This paper has been published, which ytries to link preferred T4/T3 combination therapy to the fraction of active thyroid remaining. This is a first step to legitimising combination therapy. Its only fault is that it still categorises groups as to preferred dosing, whereas it doesn't really cover individuality. However it gives ballpark estimates of the target in each category and how to achieve it.
You are absolutely right in your criticism. The basic difference between our group and them is that they assume a simple idea of the thyroid being only a T4 factory, with the body doing all of the necessary conversion to T3 and TSH overlording over everything. It is the simple paradigm which we have demolished. Once you realise that the thyroid produces T3 direct under the propelling influence of TSH,, as well as T4, and moreover defends its T3 production to the end, the paradigm they propose collapses entirely. The only good thing about the paper is that at least it explores the reason for combination therapy, and proposes it (as a complete about-turn over T4-fits all). You will note that nowhere in that article did they mention our work. It is a graphic example of US "exceptionalistic" parochiality - that they will not countenance work from elsewhere if it conflicts with their own beliefs - which still cling to the T4-is-all treatment paradigm. Bianco's group seeks to defend it with genetic bells and whistles, but it still won't fly, however they try.
I get the ‘not invented here’ point! Thanks, Diogenes, for posting and your more expanded explanation of the (wrong) underlying assumptions of the writers. Very helpful.
Thank you for posting this and you have produced an amazing study which must help all of us on the T4/3 combo.
My only query is why you did not include patients with absolutely no thyroid, owing to surgery. Would they not react differently to someone in the category of 10% or less thyroid working? Patients with some thyroid, however small, still have amounts of calcitonin and T1 and T2. How can you be sure that these are not of some value?
Thank you so very much for posting this, Diogenes.
I was struck by their use of T3 Total and T4 Total. The last endocrinologist I saw, a newly-minted doctor with a special interest in thyroid, said these measures are useless because of high variability.
I was biting my tongue through the whole visit, as I felt like Alice in Wonderland. “Isn’t TSH a bit dodgy, too?”
I have finally decided to try popping’round the pharmacy and inquiring as to the identity of doctors who prescribe T3.
Thanks for sharing the article. It's very interesting. The problem with most of the RCTs on T3 seems to be the variability of dosing strategies that limits comparison. So it's good to see an attempt at establishing a rationale for dosing on an individual basis (even if only a computer model). My first prescribed dose of T3 sent my T4 crashing and made me much worse. I mproved when I followed advice from this site and increased my levo to get my T4 back up to mid range, I think lots of T3 trials must fail because there's a lack of advice on dosing and getting the right balance,
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Debate Continues on Combination Therapy for Hypothyroidism
