This 2012 study is actually a very stimulating and forward looking paper on the value of combination treatment. What happened? Why was it ignored? The respected club actually did have doubts but they seem quickly smothered.
Combination Treatment with T 4 and T3 : Toward Personalized Replacement Therapy in Hypothyroidism?
Bernadette Biondi and Leonard Wartofsky
Department of Clinical and Molecular Endocrinology and Oncology (B.B.), University of Naples Federico II, 80131 Naples, Italy; and Washington Hospital Center (L.W.), Washington, D.C. 20010-2975
Context: Levothyroxine therapy is the traditional lifelong replacement therapy for hypothyroid patients. Over the last several years, new evidence has led clinicians to evaluate the option of combined T 3 and T 4 treatment to improve the quality of life, cognition, and peripheral parameters of thyroid hormone action in hypothyroidism. The aim of this review is to assess the physiological basis and the results of current studies on this topic.
Evidence Acquisition: We searched Medline for reports published with the following search terms: hypothyroidism, levothyroxine, triiodothyronine, thyroid, guidelines, treatment, deiodinases, clinical symptoms, quality of life, cognition, mood, depression, body weight, heart rate, cholesterol, bone markers, SHBG, and patient preference for combined therapy. The search was restricted to reports published in English since 1970, but some reports published before 1970 were also incorporated. We supplemented the search with records from personal files and references of relevant articles and textbooks. Parametersanalyzedincludedtherationaleforcombinationtreatment,thetypeofpatientstobeselected, the optimal T4 /T 3 ratio, and the potential benefits of this therapy on symptoms of hypothyroidism, quality of life, mood, cognition, and peripheral parameters of thyroid hormone action.
Evidence Synthesis: The outcome of our analysis suggests that it may be time to consider a personalized regimen of thyroid hormone replacement therapy in hypothyroid patients.
Conclusions: Further prospective randomized controlled studies are needed to clarify this important issue. Innovative formulations of the thyroid hormones will be required to mimic a more perfect thyroid hormone replacement therapy than is currently available.
(J Clin Endocrinol Metab 97: 2256–2271, 2012)
That does sound like it was good .... will be interested to read it later on .
I do sometimes wonder if "not being fascinated by the HPT axis" is a pre-requisite for a career in endocrinology ...
"Medical Students....is this the right course for you ?
Are you naturally curious ?
Are you observant ?
Do you like learning from wonderfully individual patients ?
Do you want to be at the forefront of exiting new research , and explore new paradigms in treatment ?
..... if so, then the Endocrinology dept. may not be for you ..... we like to keep things the way they are."
I appreciate the humour in what you said.
But I do genuinely wonder what does attract medical students to endocrinology?
Hasn't got a steady-enough hand for surgery.
Doesn't like the pressure (and working hours) of obstetrics and emergency medicine.
I could make a very long list of why some areas of medicine would be unattractive.
But the deceptive simplicity and very largely office-based work must seem like an easy option.
If that is why they choose endocrinology, perhaps it isn't surprising that within the field, they treat thyroid as if it were trivially simple.
Maybe I am entirely wrong. But I really would like to understand their choices.
I share your thoughts… easy peasy office based Well paid job! Bingo!
medscape.com/slideshow/2021... According to this they are the happiest of all medics and get to drive a Honda
When one qualifies it must give them a huge boost. Unfortunately they must 'toe the line' with regards to how they diagnose/treat patients especially those who cannot recover on levothyroxine. Unless they become 'private' endocrinologists.
And even then how many get treated properly when they go private, with such a lack of need for change within the discipline? I doubt many. The problem is they think they know it all. Most endos it seems are more diabetic trained, thyroid being such a defined treatment, there is not a lot to learn! Easier to deny their own lack of interest and dismiss their patients who fail to thrive on their treatment as ‘not my fault, I’ve ticked all the boxes, ergo they must be depressed’!
But it ought to be a really exciting area to be involved in, this TSH, Levothyroxine, job done rot needs binning once and for all. It’s holding everything back and keeping us ill. I fear you are spot on in your analysis - it certainly seems to attract a lot of lazy minded thinking that’s for sure…if you could even call it thinking
There seems to be not one Endocrinologist who is as knowledgeable as our 'old-fashioned' doctors who knew all clinical symptoms and diagnosed the patient through their symptoms alone. Patients were then given a trial of NDTs.
