in reply to Hidden]

Thats true 😁 I lived in a dorm , 20 girls sharing the fridge no one wanting to clean it up. Can get pretty disgusting!

[shaws]

How ignorant of Endocrinologist/doctors re the necessity of many hypothyroid patients to have some T3 added to T4 or T3 only, so that people can recover their health and fitness instead of T3 being withdrawn instantly without notice to patients who really need T3 to restore their health.

The fact the seriously ill patients were helped to recover by being given thyroid hormones (which were very low in their blood) when not even hypothyroid - shows that hypo patients might well improve when both T4 and T3 are at an optimum level. How often are both FT4 and FT3 tested in the NHS when hypo patiens still complain of symptoms?

[Gcart in reply to shaws]

I really cant understand how any doctor cant see the need for T 3 , apart from the scandal of it cost ! Despair ☹️

[shaws in reply to Gcart]

As the saying goes 'ignorance is bliss' but not for those who need T3 to function.

I have read a number of times it is because Big Pharma pushed (USA) and at times with monetary incentives to doctors/endocrinologists to only prescribe T4 when NDT was the only option. When patients complain about not improving they aren't believed considering that NDT has a number of thyroid hormones not just one.

Excerpt (and many members have found it to be true but medical professionals do NOT believe).

In Scotland alone close to 2.5million prescriptions were issued in 2015/16 at a cost of almost £11.8million to the NHS.

But Professor David Stott, a geriatrician at the University of Glasgow, who led the five-year trials, said his study showed the tablets had no impact on common symptoms attributed to the condition.

express.co.uk/news/uk/80722...

It seems to me that no Endocrinologist is properly trained, neither do they keep up-to-date with Research or just ignore it with no compunction (i.e. a feeling of guilt or moral scruple that prevents or follows the doing of something bad). Neither are GPs trained adequately so that they believe a TSH in range (even top) is adequate prescribing. Rarely is FT3 and FT4 tested and there is definitely no interest in relieving patients clinical symptoms but will give 'another' prescription even if it has no purpose.

[Hidden in reply to shaws]

True and well documented. irina (US)

[penny in reply to shaws]

I think that I read this study...if it is the same one I was spitting feathers by the end of it. The prof. concluded that as his subjects were no better on T4 than those on a placebo the T4 was of no use and should no longer be prescribed. What a plonker! I’m shouting “what about adding T3, maybe your subjects needed T3 and were not going to get better on T4 alone?” The wrong conclusion.

[Hidden in reply to shaws]

And when was the last time 'normal ranges' for lab values were re-researched and revised. They are, after all, just based on averages and frequently no longer reflect numbers required for good health. They are not the Holy Grail.

[shaws in reply to Hidden]

You are definitely very much correct and they are behind in their knowledge, diagnosing and treatment.

[Hidden in reply to shaws]

Yes, they are. And I believe a main cause is there is no money to be made (read no incentive) by updating research to more effectively help the patients feel well and improve their health.

[shaws in reply to Hidden]

We used to only be prescribed NDT which saved lives and contains all of the hormones a healthy gland would. Big Pharma saw a way to make big profits and introduced levothyroxine in the USA (initially I believe) by monetary incentives and slowly, slowly, attitudes changed as doctors who prescribed NDT gradually retired.

So the switch over to T4 was gradual but I am really surprised by one association who made critical statements against NDT (introduced in 1892 which was prescribed up until the introduction of levo and some of our members have recovered their health by sourcing their own in these modern times).

The fact that all of the Associations state that levothyroxine is preferable (even though quite a number of patients hate it) and have gradually withdrawn GP prescriptions for NDT that made patients well again. The same with T3 although that was made due to exhorbitant prices.

The same with blood tests. Blood tests were never available before the introduction of them along with levo. So they make money from them. No one minds a company having profits but not at the expense of people's health and some patients have become suicidal.

Before blood tests were introduced we were all diagnosed upon our clinical symptoms and given a trial of NDT. If we improved we kept on it. Doctors were excellent with knowing all the symptoms.

Nowadays, they know none, but will prescribe for a symptom rather than making sure the hormone levels are all at optimum, rather than using the TSH alone to adjust doses.

thyroidscience.com/Criticis...

