I have come across this article about combination T4/T3 treatment and wondered what the consensus was?

[Mollyfan]

ncbi.nlm.nih.gov/labs/pmc/a...

[Hidden]

That there is no real evidence that combination therapy works better than levothyroxine alone, but can be tried in some cases if deemed appropriate, provided adequate follow-up is provided....whatever that means (that the TSH does not drop below range?)

[DippyDame]

Consensus was amongst whom?

The conclusion drawn in the review was -

Although there is convincing evidence that there is no benefit of combination T4/T3 therapy over T4 monotherapy for management of hypothyroidism at a population level, there remains a population of patients who do not feel well on T4 monotherapy. There are several possible reasons for this, one of which is an inability to use T4 effectively in a group of patients who may respond better to combination T4/T3 therapy. This will remain a possibility until large RCTs in an appropriately targeted population can confirm or refute it, and whilst it does a trial of combination therapy in such patients may be indicated. It is important that this be performed by a clinician with adequate knowledge and experience in the area, with appropriate patient selection, clear explanation of risks and benefits to the patient for consent and careful monitoring and follow-up. Possible ways to do this are covered in this review although it is clear that further research into this area and possible methods of delivering T3 are required.

It seems clear to me that the patient outcome of T4/T3 therapy depends on the ability of the clinician to deeply understand thyroid hormones and their function, to skillfully interpret lab results and to correctly evaluate their patient's symptoms. I would suggest that anything less is courting failure....and we read examples of that regularly on the forum.

Just my view... sorry if it doesn't answer your question!

[tattybogle in reply to DippyDame]

I agree...

Unless T3/T4 combination is tried and adjusted carefully ** ~ with proper regard to the individual patients symptoms and resulting fT3/ft4 levels, then there is no evidence that combination therapy doesn't work.

** not just using their TSH Level , or some 'off the peg' random protocol like "reduce Levo to 50mcg and add 10mcg T3 .. and if they don't feel better .. bin the T3 trial, and call it proof that combination therapy doesn't work"

[DippyDame in reply to tattybogle]

Glad we agree tatty!

I'm sick and tired of reading about patients who are being treated by medics who fly by the seat of their pants while grasping a pick n mix bag of ideas.

I'm currently reading an amazing book by a world renowned prof of urology - that's another saga! - and this morning these words jumped off the page ...

" It is not subversive or obstreperous to ask that we rediscover the skilful practice of medicine based on the clinical history and examination because the necessary competence starts there"

Bingo!

[Mollyfan in reply to DippyDame]

I think we agree on this…… is there any future in specific clinics run by a team of experts like there are for menopause, strokes, Parkinson’s etc? At the moment we cannot expect GPS to have the depth of knowledge or understanding required for every condition they come across and endocrinologists are too broad in their practice. Not every gynaecologist runs a menopause clinic….. I suspect that the majority of endocrinologists would be glad to get rid of the majority of us from their general clinics!

[DippyDame in reply to Mollyfan]

Where are those additional medics to be found?

I agree, GPs are exactly that.....general practitioners

However, endocrinologists are supposed to be the experts on the endocrine system of which the thyroid is part

Some endocrinologists do develop sub-specialty interests such as thyroid disease....but they are few in number.

The expectation is that they have specialist knowledge

There should be no need for another level of care i.e. "specific clinics. "

Should they be "glad to be rid of us from their general clinics" then the question that arises is: "Why are they there?"

Improved thyroid education in med schools is perhaps the answer... but the educators must be open minded and receptive to current research not wedded to outdated protocols and practices which perpetuate the same old problems.

T3 needs to be brought into the 21st century! If used with respect and understanding it is life saving ( to which I can attest) yet medics cling to the fear that it is dangerous and expensive and steer away from it's use if possible ( I can attest to that too!)

With the correct medical, scientific, educational, financial and political will things could be radically different.

Until the medical mind set of those in high places changes - and the strict adherence to data which puts us all into reference range boxes - then those who don't fit into those little boxes and need T4/T3 or T3-only treatment will continue to struggle.

As tattybogle sums it up, "in reality i suspect that no amount of 'reading for homework' will persuade an Endo who really doesn't want to prescribe T3 to offer a trial of it ."

It beggars belief!

