Is this a reasonable argument NOT to prescribe T3 to patients with Hashimotos?

My doctor is a bit unusual in that believes in a suppressed (0.03-0.3) TSH in patients with Hashimotos as he claims that the TSH is what triggers autoimmune attacks. Non-Hashi patients on the other hand need a normal (in range) TSH. He achieves this by prescring enough levo to suppress the TSH. He claims that T3 in any form should NOT be used in patients with Hashis as this will cause the TSH to drop after you take T3, but then it will start to rise again after a few hours, going up and down like a yo-yo and increasing the risk of autoimmune attacks, whereas TSH-suppressing doses of levo will keep the TSH low 24/7. On the other hand, he has no problems prescribing low doses of T3 (he does not approve of NDT) to patients who don´t have Hashis as they don´t need a low TSH...

This is the first time I´ve heard of this...my TSH ended up below range on levo only and has stayed there, but I cannot imagine a TSH suppressed by T3 will normalise only hours after being suppressed...which is what my doctor claims happens when on T3.

Surely he must be wrong???

[jimh111]

This study sci-hub.mksa.top/10.1055/s-... (Fig. 2) shows that the percentage change of TSH from baseline is much the same for T4 only and T3 / T4 combination therapy.

I've not heard of TSH triggering autoimmune attacks, it doesn't make sense and would only apply if you had a reasonable amount of functioning thyroid left. Perhaps he is confusing it with the need to keep TSH low in thyroid cancer. It's not good to keep TSH very low if it can be avoided. He appears to be wrong on the question of TSH affecting autoimmunity and wrong as regards moderate doses of liothyronine having a substantial effect on daily TSH fluctuations.

[Hidden in reply to jimh111]

Yes, I guess many doctors mix things up...even those who seem to know a little more about thyroid treatment than most.

[tattybogle]

On the plus side , he has at least thought about the issue , which makes a refreshing change .

But other than that , i agree with Jimh111.

(except , i have heard of 'keeping TSH low to reduce the fluctuations in hashimoto's' but i don't think i've ever seen research to indicate proof of that concept, but to be fair ,i haven't looked either)

[SlowDragon Ambassador]

Interesting concept

I have Hashimoto’s and ONLY feel well with suppressed TSH.

I also have heterozygous Dio2 gene variation and severe gluten intolerance and vitamin deficiencies

I can’t tolerate high enough levothyroxine to give full replacement

But adding small split doses of T3 has given astonishing improvements

I can’t tolerate single dose T3, or even split as 2 doses

But 3 doses of T3 at equal 8 hour intervals is perfect

TSH is now suppressed, and TG antibodies dropped significantly, though still over range.

[Hidden in reply to SlowDragon]

Yes, I understand that it is very common for the TSH to drop very low, even to undetectable levels, once you add T3. The info is pretty conflicting, but I take it TSH normalisation should NOT be the goal when on T3/NDT...?

[Miffie]

An interesting theory regarding non Hashimotos patients. I would have enjoyed such a willing prescriber as I have no thyroid related autoimmunity . My thyroid was destroyed by radiation treatment.

However I think he has rather crossed wires about T3 and TSH! I wouldn’t choose him if I had somone less confused. That’s the problem with not training our GPs as rigorously as years ago.

It is normal for feel well on a supressed TSH and has been since regular blood tests were used for my thyroid monitoring.

My TSH has on my latest blood tests had risen to 1.38 for me that’s super high. At the same time FT4 is 4.8 range 12 - 22 and FT3 1.2 range 3.1 - 6.8.

When my frees are bottom of range my TSH is invariably around 0.014.

Just shows how very different we all are.

[Hidden in reply to Miffie]

Actually, this doctor may be more knowledgeable in some areas and less in others...it´s also easy for doctors to say just about anything, expecting patients to believe everything they say.

For instance, my doctor said that Hashimotos patients don´t need T3 as they are capable of making enough T3 themselves...the reason being that they have not had their thyroid glands removed. I am not sure I believe that. That may be true while you still have some hormone-producing tissue left, but what happens once you reach end-stage Hashimotos...?

Also, my doctor said that most of his patients feel much better on his regimen because he prescribes whatever dose of levo it takes to suppress the TSH (in Hashi patients)...normally 150 mcg daily or more. I can imagine why some patients feel better on that, since many doctors seem reluctant to prescribe more than a mere starting dose...strangely enough, this doctor does not seem concerned at all with optimising vitamin and mineral levels which many say are crucial to optimal T4 to T3 conversion...it would seem every time you find a doctor more knowledgeable than most in one area, he´s still ignorant in others, meaning you as a patient need to know more than they do...!?