There seems to be a global acceptance that thyroid health has reached it’s pinnacle, that there is nothing more to know. I wonder how that ethos could ever be considered acceptable in medicine.
It can’t, or at least shouldn’t.
The bottom of the barrel??
I can't remember where I saw this, but I read once that if medical students were ranked according to their first degree final exam marks that the ones with the lowest marks were most likely to go into endocrinology and anesthesia.
Endocrinology was because students thought it was too complicated and so there was less competition for that than, say, surgery. I can't remember why anesthesia attracted some of the worst students.
Take this with a pinch of salt though since I can't remember where I read this.
I worked in the NHS. Most young doctors going thru the system aspired to be GPs. Reason, more and more females training and wanted families in the future, thought it would be easy to have both ! .
For some I knew it was in psychiatry because getting to be a Consultant was easy !
This was 20 years ago. Whilst they were clever people I could see how they worked with people and importantly which ones cared . All I will say is that it varied !!
Possibly all of that, but I also feel we might look back to the beginning.
Endocrinology education in med schools is a farce!
It's easy to knock the practitioners but...
Did the "attitude" exist when they entered med school or did it develop as they were "shaped" for years by institutions entrenched in outdated and erroneous teaching.
We only see "the end product".
They basically have to toe the line
Those with open minds and different ideas might be ignored
Or worse....pilloried.
Some years ago I visited a former GP with a question about the shocking state of my fingernails.
Also present was a med student who was tasked with diagnosing the problem before reporting back to the GP (in another room) to discuss his diagnosis.
The student took one look at my fingernails and said, " I'm sure that is thyroid related"
Wow! That was my thought too, and I said so.
He then went off to discuss his diagnosis with the GP.
They both returned and I immediately said, " So it appears to be thyroid related"
The GP sounding slightly flustered replied, " Definitely not, it's fungal".
Bang!
End of discussion!
Collapse of student's face ...he said nothing and to my shame neither did I.
We just looked at one another...
He couldn't afford to disagree.
Incidentally, my nails began to improve very, very slowly once I started to self medicate with T3.
He was correct!
I often wonder what happened to that lovely friendly young man who had such promise.
Was he eventually churned out of the status-quo-sausage-machine of med schools?
Was he pressurised into spouting the "accepted" thyroid mantra.
I hope not.
I'm not defending the shocking treatment so many of us are subjected to!
Just throwing another example into the mix.
I have no idea why so many (incompetents) might have chosen endocrinology.
One of my school friends became an endo because both she and her brother were diabetic. She died many years ago.
Maybe for others it takes them away from the blood and guts of medicine.
An easier option!
For others it may give them a sense of power they crave
Or a certain status in society.
What ultimately shapes any of us?
Nature or nurture?
During lockdown I was referred back to an Endo, having avoided them for 10 years, and was doing fine without them. Until something else ‘flared’ and threw my thyroid bloods out of kilter. I never saw the man face to face. He did call me up for bloods and tests, which I did appreciate. But, he was like Jekyll and Hyde, Lovely on the phone to start with, the second call he was awful. Dismissive, flippant, no interest in the fact that other things might be affecting my thyroid levels. He even told me I could try stopping my medication and see what happened? I’m on T3 mono. Needless to say I politely declined that offer. He left me on T3, so that’s all I need from him, with that attitude.
I saw him, he walked past the nurses area as I was waiting for bloods, sauntering through the empty hospital, all smiles and waves for the nurses. I said hello, and got a very odd look, like how dare I address him, we were the only two people in that corridor, to me it was manners to say hello. Certainly didn’t look stressed! Funny how nurses, ophthalmologists and dental practitioners could see me during the lock down, up close and personal in my face, yet an Endo could not see me across a desk? Is there a pecking order to the ‘value’ of different practitioners?
Agreed. Becoming Dr's in today's world is all for the money and not for the patients wellbeing unfortunately. Years ago Dr's cared where involved and took so much interest. New the whole family. Now we become a number. Unfortunately.
It's all about the easy money
Great set of prerequisite questions… one really wonders.