[Mollyfan in reply to DippyDame]

That is exactly what people said about Parkinson’s disease and stroke! It has been accepted and proved that people who have had a stroke do better in a specialist centre where there is a level of expertise that is higher. Equally, people with Parkinson’s disease do better in specialist clinics than in a general neurology clinic. The same is true of dementia care. Some of these areas are very specialist and a generalist cannot keep up to date with all of them. We have orthopaedic surgeons who only do knees, why not a sub specialist endocrinologist who does a thyroid clinic for the 10% of people who do not do well with T4 only?

[DippyDame in reply to Mollyfan]

Why not indeed!

But setting up such clinics when the powers that be are generally not in agreement with the inclusion of T3 is another matter.

Comparing knee surgery with T3-replacement is (in present circumstances) akin to comparing apples with pears.

In an ideal world we would have excellent treatment

But things just ain't ideal in the thyroid world.

Hope you are keeping well.

[Mollyfan in reply to DippyDame]

We can but hope….. and maybe join together in making practical suggestions for improvement. If it can be done for some diseases, why not others? If the finance issue improves ( which it appears to be doing) then there is hope. I am very well thank you! I have a really excellent endocrinologist who is knowledgeable, flexible and responsive. I just wish everyone had the same level of care and support, it is out there.

Hope you are also well.

[DippyDame in reply to Mollyfan]

Thank you!Yes, I'm doing remarkably well for an ancient who needs a supraphysiological dose of T3-only to function.

Good to hear of a success story.....and of an effective endo. Stay well.

Petitions to, and debates in, both Westminster and Holyrood have so far had little impact on the use of T3

We live in hope that the plight of so many will enter the conscience of the decision makers ...but I doubt that will be in my lifetime!

[tattybogle in reply to Mollyfan]

" why not a sub specialist endocrinologist who does a thyroid clinic for the 10% of people who do not do well with T4 only? "

that would, of course, be a really good idea... but in effect, we already had some... Dr Skinner for one, and several others more recently . They've all been hounded out of practice , by having to deal with repeated, energy sapping, largely baseless complaints to the GMC. (Dr skinner was in the middle of dealing with his umpteenth one of these charades when he died, and there are many who think the stress of them was a factor in his death)

And the people driving the complaints about them didn't seem to be their patients.

There are some pretty big wig's in the endocrinology profession who do NOT want to see UK thyroid treatment protocol change from "TSH in range on Levo .... like it .... or go away and have some CBT instead "

[tattybogle]

It must be bourne in mind that this paper from 2018 is now somewhat out of date . ie.

~ The price of Liothyronnine , has since come down significantly ~ this paper still quotes £258 for (28 x 20mcg) but it's now around £100 or even slightly less.

~ There have been more recent papers ~posted by diogenes ~ showing results from trials with better information on sub groups who did better /preferred NDT. ... and also some showing no ill effects related to T3 i think.( I haven't gone to check which ones , but if you have a look in his recent posts you'll find them)

[Mollyfan in reply to tattybogle]

I agree, it is a bit out of date but I think it is the guidance that a lot of endocrinologists are sticking to ( rather rigidly!) if they prescribe T3 at all. At the time it was a major step forward in the right direction and has some interesting references and information. It does accept that T3 can be necessary and gives a suggested way of initiating it which is something. It might be a useful summary for people who are refusing point blank to trial T3?

[tattybogle in reply to Mollyfan]

yes . it's not 'useless' by any means .. but some of these outdated aspects might mean it 'gets in it's own way' if used as an argument to be offered a T3 trial... so i wonder if some of the newer papers might be of more use.

[tattybogle in reply to tattybogle]

Also note ~ the only available brand of T3 for UK is listed as 'thybon' .. i'm sure there are now 2 or 3 available ... and also, several of the NDT brands mentioned are now discontinued.

[TaraJR in reply to tattybogle]

Current Drug Tariff price for T3 is £71. That's 75% less than it was at its highest.

[Mollyfan]

True, but it is one paper to read that maybe gets most of it right rather than many many papers which contradict each other!

[tattybogle in reply to Mollyfan]

could be of more use if backed up/updated with this : healthunlocked.com/thyroidu...

and this :

healthunlocked.com/thyroidu...

but , in reality i suspect that no amount of 'reading for homework' will persuade an Endo who really doesn't want to prescribe T3 to offer a trial of it .