One of TUK's Advisers only took a blood test for the initial diagnosis and thereafter dosage was made upon clinical symptoms.

[Hidden in reply to shaws]

I agree. Moneymaking care is too often put forward and less expensive, often better, solutions swept under the rug. And I also believe doctors treat lab results as if every technician's abilities to perform tests correctly rival Einstein's IQ. Not true. I have seen more than a few errors in my time. I was never a lab technician but years ago when I worked in a dialysis unit we had to draw and spin down our patient'sblood samples. Sometimes we could be so busy and have so many patients that blood wasn't spun long enough to get a good serum sample, people waiting for the machines would take out samples so they could complete their work and get off on time. It's not a perfect world but doctors would rather believe lab results than recheck or question procedures, or, God forbid, run another more effective test to corroborate results. Just my opinion, as usual!

[Hidden in reply to Hidden]

PS Just wanted to add I think putting lab test results and reliability above patient's info is $#%backward. Several years ago I had a cholesterol level result that I knew was wrong and made my 'medical skirmishes' over my refusal to take statins that much harder. (I no longer have that doc). The cholesterol result was out of line with previous tests, I had lost weight on a plant-based diet, hadn't changed my diet and all other lab tests were inline. I could tell the doc didn't think I was being honest about my diet and when I said 'let's just repeat the test' his response to me was "Lab tests don't lie." What a jerk but probably a more common scenario for many patients than anyone cares to admit.

[shaws in reply to Hidden]

I think you are correct - they wont admit they're wrong or that they don't know. It is so easy to glance at a TSH and pronounce we're on sufficient. Even when it is above the range but below 10.

[Hidden in reply to shaws]

Very true. It seems to me suffering as an important component of a patient's medical problems has been factored out of effective careplan equations. Isn't this what quality of life is all about? I believe alleviating pain and suffering is as important as healing the disease. How bad do we have to feel and how many symptoms have to worsen before someone decides we deserve a lower TSH? Where is the cut-off point and why can't doctors decide for them selves instead of handing this power over to beaurocrats and lab technicians? I don't think too many doctors are going to allow their loved ones to lose sleep more often than not because chronic pain or distressing symptoms keep them awake and do nothing.

[crimple]

Helvella you have been very busy researching on our behalf. It is very much appreciated. Thanks for posting this latest nugget of information. As Shaws implies whilst the medics are so pig headed about the value of T3 we can carry on suffering, but I will make sure I have T3 available should I ever end up having and op and I continue to take my 6.25mcg T3 which has had such an impact on me.

[diogenes Remembering]

The answer is not so easy, as described in one of our papers. In some situations lowered FT3 may be beneficial to "rest" the metabolic rate until health resumes. In other situations lowered FT3 is a sign of a severely disrupted thyroid response from the NTI itself which is life threatening. So even if this is right, a) there has to be some demonstrable benefit other than merely normalizing FT3, and b) this increase in FT3 must not fool the body into thinking all is well, and up metabolism when that would put strain on everywhere else which is also in a weakened state.

Front. Endocrinol., 20 July 2017 | doi.org/10.3389/fendo.2017....

Thyroid Allostasis–Adaptive Responses of Thyrotropic Feedback Control to Conditions of Strain, Stress, and Developmental Programming

Apostolos Chatzitomaris1*,Rudolf Hoermann2, John E. Midgley3, Steffen Hering4, Aline Urban5, Barbara Dietrich6, Assjana Abood1, Harald H. Klein1,7 and Johannes W. Dietrich

[jgelliss]

helvella

WOW!!! It all boils down to M-O-N-E-Y . If T3 can be added to our T4 for our Well Being . That means that BIG PHARMA is losing out on Sleeping Pill Drugs Tranquilizers Blood Pressure Pills and more . It's Big Pharma's interest to Keep society sick and to keep sending people to Dr's for more drugs .

It's up to Us who benefit so much from our T3/NDT is to PUSH BACK .

[penny]

Anti-depressants are prescribed without blood, or any other tests; just the patient’s word. I was offered them instead of thyroid hormones yet I had told the doctor that. I.