This article (behind a paywall) discusses how to control T4 dose to relieve the unsatisfactory response to a particular dosing. They rightly criticise the large intervals in T4 pill dosing levels (a 12.5 dose would certainly help) but the whole tenor of the article seems to be that, if the T4 dose was fine-tuned, then most paients would be adequately served. Nothing much on T3. It's from the Newcastle group including Pearce, so we shouldn't expect much. What they fail to grasp is that because the T4 is taken in by mouth, with variable occasion-to-occasion bodily uptake owing to food interference or absorption problems, then the benefits of fine-tuning are severely undermined (at least as monotherapy is concerned). Also probably different T4 preparations have different absorption properties. It reads as if the group is desperately twisting and turning to avoid having to bring T3 into the picture at all. Bianco's upcoming book, and, we hope a publication of our description of how the HPT axis works, should show this for the small-mind temporising that it seems to be.
Getting the levothyroxine (LT4) dose right for adults with hypothyroidism: opportunities and challenges in the use of modern LT4 preparations
April 2022Current Medical Research and Opinion Follow journal
DOI: 10.1080/03007995.2022.2071059
Ulrike Gottwald-HostalekSalman Razvi
Written by
diogenes
Remembering
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They rightly criticise the large intervals in T4 pill dosing levels
I'd bet that they wouldn't prescribe levothyroxine oral solutions as way of providing totally flexible dosing! Far too expensive.
I usually find that 100 is too little but 125 too much. But the only UK 12.5 microgram dose is Teva - which upsets me.
The availability of intermediate tablet strengths of LT4 in the 25-75 μg range may facilitate precise and effective dose titration of LT4 and may also enable convenient maintenance regimens based on a single LT4 tablet daily, to support adherence to therapy.
Many other countries have intermediate doses (like 37.5, 62.5, etc.). I am not convinced that is a good route. One reason being the difficulties pharmacies already have in maintaining stocks when all makes (except Teva) do at most three dosages (25, 50 and 100). I expect it would increase costs and also make sticking to one make more difficult.
I also expect that there would be reluctance to move to the full ranges some companies provide - which go from 12.5 to 300 micrograms. The existence of which demonstrates that those who say the maximum dose is 200 are misguided.
i really want to know where they get the evidence for all this alleged 'difficulty with compliance' ... apart from it being the usual excuse for any variations / fluctuations in test results that they don't have the imagination or the interest to come up with a better explanation for ...
Unless i'm very unusual .. i would say that those patients on levo who are pretty much 'fixed' by it ,and don't have major problems with on-going symptoms, .. they may miss a day to so here or there, even a week or so, and it not bother them too much anyway , even it it did cause variations in their annual test results ,..... so 'compliance' and 'precise dose' isn't really a problem for this lot .
But the other lot .. who do have ongoing symptoms or are sensitive to very small dose changes ..they are way more likely to take their levo regularly as prescribed anyway ... precisely because they don't feel well so they are paying more attention to the whole issue of levo.
if you 're in that group , and you want to feel better, then alternate dosing or cutting pills in half really isn't that much of a big problem is it ? ... if doing so means you feel better than taking one pill a day of an 'off the shelf' dose feels .
personally i wouldn't have minded if i had to take 15 pills a day as long as they had worked to make me feel myself again .
I do think a few more manufacturers of 12.5mcg would be handy .. and would bring the stupidly high cost down ..... but i don't see the need or the benefit of getting into full ranges of sizes like the americans do ... it seems to be overcomplicating things to solve a 'non' problem . and like you say is likely to create another problem when your pharmacy can't keep up with keeping all these sizes in stock in different brands.
i really want to know where they get the evidence for all this alleged 'difficulty with compliance'
I agree.
Intellectually I knew the importance before I started levothyroxine. But since then, I have been extremely careful to take regularly, away from food, etc.
Individuals may not realise the importance of keeping to their schedule/dose but once they do, I suspect few would wantonly fail to comply.
Writing papers about trying to make life more convenient for thyroid patient by giving them one easy tablet of the exact right dose of Levo , seems a bit like polishing the brass on a boat while ignoring the bloody big hole in the bottom .
The Newcastle Lot seem to follow the 'Weetman School' of... where little in the way of 'evidence' is required... it's the "What I/we say goes" school of...
So sad that Newcastle was a forerunner in hypothyroidism - George Redmayne Murray, one of the first physicians to correct the myxedematous state in humans by administration of animal thyroid, was born at Newcastle upon Tyne, the son of an outstanding physician, William Murray, - yet for Newcastle to wind up as one of the most 'head in the sand' regimes. Tragic.
When I was, finally, diagnosed and was not yet on levo I talked to an elderly lady who said with a smile - to me 'you'll soon find that you will feel much better when prescribed with levothyroxine.
She looked so well and would have been in her fifties, so that gave me encouragement.
The pity is that it worked fine for her but not for me and that's the case for many on this forum is that doctors believe it suits every single hypo patient but I've also read a Last Testament from a poor lady who stated she could no longer continue life and was going to take her own life.
My GP was wearing a transdermal patch for T4 when I started using Levothyroxine, and that was in 2002. There surely must be patches? Unless they decided that they didn’t work???
This could be problematic.The active epidermis could itself convert some T4 to T3 before it gets into general circulation. Added to this one needs a good water soluble entrance, T4 being not too soluble. This could interfere with uptake.
Oh, hopes dashed there then. But maybe a more soluble version of T4 might be found ... I wonder if there were the same kind of challenges when HRT patches were being developed. I suspect there was a more focussed determination to provide innovation in the HRT market. Thyroid disease hasn't the public profile it needs yet. Thanks for your dedication to the research 🙌
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Benefits of split dosing T4
