As I said before, we have written a comprehensive review about our current understanding of thyroid action, diagnosis of disease, treatment options, details of preferred dosing schedules etc etc. The review is easy in parts, more difficult in others but there is plenty in it to cut and paste for any patient to give to their doctor/endocrinologist. There is however one difficult term I ought to explain. It is the term "ergodicity". What it essentially means that, say, you have a patient panel and you measure their TSH, FT4, FT3 parameters through time. Then if the panel is ergodic, all patients will go through the same proportional changes in values and therefore the average values for each parameter will be the same over time as when measuring at any particular time. If the panel is nonergodic then it is not the case that all patients will behave the same way over time. Taking foreign substances like a drug will give an ergodic response - all patients will go through the same drug values over time. But the thyroid homones are different in that each person has their own track of values which will not overlap with another's (nonergodic). It's this that destroys the value of unselected clinical trials, where any value of combined T4/T3 treatment for a minority is lost in the indifference of the majority. And it also destroys the value of trials relating TSH to osteoporosis and AF. The paper is downloadable as:
Individualised requirements for optimum treatment of hypothyroidism: complex needs, limited options
Rudolf Hoermann, John E M Midgley, Rolf Larisch, Johannes W Dietrich
Thank you Diogenes, I look forward to reading it. Thank you for explaining ergodicity, didn’t know this word existed. I did make the point of ergodicity and the flaw in the assumption that the relationship between the free thyroid hormone levels and the TSH is constant in my response to the draft NICE guidelines.
Diogenes, that is the most thorough discussion of the problems with the science behind endocrinology that I have read. Thank you, and the group, for all your work. PR
Thank you diogenes, I have at last sat down to read the whole paper and found it very interesting and I think it will be very helpful to some of us individually and to all hypothyroid patients if we can get endocrinologists to fully consider and apply the principles in practice. I wonder if you would mind me asking a couple of related questions about the history of some of the ideas in the paper.
When I was diagnosed with hypothyroidism in 1991, my GP advised me that he would not be able to tell me when I was correctly adjusted, but that I would be able to tell him. I presumed at the time that this view was based on clinical evidence but it may have been based on his clinical experience. Both that original GP and a later one have referred to the individual set point so the idea of a set point and individual treatment needs has been around for quite a long time. I wondered if these ideas just fell into disuse and became unfashionable, or whether they were never published in peer reviewed journals before?
I think the concept of using the art of medicine rather than mere biochemical categorising was the original way of doing things. The patient reported, the doctor listened and gave treatment, the patient reported again and the treatment was adjusted until the patient was reasonably satisifed. It has become now that the biochemistry says you are well, so you must be, regardless of how you actually feel. That is not art, nor is it science.
Thank you, yes that makes sense. Over 25 years ago there was an understanding by some medics of a set point, though of T4, not TSH. I suppose the focus on TSH which came later led to loss of that knowledge. The paper by you and your colleagues is very necessary, thank you.
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