This review article acknowledges the need for combined therapy but provides no reason as to the physiological basis underlying the individual's need. None of our explanatory papers mentioned - too difficult I suppose. I accessed it through the doi number. But at least it's now given full attention.
These papers are occuring with inceasing frequency, for example this one bmjopen.bmj.com/content/11/... . They have in common a lack of scientific thought. The studies look at patients diagnosed with primary hypothyroidism, on the basis of an elevated TSH. Yet we as patients know that we don't get better when our fT3 and fT4 are restored to normal (mid-intervalish) levels. Ergo our difficult to treat hypothyroidism isn't due to low serum hormone levels. There may be a failing thyroid but it's a coincidence, it isn't what is causing the problem.
Studies have failed to investigate why patients need T3, it's not primary hypothyroidism. No study has attempted to determine what doses of T3 are needed to restore clinical euthyroidism (use an EEG to measure brain response? measure ankle reflex times?). No combination therapy study has selected symptomatic patients for investigation. Barking up the wrong tree is not good science.
A key problem is that an "acceptable" collection of papers suitable for their argument seems to revolve around the same old, selected papers on the subject as here in the review. Again, it's all argued from a statistical and not a individual-patient-examination approach. Wiersinga simply cannot enter into a meaningful debate unless he takes the trouble to widen his horizons. No one will get anywhere unless they understand the basic physiology as to why this can happen. At least the failure of combination trials is admitted. But as the title tells us, he really hasn't any useful idea as to how to resolve the situation. He plainly admits his failure to produce any valid method of proceeding. It ends up being rather a wail of being "something beyond my capability of explaining". When the explanation has been aired for many years by ourselves! It does spotlight how restricted in intelligence these people are.
Why are the people who decide what is to be prescribed and what isn't shows that they seem to have no clue at all about the severe symptoms many people can develop on levothyroxine. They forget we do not have mechanical bodies but are flesh/blood.
We are also aware that people can get relief from levothyroxine but they are not searching the internet for advice/assistance.
Why have they withdrawn the NDTs despite it saving many lives from 1892 and reducing awful symptoms. They also stopped prescribing T3 despite a patient having relieved their clinical symptoms with either of these established replacements! People now have to make an appointment with an endocrinologist hoping they will be prescribed the addition of T3 to their T4. or T3 alone What a waste of time and hope and continuing misery for the patients.
T4 monotherapy led to my unsolved problem of increasing magnitude and complexity, which was simply and rapidly solved by NDT - they have got it all upside down.
The way the whole subject is dealt with by 'evidence base medicine' just makes me want to bang some peoples heads together.
Who cares how it works .
If something helps... it helps .
I don't care if it's backed up by research or not.
The only person i'm interested in research being 'done on' .... is me .
There's only one of 'me' in the universe.
I don't care if research done on '1.000.000 people who aren't me' , shows something works or not ... the only way we know if it works 'on me' ....... is to try it.
(allegedly ) I'm a grown up, so if i want to try something , why can't i just sign a disclaimer and get on with it .
What would be so wrong with 'suck it and see' .
Why can't we just have a buffet of available options to chose from .
If Levo doesn't fix someone WHY NOT try making the replacement more physiological with a bit of T3 .
Or variations thereof.
If that doesn't work why not try some NDT....... WHY NOT ?
Every 'non thyroid' thing i go to the Doctors for , they seem perfectly happy to try the 'suck it and see' approach ...... and if that doesn't help, or brings me out in galloping orange buboils , or makes me murder cats, then they have 'a different one' i can try .....
multiple variations of hormonal contraception ...
multiple variations of steroid creams for intransigent skin probs...
etc etc.....
All of which have potentially hideous side effects / long term consequences .
So why the fanatical urge to protect me from any hideous consequences of trying a different balance /form of thyroid hormone, when they don't give a monkeys if trying the contraceptive injection makes me murder cats .
( this is not a confession , all mentions of cats in any of my posts are entirely fictitious)
Sorry for the childish rant..
And thanks 'diogenes & co', for using your brains when all around you have lost theirs .
Hear, hear tattybogle! You have perfectly described what so many of us have been screaming into the vacuum of space that seems to be inhabited by doctors in their surgeries for years! My old endo, sadly now retired, had the wherewithal to give me a trial of T3 after 7 years of mono T4 hadn’t worked and gave me my life back but since he retired I have had to fight like a demon to stop his younger and more ignorant successors from taking it away from me which, on occasion, has involved a raised voice, although not quite reaching the screaming banshee level! I still have it though… 😉
They should test everyone for the DIO2 gene as I myself have one off each parent and I am Homozygous. Then we should also be tested for co morbidities as they put it and again I have only just found out that I have celiac disease after my Endocrinologist asked my GP to test for it. Oh wait we are in the real world and that would mean the Doctor's and Endocrinologists actually having to pay out of their funding and actually helping to keep us well. As for improving patient Doctor relationship I don't know how that is going to happen when we are just classed as a number on their screen and not an actual person who is desperately trying to get themselves well again
jimh111 writes, "Ergo our difficult to treat hypothyroidism isn't due to low serum hormone levels."
This makes complete sense to me!
My understanding is clearly very basic but I wonder why there appears to be no reference to the function of T3 at cellular level. Serum level is quoted, but is it not the case that T3 has to reach the nuclei of the cells before it becomes active and no matter how much T3 is sloshing around in the serum, raising FT3, it may not be enough to overcome the effects of low cellular T3. Without understanding this, a solution is unlikely to be forthcoming!
The problem appears to escape Wiersinga et al.
If the patient is suffering from cellular not glandular hypothyroidism, then the solution is surely a large enough dose of T3 to overcome the resistance preventing T3 from reaching the nuclei of the cells.
The problem then lies in how much T3 is needed to relieve the symptoms...apart from cost does lack of both knowledge and "official" guidance cause reluctance to use T3.
But, we hear, there are no tests to measure cellular T3 levels...
We then use clinical evaluation!
There is no guidance to finding the therapeutic T3 dose other than trial and error.
Are medics no longer prepared to address this incase they fail!
I apologise for this garbled reply but this is a problem I've had to work out for myself - against the advice of medics - in order to resolve the problem of a decades ( probably a lifetime) long problem of slowly declining health. I was told that a form of thyroid hormone resistance was not an option and thatT3 was not the answer. It is and it is!!
Low cellular T3!
I realise the subject here is combination therapy but I guess a basic understanding of T3 is the key...and that is frequently not in evidence!
If this is the problem we face it can feel akin to falling down the rabbit hole with Alice! Been there!
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And thanks 'diogenes & co', for using your brains when all around you have lost theirs . 
